7. Renal Dialysis Surgery


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  • 7. Renal Dialysis Surgery

    1. 1. Renal Dialysis and Surgery By Andrew Trang
    2. 2. Introduction <ul><li>Patients with End Stage Renal Disease (ESRD) requiring dialysis have an increased morbidity and mortality. </li></ul><ul><li>They appear to require significantly increased medical support and have longer stays in ICU and on the wards. </li></ul>
    3. 3. Surgical Morbidity & Mortality cont. <ul><li>Factors contributing to this include: </li></ul><ul><ul><li>A higher incidence of coronary artery disease and myocardial infarctions </li></ul></ul><ul><ul><li>Difficulty adjusting fluids and electrolytes </li></ul></ul><ul><ul><li>Failure to excrete and/or metabolise anaesthetics and analgesics </li></ul></ul><ul><ul><li>Increased bleeding complications </li></ul></ul><ul><ul><li>Poor blood pressure control </li></ul></ul>
    4. 4. Approach to medical management <ul><li>The general issues concerning the optimum medical management of a dialysis patient undergoing surgery include: </li></ul><ul><ul><li>Preoperative evaluation </li></ul></ul><ul><ul><li>Delivery of dialysis during the period surrounding the surgery </li></ul></ul><ul><ul><li>Intraoperative concerns (incl. anaesthesia) </li></ul></ul><ul><ul><li>Post operative management (eg. Pain control) </li></ul></ul>
    5. 5. Medical Mx of a dialysis patient for surgery <ul><ul><li>General laboratory evaluation </li></ul></ul><ul><ul><li>Anaemia status </li></ul></ul><ul><ul><li>Nutritional status </li></ul></ul><ul><ul><li>Fluid & electrolyte management </li></ul></ul><ul><ul><li>Blood pressure control </li></ul></ul><ul><ul><li>Evaluation for CVD </li></ul></ul><ul><ul><li>Antibiotic administration </li></ul></ul><ul><ul><li>Glycaemic control </li></ul></ul><ul><ul><li>Anaesthetic considerations </li></ul></ul><ul><ul><li>Pain control </li></ul></ul>
    6. 6. General laboratory evaluation <ul><li>Baseline values </li></ul><ul><ul><li>ELECTROLYTES </li></ul></ul><ul><ul><li>COMPLETE BLOOD COUNT </li></ul></ul><ul><ul><li>Coagulation profile </li></ul></ul><ul><ul><li>Any other specific tests relating to the individual </li></ul></ul><ul><ul><ul><li>Serum concentration of certain drugs (eg. digoxin) </li></ul></ul></ul><ul><ul><ul><li>BGL in diabetic patients pre- and postoperatively </li></ul></ul></ul>
    7. 7. Anaemia status <ul><li>Is the surgery elective and planned weeks to months in advance? </li></ul><ul><li>Aim to increase haemoglobin concentrations to the high therapeutic ranges through the use of erythropoesis stimulating agents (ESAs). </li></ul><ul><li>Why? </li></ul><ul><ul><li>Post operative state is characterised by ESA resistance and transfusions frequently necessary due to intra- or post operative blood loss </li></ul></ul>
    8. 8. Nutritional status <ul><li>Healing ability postoperatively is maximised by ensuring that the dialysis patient is well nourished. </li></ul><ul><ul><li>Adequate amounts of dialysis promote a healthy appetite </li></ul></ul><ul><ul><li>Elimination of medications which impair appetite </li></ul></ul><ul><ul><li>Nutritional supplements </li></ul></ul>
    9. 9. Fluid & electrolyte management <ul><li>If the surgery is elective, fluid and electrolyte levels should be optimised with dialysis </li></ul><ul><ul><li>Electrolyte levels </li></ul></ul><ul><ul><ul><li>Avoiding hypercalcemia/hyperkalemia in the post dialysis period </li></ul></ul></ul><ul><ul><li>Volume status </li></ul></ul><ul><ul><ul><li>Achieving an optimum volume state is based on correctly estimating the amount of fluid to be administered/lost during surgery </li></ul></ul></ul>
