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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

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

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  • 1. PERI-OPERATIVE RENALDYSFUNCTION
  • 2. Dr. M.M.PANDITRAO CONSULTANTDEPARTMENT OF ANAESTHESIOLOGY & INTENSIVE CARE RAND MEMORIAL HOSPITAL FREEPRT, GRAND BAHAMA COMMONWEALTH OF THE BAHAMAS
  • 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. 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. RISK FACTORS• Systemic Diseases: CRF, DM,• Jaundice• Advanced Age• Poor Myocardial Function• Nephro-toxic drugs: recently used• On CPB
  • 6. PHYSIOLOGY OF URINE PRODUCTION•
  • 7. AETIOLOGY OF POARF• Pre-Renal i. Ac.hypovolemia & hypotension ii. Poor cardiac function iii. Hepatic Failure• Post-Renal : Obstructive Pathology
  • 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. 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. 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. 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. 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. PERIOPERATIVEMANAGEMENT OF ESRD/ CRF
  • 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. 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. 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. Intra-operative• INDUCTION: Sensitivity to IVAs, etc. multifactorial --- * hypoproteinemia * uremia * Free active metabolites * Met.acidosis… free fractionDose, Route, Speed, Concentration etc. of Inj.
  • 18. Intra-operative (cont.)• INTRA-VASCULAR VOLUME• AUTONOMIC NEUROPATHY• L V DYSFUNCTION• INHALATIONALS• OPIOIDS• NMBDs : Benzylisoquinoliniums Vs. Amino-steroids Succinyl Choline
  • 19. Post-operative• Reversal• Ventilatory Support ????• Nursing Care
  • 20. CONCLUSION• RENAL DYSFUNCTION IS A PROBLEM• ESPECIALLY PERI-OPERATIVE ARF• UNDERSTANDING AETIO-PATHO• DIAGNOSING THE CAUSE• INVESTINGATING & MANAGING• ESRD / CRF VERY CHALLENGING