Download - Anaesthesia Renal
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Principles of the anaesthetic management ofpatient with renal failure
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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'
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=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'
C!earance not a!tered safe
A!fentani! 9 /nitia! o! ofdistriution" freedru'
C!earance not a!tered safe
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
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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
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#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
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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
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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