ANAESTHETIC CONSIDERATIONS IN CRF

1. ANAESTHETIC CONSIDERATIONS
IN CHRONIC RENAL FAILURE(CRF)
MODERATOR: DR ATRIVARADA
ASSISTANT PROFESSOR
DEPARTMENT OF ANAESTHESIOLOGY, MIMS
SPEAKER: DR V.SRAVANI
Dr.Sravani Vishnubhatla

2. INTRODUCTION
The National Kidney Foundation –
✓ About 67,000 people die of CRF every year
✓ In 2000 - nearly 47,000 pts were waiting for KT
✓ Acute shortage of donor kidneys
✓ Only a small percentage of patients receive a kidney
✓ Wait for a donor kidney can take several years
Dr.Sravani Vishnubhatla

3. CRF- PATHOPHYSIOLOGY
✓ It is the irreversible deterioration in renal function which
classically develop over a period of months to years
✓ Pathology – small, scarred, shrunken contracted kidneys.
Big & small nephrons. Glomerular hypertrophy. Normal
tubules. Tubular casts +
✓ Stages of CRF
1. Renal reserve (upto 50% nephrons damaged, no s/s)
2. Renal insufficiency
3. Frank renal failure
4. Uremia
5. Chr. hemodialysis
Dr.Sravani Vishnubhatla

4. STAGING OF CHRONIC KIDNEY
DISEASE
≥ 90
60‐89
30‐59
15‐29
<15
STAGE DESCRIPTION
GFR
(mL/min/1.73 sq m)
1.Kidney damage with normal
or ↑ GFR
2.Mild ↓ GFR
3.Mod. ↓ GFR
4.Severe ↓ GFR
5.Kidney failure
≥ 90
60‐89
30‐59
15‐29
<15
Dr.Sravani Vishnubhatla

5. CHRONIC RENAL FAILURE
COMMONEST CAUSES
✓ Diabetic Nephropathy
✓ Hypertensive Nephrosclerosis
✓ Chronic Glomerulonephritis / Pyelonephritis
✓ Polycystic Disease
✓ Vesicouretral reflux
✓ Hemolytic Uremic syndrome
OTHER CAUSES
✓ Lupus erythematosus (SLE), Wegener’s granulomatosis,
congenital anomalies, vasculitis, polyarteritis nodosa,
rheumatoid arthritis, gout, amyloidosis, myelomatosis,
sarcoidosis, Burns
5
Dr.Sravani Vishnubhatla

6. CRF
ROLE OF ANESTHETIST
Elective / Emergency
✓ Endoscopy
✓ Cystectomy
✓ Prostate surgery
✓ PCNL, ECSWL, lithotripsy
✓ Creation / revision of AV fistula
✓ Renal – Nephrectomy, drain insertion, pyeloplasty, KT
✓ Pediatric- PU valve fulguration , circumcision
✓ Non Renal Surgery
Dr.Sravani Vishnubhatla

7. S/S are due to uremia
✓ Hematuria
✓ Azotemia
✓ Hypertension
✓ Metabolic acidosis / Alkalosis
Patient dependent on Dialysis
CAUSE HAS NO EFFECT ON TREATMENT DECISION
CRF
Dr.Sravani Vishnubhatla

8. CRF
Dr.Sravani Vishnubhatla

9. CRF- MANIFESTATIONS
1. Hematological
2. Metabolic
3. Cardiovascular
4. Pulmonary
5. Neurological
6. GIT
7. Endocrine
8. Skeletal
9. Cutaneous
10. Sepsis
11. Nutritional
12. Drug therapy
13. Chronic dialysis
Dr.Sravani Vishnubhatla

10. HEMATOLOGICAL MANIFESTATIONS
✓ Anemia (Acceptable - Hb 5-7gm% (pcv 15-25%)
✓ Platelet & WBC dysfunction
✓ Dialysis induced hypercoagulopathy
Causes of anemia
1. Decreased Erythropoesis
2. Fe deficiency -
3. Increased RBC fragility
4. Increased bleeding tendency -
5. Folate deficiency
6. Intrinsic causes- Na-K-ATPase activity, pentose
phosphate dysfunction, microangiopathic hemolysis 10
Dr.Sravani Vishnubhatla