    10. 10. Fluid & electrolyte management cont. <ul><li>If the surgery is emergent </li></ul><ul><ul><li>Hyperkalemia is the most important electrolyte abnormality that needs to be addressed. </li></ul></ul><ul><ul><ul><li>Preoperative assessment </li></ul></ul></ul><ul><ul><ul><ul><li>12 lead ECG to assess physiologic effect of hyperkalemia. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If there are no ECG changes, the patient is stable and serum K + is <6.5 meq/L – the patient is able to safely undergo emergency surgery with close monitoring. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If ECG feature of hyperkalemia are present and dialysis cannot be performed, medical management is initiated (glucose and insulin). </li></ul></ul></ul></ul>
    11. 11. Blood pressure control <ul><li>Hypertension is usually the result of volume overload </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Optimise volume via fluid removal with dialysis. </li></ul></ul></ul><ul><ul><ul><li>If BP remains high despite achieving euvolemia or if surgery is emergent, intravenous antihypertensive therapy (eg. enalaprilat, labetalol, hydrazaline, diltiazem, nitroglycerin) is required. </li></ul></ul></ul>
    12. 12. Blood pressure control cont. <ul><li>Hypotension may be a result of: </li></ul><ul><ul><li>Excessive fluid removal in dialysis </li></ul></ul><ul><ul><li>Left ventricular dysfunction </li></ul></ul><ul><ul><li>Pericardial tamponade </li></ul></ul><ul><ul><li>Vasodilatation from opioid analgesic or other medications given to relieve pain/anxiety </li></ul></ul>
    13. 13. Evaluation for CVD <ul><li>A study in 1994 which used a risk stratification in patients with ESRD based on age, history of angina, type 1 diabetes , congestive heart failure and ECG abnormalities. </li></ul><ul><ul><li>50% of these patients did not have any of these RF and no further cardiac testing was performed (low risk group) </li></ul></ul><ul><ul><li>Patients with one or more RF underwent thallium myocardial scintigraphy (high risk group). </li></ul></ul><ul><li>The overall cardiac mortality was 17% to 1% for the high risk groups compared to the low risk groups, respectively. </li></ul><ul><ul><li>In the high risk group, patients with reversible thallium defects had significantly higher cardiac mortality rates than those without (23% vs 5%) </li></ul></ul>
    14. 14. Evaluation for CVD cont. <ul><li>Identifying high risk patients and referring on for non-invasive studies may lead to preoperative procedures that may reduce peri-operative morbidity. </li></ul>
    15. 15. Antibiotic administration <ul><li>Peri-operative antibiotic therapy should be administered in accordance with general surgical principles </li></ul><ul><ul><li>Associated with fewer surgical site infections than those who did not in numerous studies. </li></ul></ul>
    16. 16. Glycemic control <ul><li>35% of dialysis patients are diabetic </li></ul><ul><li>Diabetic patients glycemic control at home is much better than in the hospital </li></ul><ul><ul><li>Acute co-morbid conditions </li></ul></ul><ul><ul><li>Change in physical activity </li></ul></ul><ul><ul><li>Inability to ingest food (ie. Preparation for surgery) </li></ul></ul><ul><li>Management of a diabetic patients with ESRD involve: </li></ul><ul><ul><li>Close monitoring of BGL </li></ul></ul><ul><ul><li>Fasting patients should have IV fluids with dextrose and insulin coverage </li></ul></ul>
    17. 17. Anaesthetic considerations <ul><li>The metabolism of different anaesthetic agents vary in patients with renal failure. </li></ul><ul><li>It is preferable to use agents that are not excreted by the kidneys or to adjust the doses accordingly </li></ul>
    18. 18. Pain control <ul><li>Paracetamol is able to be used without dose modification </li></ul><ul><li>Fentanyl is the opiate of choice due to its lack of active metabolites and unchanging free fraction </li></ul><ul><li>Morphine should be cautiously used in patients with renal failure. Its metabolites (M3G, M6G) have prolonged T 1/2 as is the sedative effects </li></ul>
    19. 19. Conclusion <ul><li>Although patients on renal dialysis have a poorer morbidity and mortality, careful preoperative assessment as well as close peri- and postoperative monitoring help improve the patient’s surgical outcome. </li></ul>