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Organ Systems Involved in Renal Failure
  • Uremic encephalopathy
  • Depends on rate of rise of BUN, not absolute value
  • Peripheral and autonomic neuropathy
  • Uremic pericarditis (rare)
  • Hypertension
  • Left ventricular hypertrophy and congestive heart failure (CHF)
  • Volume overload and pulmonary edema
  • Delayed gastric emptying
  • Acidosis:
    • Non-anion gap acidosis with renal bicarbonate loss and hyperchloremia
    • Anion gap acidosis due to hyperphosphatemia
  • Hyperkalemia:
    • Worsened by acute acidosis (pH ⇓ by 0.1 causes K+ ⇑ by 0.5 mEq/L)
  • Normocytic, normochromic anemia
  • Uremic platelet dysfunction and coagulopathy:
    • Impaired von Willebrand factor (vWF) release from endothelium ⇒ impaired platelet activation
    • Can be treated with desmopressin (0.3 μg/kg) that releases endogenous vWF
  • Immunosuppression due to myelodepression
  • Catheter-related infections
  • Peritonitis with peritoneal dialysis
  • Vascular access
  • Tunneled dialysis catheter
  • Double-lumen central venous catheters (Vas Cath)
  • Arteriovenous (AV) fistula and shunts


  • How long has the patient been on dialysis?
  • When was the last dialysis?
  • How long was the last dialysis?
  • Were there any problems during the last dialysis such as hypotension, impaired fluid removal, dizziness?
  • Any recent fever, chills, or infections?
  • In case of peritoneal dialysis: when was the abdomen filled or emptied the last time?

Physical Exam

  • Examine shunt site and auscultate the shunt
  • Evaluate for signs of CHF and neuropathy
  • Examine abdomen in case of peritoneal dialysis


  • Complete blood count (anemia), serum chemistry (K+, BUN, Mg2+, phosphate), and coagulation profile
  • ECG (cardiomyopathy, low voltage with uremic pericardial effusion)
  • Chest x-ray (pulmonary edema and pleural effusions, catheter location, cardiomyopathy)

Schedule dialysis 1 day prior to surgery.

Schedule RBC transfusion during hemodialysis if necessary.

Continue peritoneal dialysis until surgery.

Regional Anesthesia

  • Possible if no coagulopathy present
  • Document preexisting neuropathy
  • Sympathectomy may exacerbate autonomic dysfunction and hypotension

General Anesthesia

  • Positioning:
    • Careful positioning of arms with attention to fistula
  • Induction:
    • Minimize sedative agents
    • Rapid sequence induction if delayed gastric emptying is suspected
    • Succhinylcholine may be used if preoperative K+ <5 mEq/L
    • Avoid rocuronium or vecuronium; preferred NMB is cisatracurium
  • Fluids:
    • Minimize fluids for minor surgery
    • For major and intermediate surgery:
      • Replace fluid loss (blood loss and insensitive losses) with lactated Ringer (LR) or other balanced salt solutions, not normal saline (NS)
      • NS causes hyperchloremic acidosis that worsens hyperkalemia and may preclude extubation
    • Drugs:
      • Normal metabolism (independent from renal function):
        • (Cis-) atracurium, succinylcholine, esmolol, remifentanil
      • Titrate all other drugs to effect:
        • Vecuronium, rocuronium, fentanyl, midazolam, hydromorphone
      • Avoid (or titrate carefully) drugs with renally eliminated metabolites:
        • Morphine, vecuronium, meperidine, midazolam
      • Sevoflurane is probably safe but avoid low fresh gas flow
    • Extubation:
      • Check arterial blood gas prior to extubation for any longer cases
      • ...

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