3. DEFINITION OF CHRONIC KIDNEY
DISEASE
•Structural/functional abnormalities of the kidney
•With or without decreased GFR
•Manifest by either:
•Pathological abnormalities, or
•Markers of kidney damage
Kidney damage for ≥ 3 months.
Kidney damage is defined as:
GFR <60 ml/min/1.73 m2 for ≥ 3
months, with or without kidney
damage
4.
5. MARKERS OF KIDNEY DAMAGE
(For patients with normal or borderline normal
GFR)
Albuminuria:
• Albumin excretion
>30mg/24 hr, or
• Albumin:creatinine ratio
>30 mg/g (>3 mg/mmol)
Urine sediment
abnormalities
Electrolyte and other
abnormalities due to
tubular disorders
Histologic
abnormalities
Structural
abnormalities
detected by imaging
History of kidney
transplantation
6. MAJOR CAUSES OF
CKD
DM, 31%
CGN, 28%
PCKD, 12%
Hypertension,…
SLE, 3% Interstitial Nephritis,…
8. PRE-ANESTHESIA ASSESSMENT
Type of
dialysis
(hemodialysis
, peritoneal
dialysis)
Frequency of
hemodialysis
or peritoneal
dialysis
Date and
time of most
recent
dialysis
Type and
location of
dialysis
access
Usual fluid
intake
Usual daily
urine output
(may be zero)
“Dry weight"
Serum urea
and
creatinine
concentration
s
Serum
electrolyte
concentration
s
Medications given
at dialysis that
may not be on
usual medication
list
Name and contact
information of
patient's
nephrologist/dialysi
s facility
9. HYPERKALEMIA
Chronic hyperkalemia (serum K+ <6 mEq/L)
without ECG changes
• Anesthesia & surgery are usually well-tolerated.
All patients with ↑K+ should have a 12-lead
ECG.
• Absence of hyperkalemic changes on the ECG until serum K+ >6 to 6.5 mEq/L
• However, the absence of ECG changes does NOT preclude the possibility of
hyperkalemia-associated cardiac arrest.
10.
11. HYPERKALEMIA
FOR ELECTIVE SURGERY
• K+<5.5 mEq/L: induction of anesthesia is reasonable
• K+≥5.5 mEq/L: dialysis (2-3 hours if on HD)
FOR URGENT OR EMERGENT SURGERY (K+>5.5
mEq/L)
• Stable, (-) ECG changes: proceed with surgery, continuous intra-op ECG & frequent serum K+
measurement (q30min)
• (+) ECG changes: dialyze if feasible (1-2 hours is enough)
12. In a life-threatening surgical situation when dialysis
is not feasible, the operation is performed
regardless of potassium level and ECG changes.
IV calcium gluconate 1000
mg or calcium chloride
500-1000 mg over 2-3 mins
IV insulin (with glucose if
serum glucose <250
mg/dL/13.9 mmol/L)
10u RI + 50 ml D5050 (25 g of glucose),
then infuse D10W (50 to 75 mL/hr), CBG
q1H x5-6H
Bicarbonate 1-2 mEq/kg if
pH <7.1-7.2. Repeat after
30min if pH remains <7.1.
Temporize with
medical
management
Succinylcholine is avoided in patients with
hyperkalemia due to the potential for life-
threatening arrhythmias preceded by
rapidly changing ECG findings.