11. ANEMIA – CONT
Consequences
✓ ↓-lead to decreased O2 content, O2 carrying capacity, SpO2,
pO2
✓ Prone to hypoxemia – poor reserve
✓ Rapid induction & emergence from inhalational agents
✓ Risk of myocardial ischemia / CCF / Pulmonary edema
Compensations
✓ ↑ 2,3-DPG ( but less than expected )
✓ Shift of ODC to R ( due to ↑ DPG & Acidemia)
✓ ↑ Cardiac output (mainly by tachycardia)
✓ Cardiomegaly
Need Higher FiO2 ( 50% N20 in O2) 11
Dr.Sravani Vishnubhatla

12. ANEMIA
Management
✓ Erythropoetin , Fe, Folic acid
✓ Blood transfusion
Indication of BT
✓ Maintain pcv of 15-25%
✓ Preoperative to KT (? improved graft survival)
✓ Intra operative hypotension / blood loss
✓ Packed washed RBCs ( leukocyte free) preferred
✓ Risk of induction of additional antibodies & risk of graft
rejection with whole BT
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Dr.Sravani Vishnubhatla

13. ERYTHROPOIETIN
Advantage
✓ I/V or S/c
✓ Supplement with Fe & Folic acid
✓ Improves Hb ,exercise tolerance
Disadvantage
✓ Expensive
✓ Increases blood viscosity
✓ Risk of cerebral thrombosis & CVA
✓ Risk of thrombosis of shunt/fistula
✓ Convulsions
✓ Derangement of LFT
✓ Hyperkalemia (improved appetite & food intake)
✓ ‘Flu’ like syndrome
Dr.Sravani Vishnubhatla

14. CRF- COAGULOPATHY
✓ ↑Bleeding time - ↓platelet quality and quantity ,
✓ ↓ Vitamin K dependent factors (II, VII, IX, X )
✓ ↓ Factor V and VIII
✓ Heparinization (maintain patency of shunt)
✓ Sub clinical diffuse DIC
✓ ↑BT, PT & PTT normal
Management
1. Hemodialysis restores platelet function
2. FFP, cryoprecipitate & desmopressin reduce bleeding
tendency
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Dr.Sravani Vishnubhatla

15. CRF- ELECTROLYTE DISTURBANCE
✓ Hyperkalemia- esp. if oliguria +
✓ Hypermagnesemia – mild, sec to antacids,  renal exc.,
(CNS & myoc & N-M depression)
✓ Hyperphosphatemia- (Ca X PO4 = >60)
✓ Hyponatremia-Urinary loss, Salt restriction, Vomiting
✓ Hypocalcaemia – (sec to PO4 & GI absorption)&
Metastatic deposition- common, no s/s (except if alkalosis+)
✓ Metabolic acidosis - H+ retention
Uncommon – hypernatremia, hypokalemia
Most disturbances improve with dialysis
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Dr.Sravani Vishnubhatla

16. CRF-HYPERKALEMIA
Factors precipitating Hyperkalemia ( AVOID)
✓ Hypoxia
✓ Acidosis
✓ Suxametonium
✓ Hypercapnia
✓ Collins solution
✓ CAPD ( K higher than on HD)
Diagnosis
ECG – tall peaked T waves, ST depression, wide QRS, VPCs,
(Digitalis toxicity ( ↓QT interval, ST ↓, T↓, bigeminy /
trigeminy.Greater risk if hypocalcaemia +)
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Dr.Sravani Vishnubhatla

17. Management (aim- Preop S. K < 5.5 mEq/Lt)
✓ Dialysis- HD up to 50 mEq K/h & PD 15 mEq/h
✓ Hemofiltration
✓ IV 500 ml D10 +50 mEq HCO3+10 U Insulin
✓ 500 – 1000 mg Ca gluconate / chloride
✓ In diabetics – 1 U insulin / 2 G glucose
✓ 100 ml each of D50+10% Ca gluco + Hco3+24 u Insulin
over 1 hr
✓ Cation exchange resin - sodium polystyrene So4
(Kayexalate 1 g binds 1mEq K & releases 1.5 mEq Na)
rectal / Oral dose = 20g in 100 ml 20% Sorbitol)
CRF-HYPERKALEMIA
Dr.Sravani Vishnubhatla

18. CRF- METABOLIC
✓ Metabolic Acidosis
✓  K, Mg, Po4, uric acid
✓  Na, Ca, Albumen
Acidosis HCO3 mEq/L pH Rx
Moderate 10-20 7.2-7.3 nil
Severe < 10 < 7.2 active
Increased risk of arrhythmias
Management
HCO3 (0.2 x body wt x base deficit (1/2 dose. Reassess after 2 hrs)
Dangers of HCO3–volume overload, tetany, metabolic alkalosis
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Dr.Sravani Vishnubhatla

