Presentation is loading. Please wait.

Presentation is loading. Please wait.

Anesthetic Management of Patient With Chronic Renal Failure Dr Sanjeev Aneja MD. DNB, FFARCS Sr Consultant in Anesthesia & Intensive Care

Similar presentations

Presentation on theme: "Anesthetic Management of Patient With Chronic Renal Failure Dr Sanjeev Aneja MD. DNB, FFARCS Sr Consultant in Anesthesia & Intensive Care"— Presentation transcript:

1 Anesthetic Management of Patient With Chronic Renal Failure Dr Sanjeev Aneja MD. DNB, FFARCS Sr Consultant in Anesthesia & Intensive Care

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.

34 Thank you

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

Download ppt "Anesthetic Management of Patient With Chronic Renal Failure Dr Sanjeev Aneja MD. DNB, FFARCS Sr Consultant in Anesthesia & Intensive Care"

Similar presentations

Ads by Google