RENAL PATIENTS FOR VASCULAR ACCESS :

PERI-OPERATIVE MANAGEMENT

CHALLENGES, LESSONS LEARNT &

RECOMMENDATIONS!

PROF. MRIDUL M. PANDITRAO

CONSULTANTDEPARTMENT OF ANESTHESIOLOGY

PHA’S RAND MEMORIAL HOSPITALFREEPORT

GRAND BAHAMATHE BAHAMAS

Challenge Oriented Approach

• Related to the Primary pathology

• Related to the Surgical procedure

• Related to Anesthesia

• Related to Logistical/Infrastructural facilities

Primary Pathology:• CRF/CRD/CKD/ESRDS/Uremia• Defined as

http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm

Primary Pathology: Chronic Renal Failure

• One of the commonest problems we face• Variety of etiopathogenesis• Varied age group belonging to both the sexes• Most commonly elderly age group• Associated multiple co-morbidities• Multiple pharmacological agents• Multiple exposures for surgical procedures

Primary Pathology: Chronic Renal Failure

• Multi-systemic pathology

• Accumulation of CNS depressing substances

• Very large distribution volume

• Compromised excretory function

• Delay in the excretion of pharmacological agents

• Actions of all the drugs significantly prolonged

Systemic Effects of CRD• Cardiovascular system: Hypertension, ischemic heart disease, cardiac failure,

pericarditis (severe uremia)

• Respiratory system :Pulmonary edema, pleural effusion, respiratory infection

• Gastro-intestinal: Stress ulceration, delayed gastric emptying, malnutrition

• Central Nervous System :Peripheral neuropathy, autonomic neuropathy,

mental slowing, convulsions, coma

• Renal :Fluid and electrolyte imbalance, altered drug handling

• Haematological : Anemia, Coagulopathy

• Immunological : Immunosupression (physiological, pharmacological)

S.Rang, NL. West , J. Howard, J Cousins : Anaesthesia for Chronic Renal Disease and Renal Transplantatione a u - e b u update s e r i e s 4 ( 2 0 0 6 ) 246–256 www.europeanurology.com

Pharmacological effects of CRD

• Non-depolarizing neuromuscular blocking drugs– Unpredictable duration of action– Incomplete reversal of paralysis

• Antibiotics :Unwanted side effects: e.g. – Aminoglycosides: ototoxicity or nephrotocity

• Opioids: Unwanted side effects of active metabolites: e.g. – Morphine-6- glucuronide: respiratory depression

Dialysis

• Anesthesia and surgery should take place in a near normal physiological environment

• Therefore seems logical that dialysis should take place just before surgery.

• However, the dialysis process may itself cause physiological disturbance viz; – Fluid depletion and redistribution to extravascular

spaces resulting in depletion of intravascular volume– Electrolyte disturbance, especially hypokalaemia– Residual anticoagulation from heparinization of the

haemodialysis circuit.

Post- Dialysis

• Hypotension (Volume constriction) — 25 to 55 %– Acute episodic hypotension– Chronic persistent hypotension

• Cramps (Electrolyte disturbances)— 5 to 20 % • Nausea and vomiting — 5 to 15 % • Headache — 5%• Itching — 5 %• Petechiae/Oozing (Coagulopathy) — 2 to 5 %• Chest pain — 2 to 5 %• Back pain(Hemolysis) — 2 to 5 %• Fever and chills — Less than 1 %

Surgical Procedures

• Related to Primary pathology/Intervention – Vascular access for hemodialysis*

– Procedures for peritoneal dialysis– Renal transplantation

• Unrelated co-incidental pathology

Vascular Access:

• Temporary

• Permanent

Temporary

• Peripheral – Short • Peripheral – Midline • Central – Peripherally Inserted Central Catheter

(PICC) • Central – Tunneled Central Venous Catheter • Central – Percutaneous Non-Tunneled Catheter • Central – Implanted Port • Subcutaneous Infusions (Hypodermoclysis)

Temporary Catheter

Permanent:AV Fistula & Graft

AVF/AVG

Challenges

• Leading normal life is a stress

• Added stress of anesthesia and surgery

• Decompensate the patients

• Avoidable errors of judgment

• High Morbidity and Mortality

Challenges!

• Repeated/ multiple surgeries

• Increased degree of difficulty for surgery, successively

• Multiple procedures needed at the same time

• Increased surgical time ∞Increased anesthesia time

• Increased complications/ challenges

• Multiple exposure to GA: enzyme induction

Systems review & pre-operative preparation• GI Reflux: Delayed gastric emptying

– Antacid prophylaxis– Alteration of anaesthetic technique to protect airway

• Neurological: Peripheral neuropathy – Positioning on operating table– Pressure area care

• Autonomic neuropathy:– intraoperative hemodynamic instability– ???Intraoperative invasive blood pressure monitoring

• Anaesthetic drug/ dose alteration• Haematological : Anaemia

– Consider acceptable perioperative haemoglobin concentration• Immunological: Immunosupression

– Antibiotic prophylaxis• Steroid supplementation• Minimize invasive procedures

AnesthesiaAims& Objectives: • Ensure intraoperative patient comfort• Optimize surgical conditions• Minimize risk of anaesthetic complications,

e.g. Perioperative cardiac events,• Optimize postoperative state – avoidance of prolonged sedation, – minimize strong postoperative analgesia– avoid all possible complications

Anesthesia

• Two choices– General Anesthesia

– Regional technique: Supra-clavicular brachial Plexus Block

GA

• Anesthetic agents: IV or Inhalationals– Cardio-depressants– Arrythmogenic– Peripheral vasodilatation– Negative inotropism– No chance of poly-pharmacy– Fluid restriction– Co-morbidities

GA

• Conventional technique:– Pre-anesthetic medication: H2 blocker, pro-kinetic, – Intra-venous induction: Propofol, thiopentone– Neuro-muscular paralysis: Depolarizing/ Non-de– Airway management: ET intubation, LMA– Intra-op: Monitoring, fluid restriction– Reversal/ extubation– Post-operative analgesia– Recovery room: monitoring

Complications of GA

• Disrrythmias• Hypotension• Inability to use vasoconstrictors • Dependency on Inotropic support• Delayed recovery• Persistent neuro-paralysis• Difficulties in choice of Post-operative Analgesia

Regional

• Useful for temporary/ peripheral placement• Supra-clavicular Brachial plexus Block:• Single shot or Continuous catheter technique• Modalities– Ultra-sound Guided– Peripheral Nerve Locator guided– Blind technique

Limitations!