19. CARDIO VASCULAR MANIFESTATIONS
✓ Hypertension ( cause or effect of CRF) Refractory in 15%
✓ Rx- salt & Fluid restriction, β blockers,clonidine, methyldopa,
hydralazine, guanethidine, CaChBs, HD, renal A
endarterectomy / Nephrectomy
✓ CAD,CCF& CVA
✓ Painless Pericarditis, Pericardial effusion
✓ Rx- Dialysis for about a week helps, intra pericardial steroid
injection, pericardiectomy
✓ Increased risk of myocardial ischemia / infarction
✓ Arrhythmias
✓ Vascular calcification
✓ Accelerated atherosclerosis
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Dr.Sravani Vishnubhatla

20. PULMONARY MANIFESTATIONS
✓ Pulmonary infections
✓ Pulmonary atelectasis
✓ Pleural effusion
✓ Uremic lung - alveolar / interstitial edema,
hyperventilation
✓ COPD / Emphysematous changes
✓ Restrictive lung disease
✓ Posture & alteration in PFT
✓ Elderly patients
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Dr.Sravani Vishnubhatla

21. NEUROLOGICAL MANIFESTATIONS
✓ General - irritability, fatigue, depression
✓ Autonomic neuropathy
✓ Peripheral neuropathy- tingling, numbness, paresthesia,
pain in extremities (Median N & Peroneal N involved
commonly). RESTLESS LEG SYNDROME
✓ Myopathy – muscle weakness, muscle twitching
✓ Dementia – Aluminium toxicity (in dialysis fluid & antacids)
✓ Convulsions (Cerebral edema)
✓ Encephalopathy - asterexis, clonus, lethargy, confusion,
seizures, coma
✓ Sensory deficits - rare
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Dr.Sravani Vishnubhatla

22. GI MANIFESTATIONS
✓ Anorexia-NAUSEA AND VOMITING
✓ Acidity – Ranitidine preferred (cimetidine - exc via kidney, inhibits C-
P450, BM depression)
✓ Slow gastric emptying- risk of regurgitation & aspiration
✓ Ulcers- gastric/ duodenal (avoid Al / Mg antacids)
✓ GI Bleeds
✓ Adynamic Ileus
Dr.Sravani Vishnubhatla

23. ENDOCRINAL MANIFESTATIONS
✓ Secondary Hyperparathyroidism
✓ Glucose intolerance
✓ Hypertriglyceridemia
Hyperparathyroidism
✓ sec to hypocalcemia & Hyperphosphatemia
Consequences
✓ Bone decalcification, risk of fractures
✓ Osteodystrophy
✓ Metastatic calcification – skin, joints
✓ Pruritis
Dr.Sravani Vishnubhatla

24. Skeletal Manifestations
➢ Osteodystrophy
➢ Periarticular calcification
➢ Prone to fractures
Careful handling and positioning
Cutaneous Manifestations
➢ Hyper pigmentation
➢ Ecchymosis
➢ Pruritis
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Dr.Sravani Vishnubhatla

25. SEPSIS
Most common cause of death
Increased risk of infection
✓ immunity
✓ Immunosuppression
✓ Steroid therapy
✓ Serum hepatitis following dialysis – attendant also at risk-
screening 6 mthly
✓ TB very common- may have no chest signs
✓ viral, atypical infections (CMV, mycoplasma pneumonia,
legionelle pneumonia, influenza pneumonia)
Use ALL aseptic precautions
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
Dr.Sravani Vishnubhatla

26. DIETARY CONSIDERATIONS
1. High caloric (90% cal) (1 L D50 + 40-60 U insulin /day keeps
blood sugar <200 mg/dl
2. Salt restricted diet
3. EAA
4. Albumin .5-.8 g/kg/day
5. Glucose better than Fructose/ Sorbitol in Intralipid
6. If daily HD - replace K & maintain Na 130-135meq/L
7. Ca+ not needed
8. Check S.PO4 twice a week & weekly Zn, Mg
9. H2O soluble vitamins lost during HD- replace
10. Folic acid 10 mg / day
11. Fluid - 0.5 L + daily urine volume
12. Fluid loss in HD = 2 L/day, & PD 1-2 L/day
Dr.Sravani Vishnubhatla

