1. Anesthetic Management of Patient With Chronic Renal Failure Dr Sanjeev Aneja MD. DNB, FFARCS Sr Consultant in Anesthesia & Intensive Care www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com

2. Important Terms & Definitions  Renal Failure Chronic Renal Failure  GFR  Creatinine Clearance  Azotemia & Uremia  BUN/ Creatinine  Auto regulation of Renal blood Flow

3. Chronic Kidney Disease  Presence for at least three months of either of the following Structural or functional abnormality of kidney with or without fall in GFR GFR <60ml/ml/1.73sq mt (NKF 2003)

4. Stages of Chronic Kidney Disease (NKF,2003) StageDescriptionGFR 1Kidney Damage with normal GFR >/=90 2Kidney Damage with mild fall in GFR 60-89 3Moderate fall in GFR30-59 4Severe fall in GFR15-29 5Kidney Failure<15

5. GFR  Best overall measure of function  Normal level of GFR varies with age, sex & physiological state  25% of individuals above 70 yr of age have GFR <60 ml  GFR is estimated from urinary clearance of a filtration marker

6. GFR contd.  Estimation of GFR using exogenous filtration marker  Estimation of GFR using endogenous filtration markers urea creatinine Cystatin C

7. GFR contd  Estimating equations for GFR using serum creatinine  Cockcroft-Gault Equation Ccr= (140-Age) x weight( 0.85 if female)/(72xPcr) MDRD study equation

8. Chronic Kidney disease & Anesthetist  Patients on replacement support pts. With GFR<15 ml pts. With GFR 15-29 ml Patents with GFR 30-59 ml

12. Discussion  History Duration of disease Cause of disease Manifestation of systemic disease Complications of CRF

13. History  Type of dialysis  Frequency of dialysis  Tolerance of dialysis  Dry weight of the patient

14. Physical Examination Mark & Record the site of venous access for Dialysis

15. Cardiovascular Disease in CKD  CVD is the main cause of death in patients with CKD  Persons with CKD are predisposed to three types of CVD—atherosclerosis, arteriosclerosis, and cardiomyopathy

16. CVD in CKD  Hypertension  Uremia  Anemia  Coronary & valvular calcification  Dyslipidemia  Increased markers of inflammation

17. CVD in CKD No guidelines for cardiovascular evaluation in ESRD patients Pt. <50yr no diabetes & symptom of CAD Pt..50yr with diabetes without symptom of CAD Pt. With symptom of CAD or CHF

18. Assessment of Other Systems  Respiratory  Hematology   Fluid & Electrolyte  Gastro intestinal

19. Pre Operative Preparation  Treat anemia  Dialysis When to Dialyse How much fluid to be removed Effects of Dialysis

20. Anesthesia planning  GA Vs Regional  Premedications  Intraoperative Management  Post operative pain & fluid management

24. Anesthesia for Renal Transplantation 1936 (VORONOY)1 st Cadaver Human Renal Allograft 1954 (MERRILL)1 st Living related donor graft between twins. 5 Years Survival After Transplants: 70% After Dialysis:30% (8 out of 23,546 Pts.) (Anaestesiology clinics of North America, 22, 2004)

25. Surgical Field: Renal Transplant Extra Peritoneal Donor Renal Artery To external / common iliac Artery Donor Renal Vein To external / common iliac vein Donor Ureter To Bladder (Ureterocystostomy)

26. Pre-operative Preparation Pre-Op visitReassurance ICU Stay/Central Line/Pain Relief/PCA-Epidural. Hep. B,C/ HIV Status. A-V Fistula Fluid/Electrolyte Status Plan of Immunosuppression Therapy – Cotisone / Cychosparin / Azathioprine

27. Choice of Anaesthetic Technique General Anaesthesia (GA) Regional Anaestehsia (RA) – Spinal/Epidural/CSE Combination of GA + RA ? Epidural haematoma ? Use of RA in Autonomic neuropathy ?Use of Vasopressors (avoided)

28. Conduct of Anaesthesia Induction: Rapid Sequence induction Propfol / Thiopentone / Ketamin Fentanyl (5mcg/kg) / Esmolol Atracurium / O 2 + N 2 O + isoflurane ? Sevoflurane (Compound A controversy)

29. Equipment / Monitoring Sterile disposable anaesth. circuits / ETT / Laryngoscope Use of gloves / Gowns / IV Lines (avoid forearm) NIBP / ECG / SPO2 / ETCO2 / PN Stimulator / agent / Temperature / CVP (IJV) / Urine Output Electrolytes / ABG / haemotocrit ? IBP / ?PAWP

30. Fluid & Diuretic Therapy (Intra – op.)  Adequacy of Perfusion at vascular clamp release.  Intra-op volume expansion - ↑ RBF & improved immediate graft function / graft survival / lower pts mortality.  Guided by CVP (10-15cm H 2 O) Small vol. colloid / N-saline (Avoid RL)  Cadaver Kidney – needs ↑ BP & ↑ plasma vol. to initiate diuresis than normal kidney.  Frusemide / Mannitol / Dopamine infusion.

31. Immunosuppression Methyl Prednisolon – (500 mg. Solumedrol) IV Slowly (30-60 mins) before transplant. Cardiac Arrest Arrhythmias Circulatory Collapse Azathioprim Cyclosporin

32. Post operative period Recovery ICU Stay – Protocols – Fluid / Urine output. Pain Relief – PCA / Epidural Haemodialysis CXR

33. Dual Kidney Transplant Two kidneys from aged donor are placed in to one recipient. Long duration of surgery / Otherwise no difference in management.

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35. Clinical settings when BUN and creatinine levels may not reflect alteration in renal function High urea with normal renal function: Hypercatabolism, high protein load, GI bleed, hematoma breakdown Normal urea with decreased renal function: Decreased urea synthesis in hepatic failure or malnutrition High creatinine with normal renal function: Excess creatinine release due to seizures, muscle injury, inflammation, or ischemia Normal creatinine with decreased renal function: Decreased creatinine synthesis from muscle due to malnutrition or atrophic muscular disorders