anaesthesia renal

8/9/2019 Anaesthesia Renal

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Principles of the anaesthetic management ofpatient with renal failure


2/18

Define chronic & acute renal failure

Calculation of glomeral filtration rate

Anaesthetic considerations:

Pre-operative Intra-operative

Post-operative

AIms


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Presence for at least three months of either of the following

Structural or functional abnormality of idney with or without

fall in !"#!"# $%ml'ml'()*+m,

Chronic idney Disease


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.ormal level of !"# varies with age/ se0 & physiological state

!"# estimated from urinary clearance of a filtration marer:

1ndogenous: urea/ creatinine

10ogenous: inulin

Coccroft-!ault 12uation

Creatinine clearance 3 4(5-Age6 0 weight4 )78 if female6'

4*,0Pcr6

9D#D study e2uation9D#D study e2uation

!"# 4m'min'()*+ m,6 3 (*8 ; 4Scr6-()(85; 4Age6-),+; 4)*5, if female6 ;4(),(, if African American6

!lomerular filtration rate


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Stages of Chronic idney Disease

4."/,+6

Stage Description !"#

( idney Damage with normal !"#


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1.Rapid time course ( 48 hrs)

2.Reduction in Kidney functions:

a) Rise in Creatinine- Aso!ute " in #.Creatinine of$%.&m'd! ($ 2.4 *mo!!) or a percenta'e " in

#.Creatinine of $+%, (1.+ fo!d from ase!ine).

) Reduction in urine output (documented o!i'uria of %.+m!'hr for more than si hrs).

(from Acute Kidney /n0ury etor - AK/)

Acute idney in0ury


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3iided into three ma0or cate'ories:

1. 5rerena! AR6(7++,)- 3iseases that cause rena!hypoperfusion resu!tin' in 9 function ithout fran

parenchyma! dama'e

2. Rena! or /ntrinsic AR6 (74%,)- 3iseases that direct!y ino!ethe rena! parenchyma

&. 5ostrena! AR6 (7+,)- 3iseases associated ith urinary tractostruction.

tio!o'y and 5athophysio!o'y


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5re-operatie optimisation

Ris strati;cation


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Peri-operative ris of AI


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5rotein ound dru's hae increase free fraction due to hypo-a!uminaemia and acidosis.

>ipid inso!u!e dru's ecreted y idney.

?epatic metao!ites of !ipid so!u!e dru's are ecreted yidney.

@remia and metao!ic acidosis chan'es structure andfunction of dru's.

ect on dru' hand!in'


11/18


12/18

=orphine Con0. to =-&-F =--F actiemetao!ite respdepresion

Actie metao!ite hasrena! e!imination 4%,con0 occurs in idney

3osead0ustmentreEuired

=eperidine(5ethidine)

ormeperidine C#toicity

Actie metao!ite hasrena! e!imination

3osead0ustmentreEuired

6entany! 9 5!asma proteinindin'" free dru'

C!earance not a!tered safe

#ufentani! 9 5!asma proteinindin'" free dru'


A!fentani! 9 /nitia! o! ofdistriution" freedru'


Remifentani!

o chan'e C!earance not a!tered safe

>pioids


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?a!othane /nor'anic uoride !ee!s are !ess oeprotoicity

/sourane /nor'anic uoride !ee!s are !ess oeprotoicity

3esurane /nor'anic uoride !ee!s are ery !ess hi'h!ysta!e G resists de'radation y soda-!ime G!ier

oeprotoicity

#eourane /nor'anic uoride !ee!s are !ess ut notsta!e de'raded y soda-!ime to compoundA G under'oes !ier metao!ism

Compound A isneprotoic

nurane Hiotranformed to inor'anic uoride !ee!safter pro!on'ed use (I 4hrs)

ephrotoicafter pro!on'eduse

=ethoyurane Hiotranformed to hi'h inor'anic uoride!ee!s

?i'h!ynephretoic

?olatile agents


14/18

Jhiopentone C# eect reersed yredistriution G hepaticmetao!ism a!so 8%, proteinound 9a!umin in uremia "free dru' more free un-ioniseddru' in acidosis

=etao!ismunchan'ed 9 ecretion

@sed in 9 dose

5ropofo! =etao!ised y !ier o aderse eect

tomidate =etao!ised y !ier partia! rena!ecretion

o aderse eect

Henodiaepines

=etao!ised in !ier G ecretedy idney !on'er actin' HL3accumu!ate " duration of action

" /ntera! or 9dose

I? agents


15/18

#ucciny!cho!ine

=etao!ised to non toic productshich are ecreted y idney"duration in #R3 a!so 9psedocho!inesterase in uremiaAssociated ith rapid transient "KM

(%.+mE>)

>on'er !oc in#R3 G uremiaCautious!y used inhypera!emia

Atracurium 3e'raded y enymatic esterhydro!ysis G non enymatic a!a!inede'radation (?omann e!imination) toinactie products

ot dependent onrena! e!imination

=iacurium =etao!ised y p!asma

psedocho!inesterase

>on'er !oc in

#R3Cis-atracurium NN, homann e!imination G 1, rena!

e!imination=i!d eect

Decuronium &%, rena! e!imination 5ro!on'ed duration

Rocuronium "Do! of distriution o chan'e inc!earence

5ro!on'ed duration

5ancuronium 4%-+%,rena! ecretion part!y ia !ess 5ro!on'ed duration

9uscle rela0ants


16/18

Aim to maintain adeEuate rena! perfusion:

Appropriate /D uid rep!acement

Aoid nephrotoic dru's

=aintain adeEuate =A5

Oincreased monitorin'

Anticipation of anaesthetic G sur'ica!!y inducedhaemodynamic instai!ity oth intra- and post-operatie!y

Reersa!: eosti'mine has +%, rena! ecretion

F!ycopyro!ate has 8%, rena! ecretion

/ncreased duration of !oc

/ntraoperatie mana'ement


17/18

Remain at ris of AK/

3ue to hypoo!aemia

=edications (#A/3#)

Residua! eects of anaesthesia

nsure adeEuate uid therapy

=ay e reEuirements for RRJ

5ost-operatie =ana'ement


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Rena! disease is common

=ana'ement ino!es: Food preoperatie assessment

#imp!e measures reduce ris

#@mmary

anaesthesia renal

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