27. PRE OPERATIVE DRUG THERAPY
✓ Antihypertensive
✓ Beta blockers
✓ CaChB
✓ Steroids
✓ Antibiotics
✓ Immunosuppressant
✓ Antacids
✓ H2 blockers
✓ Digitalis
✓ Antiarrhythmics
✓ Diuretics
✓ Bronchodilator
✓ OHA/INSULIN
✓ Heparin
✓ Aspirin
✓ Bicarbonate
✓ Calcium
✓ Iron, Folic acid, Vit B12
Dr.Sravani Vishnubhatla

28. IMMUNOSUPPRESSANTS
1. Steroids
2. Anti metabolites - Azathioprine, Cyclosporin,
Cyclophosphamide
3. Antibodies - Retro placental γ globulin -RPGG, Anti
lymphocytic globulin (ALG), Anti-thymotic globulin (ATG),
Monoclonal antibodies
4. Total lymphocytic irradiation
5. Thoracic duct drainage, plasma/ leukophresis
6. Newer antirejection drugs - Tacrolimus, Sirolimus,
Mizoribin (less S/E & useful after episodes of rejection)
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Dr.Sravani Vishnubhatla

29. STEROIDS
✓ To prevent graft rejection
✓ To prevent adrenal insufficiency post op (Chr steroid
therapy) (hydrocortisone 100 mg tds / qid)
✓ Premed-100 mg Hydrocortisone H.S & at 6 a.m.
✓ At induction- 300 mg hydrocortisone /1g Inf methyl
prednisolone
✓ Post op – continue.
✓ Reduce by 20% / day from 3rd day onwards. If complications
– may have to increase dose
✓ Maintenance – dose tailored to patient’s need
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Dr.Sravani Vishnubhatla

30. Side effects
✓ Easy bruising
✓ Osteoporosis
✓ Avascular necrosis (bone death)
✓ High blood pressure
✓ High blood sugar
✓ Peptic ulcers
✓ Weight gain
✓ Acne, mood swings, round facies
Management
✓ Reduce the maintenance dose
✓ Replace with other drugs
STEROIDS
Dr.Sravani Vishnubhatla

31. CYCLOSPORIN
✓ Fungal peptide metabolized by enzyme P 450
✓ Specific against T lymphocytes
Advantage
✓ Less rejections
✓ No effect on blood glucose- indicated in DM
Disadvantage
✓ Expensive
✓ Nephrotoxic
✓ Gum hypertrophy, tremors, hypertension
✓ Hirsuitism
✓ Difficult in diagnosing acute rejection
✓ Potentiates action of - NDMRs, Propofol, phenytoin,
phenobarbs, antiepileptic, cimetidine, nifedipine
Dr.Sravani Vishnubhatla

32. Azathioprine
✓ Slows production of T cells
✓ Used for long-term maintenance
Side effects
✓ Bone marrow suppression
✓ Liver damage
Many transplant centers are now using a newer drug called
Mycophenolate Mofetil instead
Dr.Sravani Vishnubhatla

33. CHRONIC HEMODIALYSIS
BENEFITS +++++
Problems
✓ Hepatitis B
✓ ↓ S. pseudo cholinesterase levels +-
✓ Prolonged gastric emptying time during dialysis (300 min
in uremia, +-700 min during dialysis)
✓ Psychological disturbances
✓ Infections
✓ Chronic refractory ascitis
✓ Hypersplenism
✓ Rebound Heparanization – 6-12 hrs post dialysis 33
Dr.Sravani Vishnubhatla

34. What Dialysis cannot correct?
✓ Refractory HT
✓ Pericarditis
✓ Infertility
✓ Sexual dysfunction
✓ Osteodystrophy
What new with Dialysis?
Dialysis disequilibrium syndrome (dialysis >5-6 yrs) –
headache, N,V, muscle twitching, convulsions, coma,
death
Prevention – frequent, shorter duration, slower dialysis
CHRONIC HEMODIALYSIS
Dr.Sravani Vishnubhatla

35. INDICATIONS FOR DIALYSIS
✓ Fluid overload
✓ Hyperkalemia (>7 mEq/L)
✓ Severe acidosis (pH <7 & HCO3 < 12mEq/L)
✓ High S. creatinine ( > 7mg%)
✓ Raised BUN >150 mg% & Urea > 300 mg%
✓ Metabolic encephalopathy
✓ Coagulopathy
✓ Drug toxicity
✓ Pericarditis
✓ Worsening condition despite Rx
Dr.Sravani Vishnubhatla

