Transcript 3 MB - renal failure

ANAESTHETIC MANAGEMENT OF
PATIENTS WITH AV FISTULA FOR
INCIDENTAL SURGERY
?
Dr.S.Parthasarathy
MD DA DNB
Books , laptop, internet ??
Cell phones to many
professors??
Topic??
 Anaesthetic management of
patients with chronic renal
failure on haemodialysis
Causes of CKD
 Diabetes,
 Hypertension
 CGN
 Polycystic disease
 Analgesics
Why should we know
 CKD - increased surgical morbidity
 Due to
 Acute renal failure
 Volume overload,
 Infections,
 Hyperkalemia(K+)
 (KAVI)
GFR
 Mild 60-90 ml/min.
 Moderate 30-60 ml/min.
 Severe 15-30 ml/min.
 Less than 15 – hemodialysis
Preop
 Symptoms and
signs –
undetectable.
Cardiovascular system
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Increased risk of vascular death
Dyspnoea
Orthopnoea
Edema
Hypertension
Autonomic neuropathy
Arterial stiffness and LVH
Increased cardiac output
Cardiovascular system
 Pericarditis
 Associated CAD
 Elevated troponin levels
 Elevated pulmonary art. Pressure
20 to 40 !!
 Temp. closure of AVF decreased PAP !!
hyperparathyroidism
 Calcific valvular diseases
 AS, MR, endocarditis
 H/O syncope
 Not only IHD but AS
 Look for hair in lower limbs
Nil means undiagnosed PAD !!
 Associated problems
 Acidemia, hyperkalemia,
 hyper or hyponatremia
Hematological system
 Anemia
 60 -80 % of CRF
 WHY ?
 BM fibrosis
 Erythropoietin def.
 ↑ osmotic fragility
 Maintain haematocrit 30%
Coagulation problems
 Platelet dysfunction
 All tests normal but they will bleed.
 Rarely dialysis –
 can activate platelets to produce thrombotic
episodes and pulmonary embolism.
Coagulation problems
 Heparin induced throbocytopenia
 LMWH– ok
 But severe bleeding reported
 Tinazaparin ideal
GI system
 Liver dysfunction due CVC
 Viral hepatitis
 Delayed gastric emptying (autonomic
neuropathy)
Nervous system
 Uremic neuropathy
 Mixed mainly lower limbs
 Beware – regional !
Diagnostic testing
 Hb
 CBC
 Platelet
 Coagulation profile,
 Blood urea ,sugar, creatinine, electrolytes
 ECG, CxR, ABG
 ECHO, creatinine clearance
Premed.
 Sensitive to sedatives and narcotics
 Temazepam
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ranitidine
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 No to pethidine ,anticholinergics
 Fentanyl in low doses OK
Premed.
 Insulin infusion
 Corticosteroids.
 Antibiotics
 to continue
Talk to patients – IV access
everywhere pricked!
Care of AV fistula
Care of AV fistula
 Keep the access site clean at all times to prevent
infection.
 Avoid injections, intravenous (IV) needles or
fluids, or taking blood samples in the access site
arm.
 Needle insertions for hemodialysis treatments
should be rotated so that one spot is not
repeatedly stuck and weakened.
 Do not take blood pressure or put pressure on
the access arm.
Care of AV fistula
 Advise patients to avoid wearing jewelry or
tight clothing, sleeping on, or lifting heavy
objects with the access arm.
 Check the temperature and color of the fingers
and the pulse of the access arm for adequate
circulation. (steal syndrome)
 Use your access site only for dialysis.
 Use color doppler for patency of AVF
AV fistula
Anaesthesia
 All patients to be dialysed 24 hours before
any anaesthesia
 Electrolytes acid base fluid problems get
corrected fast but coagulation defects take
24 hours
Anaesthesia
 Atracurium and isoflurane are ideal
 Scoline is acceptable if needed --
if preop dialysis stabilized K+ values.
 FiO2 0.4 may be needed.
Periop myocardial protection
 Beta blocker therapy
 Maintain 50 – 60 beats /min.
↓ CAD risk
 Patients may be on other drugs like tegritol,
cyclosporin ,diltiazem ,theophyllines
 Think of drug interactions.
Fluids intraop
 Insensible loss -- 5% dextrose – 500 ml/ day
 Urine output -- 0.45 % saline
 Blood -- fresh NS washed packed red cells
 Third space loss – 2-5 ml/kg/hour
 No potassium containing fluids
Monitoring
 Routine +
 NMJ +
 A dialysis unit ready
 No NSAIDS
 No nephrotoxins
 Maintain Blood pressure, CVP, urine output,
electrolytes, acid base,
Regional is ok
 No narcotics,
 No muscle relaxants
 No intubation – no pulmonary infections
 No aspiration
 But neuropathy, autonomic and peripheral,
coagulation problems are limitations.
Iodinated radio contrast
material
 Precipitate ARF
 Possibly
 Use oral acetyl cysteine
 Sodabicarb with 0.45 % saline to prevent ARF.
Post op care
 Recurarization
 Normovolumia
 Urine output
 Oxygen
 And a team work of nephro, surgeon and
anaesthesiologist
In short
 Preop assessment of kidney and systemic
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illness – anemia,coagulation and CAD in
particular
No atropine/pethidine,
Preop dialysis
GA – atracurium and isoflurane ideal
Protect AV fistula
Regional is optimal,
Asepsis and hepatitis precautions. No NSAIDs
Maintain urine, electrolytes, volume