13. FLUID IMBALANCES
Hypervolemia
May happen if: during
preop HD, dry weight
is not achieved; large
fluid volume is
received intra-op
Pulmonary edema
Emergency dialysis
and noninvasive PPV
or controlled
mechanical
ventilation
Hypovolemia
May happen if too much fluid
is removed during preop HD
Intraoperative hypotension
d/t anesthesia-induced
systemic vasodilation
May cause thrombosis of AV
access site
If CKD patient has CHF: do invasive hemodynamic
14. HEPARINIZATION
IF HEMODIALYSIS IS PERFORMED ON THE DAY OF
SURGERY
(PERITONEAL DIALYSIS DOES NOT REQUIRE HEPARIN)
ELECTIVE CASES
Perform heparin-free
hemodialysis on the day of
surgery, or
Wait for coagulation status
to return to normal after
HD with heparin (about 4
hours after)
URGENT/EMERGENT
CASES
Administer protamine to
reverse the effects of
heparin
15. COMORBIDITIES: CARDIOVASCULAR
DISEASE
Venous thrombosis
•Which may make insertion of
central venous access difficult
Hypertensio
n
CAD
CVD
Peripheral vascular disease
•Preop Doppler studies to ID
best sites for arterial catheter
insertion
Heart failure
•Focus on fluid
management
Pulmonary
hypertension
Atrial fibrillation
•Correct preop electrolyte
imbalances
16. COMORBIDITI
ES
Diabetes
•Treat glucose levels >180 mg/dL all
throughout perioperative period
Pulmonary
disease
•Pulmonary edema or pleural effusion may be
present
Gastrointestinal
disorder
•Gastroparesis associated with uremia &
diabetes, hence with ↑risk of pulmonary
aspiration
•Uremia-induced platelet dysfunction
esophagitis, gastritis, duodenitis or UGIB
•Contraindication to TEE monitoring
17. COMORBIDITI
ES
Anemia
•Managed with iron and EPO
•If stable, generally, blood is not transfused if
Hgb >7 g/dL
•If on transplant waiting list, not transfused to
avoid rejection d/t transfusion-induced
increases in antibody levels
Coagulation
abnormalities
•Increased bleeding tendency due to:
•antiplatelet agents, uremia, anticoagulation
for AF, residual heparin used for dialysis,
anemia, and ↑ production of nitric oxide
•Some are hypercoagulable.
18. MANAGEMENT OF BLEEDING
DIATHESIS
ELECTIVE SURGERY
Tests: PT, aPTT, INR, platelet
count
Heparin-free dialysis will
improve platelet fxn
• 1 hour before procedure
• Duration: 4-8 hrs
• May repeat q12h (but with
tachyphylaxis on 2nd or 3rd dose)
IV desmopression (dDAVP)
0.3 mcg/kg
NONELECTIVE
SURGERY
•IV dDAVP 0.3 mcg/kg
•Protamine if recently given
heparin
With uremic platelet dysfxn:
• Give platelet (1 apheresis unit or 6
units of pooled plt) even in the
absence of thrombocytopenia
• Plus 10 units of cryoprecipitate
With active bleeding:
19. PREMEDICATION
Aspiration prophylaxis
• Avoid sodium citrate if
patient takes aluminum-
containing phosphate
binders
• Citrate increases aluminum
absorption and toxicity
Anxiolytics
• Reduce and titrate IV
midazolam (0.5-1 mg
increments)
• ↓ elimination of midazolam
& its metabolite (a1-
hydroxymidazolam)
• ↑free plasma levels of
midazolam
Opioids
• Fentanyl may be given in
small doses (25-50 mcg IV)
20. VASCULAR ACCESS
Avoid AVF or graft and HD catheters
•No BP measurements, venipuncture and vascular
access.
•Avoid potential future fistula sites, too.
•Do not give drugs via HD catheter.
Sites for IV access
•Peripheral: veins at the dorsal part of the
dominant arm; avoid PICCs
•Central: do not place on the same side as the HD
catheter; ultrasound-guided insertion is
22. LOCAL ANESTHESIA WITH MAC
Medications with rapid
onset and short duration
of action are preferred
for sedation/analgesia.
Doses are reduced and
carefully titrated.
23. REGIONAL ANESTHESIA
(-) potentially hazardous general
anesthetic
(-) need to administer multiple IV
anesthetic agents that may have
delayed metabolism and excretion
(+) superior postoperative analgesia;
↓ requirements for systemic
analgesic agents (particularly
opioids)
(+) bleeding diathesis in many
dialysis-dependent patients
(+) residual anticoagulation after
heparin administration may be present
in patients up to four hours after HD
(+) need to check coagulation profile
prior to removal of a neuraxial
catheter, if patient is on post-op HD +
heparin
(+) possible low serum bicarbonate
levels: may slow the onset of action of
local anesthetic drugs
(+) possible shortened duration of
local anesthetic action due to reduced
protein binding
ADVANTAGES
DISADVANTAG
ES
24. CENTRAL
NEURAXIAL
TECHNIQUESFor lower abdominal
and lower extremity
surgery
Labor analgesia and
cesarean delivery
PERIPHERAL
NERVE
BLOCKS
Upper extremity – for
AVF creation
• Better intraop hemodynamic
stability, good analgesia,
regional sympathectomy
improves blood flow
Lower extremity
Trunk
• e.g., TAP block
• For thoracic & abdominal
wall procedures
SPECIFIC REGIONAL TECHNIQUES
25. GENERAL ANESTHESIA: INDUCTION
PROPOFOL
1-2.5 mg/kg
(pharmacodynamic
s & kinetics not
markedly affected
by CKD)
Reduced to 1-2
mg/kg & titrated
carefully if CKD pt
is elderly, with CHF
or is hypovolemic
NMBA
Succinylcholine –
safe to use in RSII if
K+ is <5.5 mEq/L,
without ECG
changes
• Transient ↑ in K+
by 0.5-1 mEq/L
• ↓ plasma
cholinesterase
levels hence effect
may be prolonged
If K+≥5.5 mEq/L,
use NDNMBA:
REMIFENTANIL
Alternative if SCH
and NDNMBAs are
both
contraindicated.