• Limited applicability• Useful only if distal/Forearm vessels planned• Relative contra-indications– Patient acceptability– More proximal vessels– Coagulopathy– Anticipated longer time required

Logistical/ Infrastructural

• Time constraints

• Human resources/ manpower

• Perception related

• Overall team approach

Time management

• Routine elective surgical hours: 6-8 hours/day• Average time required for one case: 90-120

minutes• Additional time lost between cases: 10-15

minutes• Effectively the number of case can be safely/

practically done : 3 major (GA)± 1 minor (LA)

Human resources/ manpower

• The multiple teams of health providers involved

• Limitations of staffing/ number

• Limitation of the available OR slots

• Excessive loading: errors/ morbidity &

mortality!

Consumables!

• Anesthetic medications/Equipment– Centrally acting α2 agonists : dexmedetomidine– Cardio-stable NMBDs : Rocuronium– “Turn on-Turn off’ Opioids: Remifentanil– Specific anti-cholinergics : Glycopyrrolate

• Other consumables: surgical/miscellaneous

Teams!!

• Co-ordination between the team members– The Renal team– The Admitting/Medical team– The Surgical team– The Anesthesiologists– The Nursing team• The Ward• The OR

– The Ancillary staff team

Our Experience/ evidence

1st April 2012 - 30th September 2013(18 Months)• Total Number of surgical procedures: 2661

• Day cases: 635• Inpatients: 2026

• Total number of renal cases:201• Percentage: 7.5%• Total number done under GA:103• Percentage: 3.9%• Morbidity/Mortality: 1 Death

Lessons learnt!

• Proper considerations to the “ground realities!”• Communication-communication-communication!• “Renal patients do not behave like normal patients• “ All Renal patients for LA/Regional/GA must have

pre- anesthesia assessment/optimization”• “Pre-operative dialysis not necessarily means

everything is OK!”

More Lessons learnt!

• “Over-enthusiasm is more harmful than having any benefits” especially : number of patients postings for surgery

• Intra-operatively:“ Anticipate the most unanticipated and be forewarned/ forearmed”

• “Mutual respect between team members/ specialties is of paramount importance”

• “This is an ongoing process and not the endpoint”

Recommendations!

General:• Practicality based planning for number of

patients to be posted for surgeries• Proper and in-depth preparation• Mandatory pre-anesthetic assessment • Post-dialysis review• Electrolytes/coagulation profile• Pre-anesthetic medication

Recommendations!General:• Co-ordination between the teams• Confirmation of the vascular access site before

siting IV cannula• Reserving the specific OR day exclusively for

vascular access cases• Having adequate infra-structural/ Human

resources support

Recommendations!Timing of preoperative dialysis :• Dialysis is usually scheduled about 12–24 hours prior

to surgery. • The ionic content of the dialysate may be altered to

influence the amount and composition of fluid removed

• Co-ordination between anesthesia and renal physicians pre-preoperatively is very important.

• A post-dialysis measurement of serum electrolytes is required before surgery – as dialysis induced electrolyte disturbance can predispose

to intraoperative cardiac dysrhythmias.

Recommendations!

Intra-operative (specific):

• Modifications in anesthetic approach

– Avoiding Cardio-inhibitory anesthetic agents!

• Intravenous induction to be voided; propofol/thiopentone

• Volatile Induction Maintenance Anesthesia(VIMA): sevoflurane …

3MAC →1-1.3 MAC

– Laryngeal Mask airway(LMA)/ Avoiding ETT

– Avoiding depolarizing/ Non-depolarizing NMBDs

Recommendations!– Balanced/ adequate intra-operative analgesia

(Avoiding excessive Intra-operative Use of Opioids)– Intra-operative Volume- restriction– Intra-operative Eternal vigilance/ excellent

monitoring and treatment• Hypotension: ephedrine in successive boluses/ avoiding

vasoconstrictors • Arrhythmias: good depth of anesthesia, Watchful Non-

intervention!

– Watch for surgical complications: hemorrhage/ oozing!

Recommendations!

Post-operative

• Impeccable Post –operative care:

– In Post-operative recovery room

• Continued same level of vigilance as in OR

• Balanced post-operative analgesia

– In the wards

• Intuitiveness on the part of staff/ doctors

• Promptness of action

Conclusion!

• CRF/ESRDS patients pose multiples of challenges

• Especially in peri-operative period• Whether for Vascular access/ Renal transplant

or co-incidental surgical procedure• Well coordinated team approach is an

absolute necessity• Communication is the key issue

Conclusion!

• Vascular access is an absolute necessity• With functioning temporary access in place• Permanent access must be achieved in

planned/elective manner• Logistical and ‘ground realities’ need to be

taken in to consideration• Well planned protocol based peri-operative

management is desirable/ mandatory

Take Home Message!!!!

No Justification in having additional Morbidity/ mortality, than inherent

to the primary pathology due to inadequate/improper planning,

Overzealousness &

Non-coordination!!

Thank

You!