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Peri-operative management of the dialysis patient Pelonomi: Firm 4 Consultant: dr Flooks Registrar: A vd Horst.

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Presentation on theme: "Peri-operative management of the dialysis patient Pelonomi: Firm 4 Consultant: dr Flooks Registrar: A vd Horst."— Presentation transcript:

1 Peri-operative management of the dialysis patient Pelonomi: Firm 4 Consultant: dr Flooks Registrar: A vd Horst

2 Our patient 49yr lady from Rocklands Hypertensive nephropathy on chronic haemodialysis Anterior abdominal wall mass ? Desmoid tumor Excision biopsy

3 Special investigations Na 135 Cor Ca 3.10 K 3.2 Mg 0.76 Ur 3.0 P 0.63 Cr 214 Liverfunctions: albumin 22 tot protein 76 rest normal

4 Special investigations FBC: wcc 8.4 x 10 9 /ℓ Hb 8.0g/dℓ mcv 88.9fl pl 416 x 10 9 /ℓ Iron studies: serum iron 5.4ųmol/ℓ transferrin 0.7g/ℓ TF saturation 31%

5 Peri-operative management of the dialysis patient

6 Increased morbidity and mortality High incidence of CAD and myocardial dysfunction Difficulty in managing fluid and electrolytes - potassium Inability to metabolize and excrete anaesthetic and analgesic agents Bleeding complications Poor BP control: both hypo – and hypertension

7 Issues of concern

8 1.Baseline lab evaluation 2.Anaemia 3.Nutritional status 4.Dialysis dose 5.Fluid and electrolyte management 6.BP control 7.Evaluation for cardiovascular disease 8.Correction of bleeding diathesis 9.Antibiotics 10. Glucose metabolism 11. IV access 12. Anaesthetic considerations

9 1. Laboratory evaluation Baseline investigations: - electrolytes, urea and creatinine - glucose - albumin - full blood count - coagulation profile - iron studies if anaemic - drug levels - digoxin

10 2. Anaemia status Elective surgery: Hb 12-13g/dℓ Erythropoiesis stimulating agents (ESA) Important, because post – operatively: transfusions are often needed due to blood loss intra-operatively ESA – resistance

11 3. Nutrition Ability to heal post-surgery Protein catabolic rate and albumin should be optimalized Stop drugs decreasing appetite Drugs to ameliorate gastroparesis Nutritional supplements

12 4. Intensive dialysis Unknown whether delivery of intensive doses of dialysis prior to or during surgery improves outcome (Uptodate) Discussion between the anaesthetist and the nephrologist

13 5. Fluid and electrolyte management Optimal volume status: estimation of the amount of fluid lost and administered during surgery Normal saline vs Ringer’s lactate Electrolytes – calcium and potassium

14 Hyperkalemia and emergency surgery ECG – asses the physiological effect of hyperkalemia Chronic renal failure patients – increased tolerance ECG changes due to alteration in transcellular K⁺ gradient and not the absolute value CRF – increased total body and intracellular K⁺ = normal ECG

15 Course of action is based on the clinical setting If: no ECG changes, stable patient, K⁺ 6 – 6.2 mmol/ℓ == cont surgery If : ECG changes present = dialysis

16 If no dialysis facilities available: Medical treatment - Calcium - Insulin and dextrose - Sodium bicarbonate - β-stimulants - Cation exchange resins - can be give PR if NPO - potential for post-op intestinal necrosis

17 6. Blood pressure control Hypertension 1. Optimize volume status – optimal dry weight 2. Parenteral antihypertensives: labetolol, hydralazine ( with β – blocker) diltiazem, nitroglycerine, nitroprusside 3. Post-op – normal oral antihypertensive regimen, with close monitoring

18 Hypotension 1. Excessive fluid removal 2. Left ventricle dysfunction 3. Autonomic dysfunction 4. Pericardial tamponade 5. Vasodilatation from opioids / anxiolytics = Titration of anti-hypertensive treatment

19 7. Cardiovascular evaluation 50% of dialysis patients have CVS disease American College of Cardiology / AHA Risk stratification

20 8. Bleeding tendency Increased tendency to bleeding Platelet dysfunction – uremia, anemia, hyperparathyroidism, aspirin Bleeding time not recommended as screening test pre-op, except for renal biopsy and major vascular surgery Raising hkt, desmopressin, cryprecipitate, dialysis, estrogen

21 9. Peri-operative antibiotic use In accordance with general surgical guidelines Dose adjustments Loading dose unchanged Access procedures - fewer access infections

22 10. Glucose metabolism Better control @ home, than in hospital - change in physical activity - acute comorbid conditions - inability to ingest food - reality of surgery schedules

23 Type 1 DM – brittle - wide variations in glucose metabolism - serum ketones if DKA Type 2 DM – induction of hyperglycemia - increased t½ of oral drugs

24 11. IV access Frequent IV lines may destroy future access sites Avoid subclavian central lines = subclavian stenosis CVP should not be placed on the same side as the AV access

25 12. Anaesthetic considerations Thiopental – doubled free fraction Ketamine – hypertension Propofol – hepatic metabolism - well tolerated

26 Succinylcholine – Hyperkalemia - K < 5mmol/ℓ - succinylmoncholine NDMR: pancuronium and gallamine renally excreted = prolonged paralysis atracurium, vercuronium

27 Sedatives: benzo’s are protein bound = free fraction in CRF intermediate metabolites

28 Analgesia Opioids – fentanyl drug of choice - avoid pethidine, propoxyphene - effects of morphine prolonged - half-life of metabolites prolonged Paracetamol can be used without any dose adjustments

29 In short

30 Peri-operative management of the dialysis patient requires a focussed assessment of all 12 aspects, as well as careful liaison between the physician, surgeon and anaesthetist.

31 Back to our patient She underwent surgery without any complications. Histology: Lipoma

32 Thank you

33 Bibliography Uptodate Miller’s Anesthesia, 6 th edition

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