Propofol 1-2
mg/kg, followed by
remifentanil 2-3
mcg/kg – good
intubating
conditions in 2mins
Ephedrine 10 mg is
also administered
to minimize
26. INHALATION vs TIVA
• If inhalation: isoflurane,
sevoflurane or desflurane ± N2O
• Concern with sevo: theoretical
renal toxicity d/t “compound A”
especially if low FGF; but used
safely in pts with stable CKD on
dialysis
• TIVA:
• Continuous IV infusion of both
hypnotic agent & short-acting
opioid
OPIOID
• Short-acting:
• Fentanyl – metabolized in the liver to
inactive norfentanyl
• Sufentanil – 5-10x more potent than
fentanyl; metabolized in the liver &
small intestine
• Remifentanil – rapidly broken down by
plasma & tissue esterases
• Long-acting:
• Generally avoided
• If necessary, hydromorphone/
GENERAL ANESTHESIA:
MAINTENANCE
27. NMBA
• Atracurium (0.5 mg/kg)
• Via Hoffman
elimination
• Cisatracurium (0.15
mg/kg)
• 4x more potent than
atracurium, but (-)
histamine release
• Mivacurium (0.07-0.25
mg/kg)
• Plasma cholinesterase
• Duration: 15-20 min
NMBA
• Rocuronium (0.6 mg/kg)
• Clearance ↓ by 33-39%
• Metabolite: 17-
desacetylrocuronium
(20% activity)
• Vecuronium (0.1 mg/kg)
• Excreted thru biliary +
renal (hence effect if
prolonged)
• Metabolite: 3-
desacetylvecuronium
(60%)
REVERSAL
• Neostigmine
• Pharmacokinetics not
different
• Suggamadex
• Chelates rocuronium or
vecuronium
• Creates complexes that
are retained in the
body, but can be
removed thru dialysis
GENERAL ANESTHESIA:
MAINTENANCE
28. Fluid management
• Use 500-ml infusion bags with microdripper
• Crystalloids
• (+) hyperkalemia if on NPO & receiving plain IV
fluids
• Avoid D5-containing fluids if with hyperglycemia
or hypokalemia
• Normal saline – hyperchloremic metabolic acidosis
• Colloids
• 5% albumin if urgent & significant blood volume is
needed & pRBC is n/a
• Blood
Glucose control
• Maintain blood glucose
at <180 mg/dL (<10
mmol/L)
• If insulin is given, check
glucose after 1hr
• If on insulin infusion,
check q30-60mins to
avoid hypoglycemia
• Hyperglycemia: 2-4x
increase in risk of
myocardial ischemic
GENERAL ANESTHESIA:
MAINTENANCE
29. POST-OPERATIVE CARE: FLUIDS &
ELECTROLYTES
Check serum urea, creatinine &
electrolytes
Dialysis should be delayed until the
risk of surgery-induced fluid shifts
and hemorrhage has diminished.
If the patient is on hemodialysis,
heparinization of the circuit may be
reduced or omitted to avoid
postoperative bleeding.
In some hemodynamically unstable
patients, continuous renal
replacement therapies (CRRT) may
be used instead of hemodialysis in
the postoperative period.
30. POST-OPERATIVE CARE: PAIN
MANAGEMENT
Multimodal
approach
•Avoid long-acting
opioids.
•Avoid meperidine –
active metabolite:
normeperidine may
cause respiratory
depression &
neuroexcitation
(seizures/myoclonu
s)
May use RA or
wound
infiltration with
LA, plus non-
opioid
analgesics:
•Paracetamol – no
dose modification
•NSAIDs – avoided
esp if pt has
residual kidney fxn
(may worsen
condition)
•May cause
bleeding (anti-
PCA with opioid
•Fentanyl is used if
patient requires
short-term opioid
administration
Date and time of most recent dialysis – Although patients on maintenance hemodialysis will generally be dialyzed 12 to 24 hours prior to elective surgery, those undergoing nonelective surgery may not have received dialysis for up to 72 hours prior to presentation, or longer if there has been a missed treatment. Patients on peritoneal dialysis generally are receiving daily dialysis that may be continued until just before surgery.
