PERI-OPERATIVE    RENALDYSFUNCTION
Dr. M.M.PANDITRAO        CONSULTANTDEPARTMENT OF ANAESTHESIOLOGY &        INTENSIVE CARE    RAND MEMORIAL HOSPITAL    FREE...
PERI-OPERATIVE RENAL    DYSFUNCTION Peri-operative Acute Renal Failure i. Pre-existing pre-op risk factor     ii. Intra-o...
POARF         : Principles• Pre-disposing pre-op risk factors• Physiology of Urine Production• Differentiate and Manage ca...
RISK FACTORS•   Systemic Diseases: CRF, DM,•   Jaundice•   Advanced Age•   Poor Myocardial Function•   Nephro-toxic drugs:...
PHYSIOLOGY OF URINE PRODUCTION•
AETIOLOGY OF POARF•   Pre-Renal     i. Ac.hypovolemia & hypotension         ii. Poor cardiac function             iii. Hep...
AETIOLOGY OF POARF (                     CONTD.)•      INTRINSIC ARF (RENAL)        i. Prolonged ischemia: aortic cross-  ...
PATHOPHYSIOLOGY OF RENAL ISCHEMIA                        RENAL ISCHEMIA                          >Decreased renal perfusio...
Diagnosing aetiology of ARF          urinary indices of ARF                                       PRE             INTRINSI...
Management of Intra-op Oliguria       prevention & treatment•   Euvolemic state + stable haemodynamics•   Patent Foley and...
Management of Intra-op Oliguriaprevention & treatment ( cont.)• If no Invasive --- 2 simple tests• Inspite of Volume loadi...
PERIOPERATIVEMANAGEMENT OF   ESRD/ CRF
End Organ Effects of ESRD NS – Uremia : sedation, fatigue, encephalopathy       - Ch. Dialysis : dementia, dialysis diseq...
End Organ Effects of ESRD              (cont.)• BLOOD: Anemia, Platelet dysfunction,         Blood Transfusion – Caution  ...
Pre-op. Concerns of ESRD• Strict evaluation of End-Organ damage• Review of last Dialysis record• Review of Aetiology of C ...
Intra-operative• INDUCTION:         Sensitivity to IVAs, etc.  multifactorial --- * hypoproteinemia                      *...
Intra-operative (cont.)•   INTRA-VASCULAR VOLUME•   AUTONOMIC NEUROPATHY•   L V DYSFUNCTION•   INHALATIONALS•   OPIOIDS•  ...
Post-operative• Reversal• Ventilatory Support ????• Nursing Care
CONCLUSION•   RENAL DYSFUNCTION IS A PROBLEM•   ESPECIALLY PERI-OPERATIVE ARF•   UNDERSTANDING AETIO-PATHO•   DIAGNOSING T...
Peri operative renal dysfunction by prof.mridul m panditrao
Peri operative renal dysfunction by prof.mridul m panditrao
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Peri operative renal dysfunction by prof.mridul m panditrao

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Prof. Mridul M. Panditrao explains the problem of Peri-operative renal dysfunction

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Peri operative renal dysfunction by prof.mridul m panditrao

  1. 1. PERI-OPERATIVE RENALDYSFUNCTION
  2. 2. Dr. M.M.PANDITRAO CONSULTANTDEPARTMENT OF ANAESTHESIOLOGY & INTENSIVE CARE RAND MEMORIAL HOSPITAL FREEPRT, GRAND BAHAMA COMMONWEALTH OF THE BAHAMAS
  3. 3. PERI-OPERATIVE RENAL DYSFUNCTION Peri-operative Acute Renal Failure i. Pre-existing pre-op risk factor ii. Intra-operative event ESRD /CRF Patient requiring care
  4. 4. POARF : Principles• Pre-disposing pre-op risk factors• Physiology of Urine Production• Differentiate and Manage causes• Effects of Anaesthetics and Surgery• Prevent insults of these on Kidneys
  5. 5. RISK FACTORS• Systemic Diseases: CRF, DM,• Jaundice• Advanced Age• Poor Myocardial Function• Nephro-toxic drugs: recently used• On CPB
  6. 6. PHYSIOLOGY OF URINE PRODUCTION•
  7. 7. AETIOLOGY OF POARF• Pre-Renal i. Ac.hypovolemia & hypotension ii. Poor cardiac function iii. Hepatic Failure• Post-Renal : Obstructive Pathology
  8. 8. AETIOLOGY OF POARF ( CONTD.)• INTRINSIC ARF (RENAL) i. Prolonged ischemia: aortic cross- clamping ii. Myoglobinuria iii. Haemoglobinuria : transfusion reaction iv. Nephro-toxics v. Renal Artery Thrombosis/ embolism vi. Renal Vein Thrombosis vii. Interstitial Nephritis/ Ac. GN/ Vasculitis
  9. 9. PATHOPHYSIOLOGY OF RENAL ISCHEMIA RENAL ISCHEMIA >Decreased renal perfusion Hypoxic injury to renal tubules Tubular endothelial swelling Vascular congestion within outer medulla Sloughing of tubular necrotic debris Tubular obstructionIncreased backpressure in Bowman’s capsule decreased GFR increased backleak of ultra-filtrate OLIGURIA
  10. 10. Diagnosing aetiology of ARF urinary indices of ARF PRE INTRINSICUrine Na+ (meq/ lit.) <20 >40Urine Osmo.(mosm/ lit.) >500 <350Fractional excretion of Na <1 >2( FeNa)*Renal Failure Index(RFI)** <1 >2Urine sediments Clear/ Brown casts granular casts • *FeNa = Urine Na/ Plasma Na X 100 ** RFI = Urine Na Urine creat/ Plasma Creat Urine creat/ Plasma creat
  11. 11. Management of Intra-op Oliguria prevention & treatment• Euvolemic state + stable haemodynamics• Patent Foley and adequate BP• CVP• Review Blood loss• Expand Blood volume• PA catheter & PCWP• Check Hb / Haematocrit / Urine for indices
  12. 12. Management of Intra-op Oliguriaprevention & treatment ( cont.)• If no Invasive --- 2 simple tests• Inspite of Volume loading  low C. O. Dopamine / Dobutamine / adrenaline• Loop Diuretics• Mannitol ?????• Under Trial : ANP & Urodilatin• Vasoactive renal protective drugs: PGs, Endothelin antagonists, Theophylline, Calcium Channel Blockers
  13. 13. PERIOPERATIVEMANAGEMENT OF ESRD/ CRF
  14. 14. End Organ Effects of ESRD NS – Uremia : sedation, fatigue, encephalopathy - Ch. Dialysis : dementia, dialysis diseqilibrium ** Sensitivity to sedatives/hypnotics/IVAs/ Inhalationals - Uremia : Peripherral & autonomic neuropathy*** autonomic Neuropathy - Haemodynamic instability$$ Medico-legal implications CVS – Hyperlipidemia—atherosclerosis --- hypertension—DM---IHD/ LVH/ LVF/ CHF Pericarditis ―Leaky Pulm. Capillary Syndrome‖--- Pulm.Oedema
  15. 15. End Organ Effects of ESRD (cont.)• BLOOD: Anemia, Platelet dysfunction, Blood Transfusion – Caution Uremic toxins• ELCTROLYTES: K+ : Ca+, PO4---, Bone ―Renal Osteodystrophy‖• ACIDOSIS : HCO3- ???• INFECTIVE : A-V Grafts / antibiotics Hepatitis
  16. 16. Pre-op. Concerns of ESRD• Strict evaluation of End-Organ damage• Review of last Dialysis record• Review of Aetiology of C R F• Avoid K+ containing I V fluids : R L• Review recent electrolytes, urea. Creatinine• Care and safety of A V Fistula
  17. 17. Intra-operative• INDUCTION: Sensitivity to IVAs, etc. multifactorial --- * hypoproteinemia * uremia * Free active metabolites * Met.acidosis… free fractionDose, Route, Speed, Concentration etc. of Inj.
  18. 18. Intra-operative (cont.)• INTRA-VASCULAR VOLUME• AUTONOMIC NEUROPATHY• L V DYSFUNCTION• INHALATIONALS• OPIOIDS• NMBDs : Benzylisoquinoliniums Vs. Amino-steroids Succinyl Choline
  19. 19. Post-operative• Reversal• Ventilatory Support ????• Nursing Care
  20. 20. CONCLUSION• RENAL DYSFUNCTION IS A PROBLEM• ESPECIALLY PERI-OPERATIVE ARF• UNDERSTANDING AETIO-PATHO• DIAGNOSING THE CAUSE• INVESTINGATING & MANAGING• ESRD / CRF VERY CHALLENGING

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