Usual fluid intake (may be restricted; therefore, care with perioperative intravenous [IV] fluid volumes is required).
"Dry weight" (ie, the target weight). The target weight is commonly established by the outpatient nephrologist as documented on the outpatient dialysis chart. The target weight may not have been achieved after the last dialysis session, or may not be accurate in patients who have recently lost weight due to illness.
Hyperkalemia is a potential indication for preoperative dialysis. There are no guidelines that specify a maximum safe level of potassium prior to induction of anesthesia. Decisions regarding treatment of hyperkalemia depend upon the urgency of surgery (ie, whether it is safe to delay surgery for three to four hours to perform dialysis), as well as the likely degree of tissue damage and release of potassium during the planned operation, anticipated blood loss and fluid shifts, chronicity of hyperkalemia, and existing or impending acid-base disturbances that may affect the intraoperative rate of rise of the serum potassium concentration (eg, metabolic acidosis).
12-L ECG: There may be absence of hyperkalemic changes on the ECG until serum potassium concentrations exceed 6 to 6.5 mEq/L, however, the absence of ECG changes does NOT preclude the possibility of hyperkalemia-associated cardiac arrest.
IV calcium (eg, calcium chloride 500 to 1000 mg) to directly antagonize the cell membrane actions of hyperkalemia. Since hypocalcemia exacerbates potassium-induced cardiotoxicity, ionized calcium levels are monitored, and hypocalcemia is treated.
IV insulin (typically given with intravenous glucose) to drive extracellular potassium into cells. \
Bicarbonate therapy 1 to 2 mEq/kg may be administered to raise pH and drive extracellular potassium into cells if severe acute metabolic acidosis is present (ie, pH <7.1 to 7.2). The bicarbonate dose may be repeated if pH remains <7.1 after 30 minutes.
Protamine:
-if exceeds 50 mg/10 mins: anticoagulant effect
-monitor aPTT 5-15 min after dose then in 2-8 hr
-if without bleeding complications, observe rather than reverse to avoid ADR’s
Diabetes: many dialysis-dependent patients have diabetes since this is the most common risk factor for development of ESKD. Even in those without diabetes, glucose intolerance is a feature of uremia. Surgery and general anesthesia typically lead to worsening hyperglycemia due to neuroendocrine stress responses and impairment of insulin secretion. Other aspects of perioperative management of blood glucose in dialysis patients are discussed separately.
dDAVP 0.3 mcg/kg is administered to facilitate platelet aggregation by increasing the release of large von Willebrand factor (vWF) multimers from endothelial cells
Cryoprecipitate enhances platelet aggregation by increasing factor VIII:von Willebrand multimers and/or fibrinogen level.
Hence, a coagulation profile (eg, international normalized ratio [INR] and partial thromboplastin time [PTT], as well as platelet number) is checked for normality before beginning any neuraxial anesthetic procedure.
Elimination of atrac and cisatrac is independent of renal function. However, because of their slow onset (three to four minutes for atracurium and five to seven minutes for cisatracurium), atracurium and cisatracurium are not ideal for patients who require RSII due to aspiration risk.
Rocuronium:
primarily eliminated by direct liver uptake and excretion in bile, but some is excreted renally
Neuromuscular blockade may be markedly prolonged after administration of a large intubating dose of rocuronium.
Although sugammadex typically avoided in patients with ESKD, reversal of rocuronium effects is possible with this agent. The sugammadex/rocuronium complex can be removed by dialysis if necessary.
Short-acting opioids – Generally, the pharmacokinetic and pharmacodynamic responses to short-acting opioids (eg, fentanyl, remifentanil, and sufentanil) are not affected by ESKD, although interindividual variability exists. Also, acute alkalinization induced by hemodialysis may increase distribution of opioids across the blood-brain barrier into cerebrospinal fluid (CSF). Thus, it is particularly important to monitor for perioperative respiratory depression
Neostigmine: 0.03-0.07 mg/kg, with atropine (0.01 mg/kg) or glycopyrrolate (0.75 mg)
Sugammadex: 2-4 mg/kg