36. Dartmouth Medical centre – Pre KT
Investigations
1. Physical exam
2. Chest X-ray
3. ECG
4. Blood count, chemistry, clotting
5. Viral tests- Hepatitis, CMV, Epstein-Barr (EBV), AIDS
6. Blood and tissue typing - Blood Group of both donor & recipient
7. Panel Reactive Antibody (PRA) - measures the activity of immune system (lower PRA – less rejection) PRA
increases with BT, pregnancies, previous KT, infection
8. Dental exam –pt must have good oral health (risk of post-op infections) Also need Dental every year while waiting
for KT
9. Mammogram – in female pts >40 yrs old
10. Pap smear – in female pts >18 yrs old
11. Prostate exam & PSA test – in male pts > 50 yrs age
12. Colonoscopy – in all men > 40 yrs old & all women > 50 yrs old
13. Stress echocardiogram
14. MRI – to examine blood flow to legs
15. Dexascan X-ray to check bones density
16. PFT
17. Upper gastrointestinal (GI) series – ensure no GI disease
Dr.Sravani Vishnubhatla

37. CRF- PREOP INVESTIGATIONS
✓ Hemogram with complete counts
✓ Urinalysis- R/ ME/ DCS
✓ Electrolytes – Na, K, Ca, Mg, Cl
✓ Blood sugar- F/ PP
✓ KFT- BUN, creatinine
✓ Coagulation Profile - platelet counts, PT, PTT
✓ LFT- Bilirubin, albumin, globulin & A:G, SGOT, SGPT
✓ Arterial Blood Gas analysis
✓ Acid Base Status
✓ X ray chest, ECG
37
Dr.Sravani Vishnubhatla

38. CRF – ROLE OF ECG
Essential Preop Investigation
✓ Electrolyte imbalances , arrhythmias
✓ Dx of Digitalis changes/ toxicity
✓ Dx of hypertensive heart disease
✓ Dx of ischemic heart disease
Dr.Sravani Vishnubhatla

39. CRF – PREOP PREPARATION
✓ Evaluate latest reports (esp. K)
✓ Consider current drug therapy- may need dose adjustment of
insulin, steroids
✓ Limited time available for correction of anemia, acidosis, fluid &
electrolyte imbalance
✓ All peripheral veins thrombosed or used up
✓ IV line in contra lateral saphenous vein
✓ If HD within 24 hrs- hypovolemia (HD > 2-3 days ago–
hypervolemia & risk of pulmonary edema)
✓ Regardless of procedure/technique, complete PAE is
mandatory - ensure optimization of Uremic manifestations
Dr.Sravani Vishnubhatla

40. Factors altering drug action in CRF
1. Anemia
2. Hypoprotenemia
3. Electrolyte disturbance
4. Body fluid relocation
5. Acidosis
6. Abnormal cell membrane activity
7. Impaired mechanisms of biotransformation
8. Generalized depression of all enzyme systems
9. Decreased renal excretion
10. Altered blood brain barrier
11. Intrapulmonary shunting
12. Uremia and CNS depression
Dr.Sravani Vishnubhatla

41. CRF- PREMEDICATION
Several combinations
✓ Sedative
✓ Hypnotics
✓ Narcotic
✓ Antihistaminic
✓ Anticholinergics
✓ Antiemetics
✓ H2 blockers
✓ Antacids
✓ Steroids
✓ Antihypertensive
✓ Antibiotics
✓ Immunosuppressants
41
Dr.Sravani Vishnubhatla

42. CRF & PREMEDICANT DRUGS
Drug Metabolism Action Remarks
Midazolam Liver ↑ d.o.a Safe
Diazepam Liver to active des methyl form,
protein bound
↑ free form,
↑ sensitivity
Safe, use in low doses.
long t ½
Promethazine Liver Hypotension Safe
Morphine Liver to active glucoronide Risk of
accumulation
Respiratory depression,
avoid
Pethidine Demethylated in liver to nor
pethidine (active)
Risk of
accumulation
CNS excitation/ seizures.
?avoid/with caution
Fentanyl In liver to nor Fentanyl Short d.o.a Safe
Sufentanyl Liver to desmethylsufentanyl Short d.o.a Safe
Alfentanyl Liver, KFT do not affect
clearance
Shorter d.o.a Safe
Remifentanyl Ester hydrolysis Short d.o.a Safe
42
Dr.Sravani Vishnubhatla

43. CRF – INTRA OP CARE
✓ Twin interconnected OT’s
✓ Absolute asepsis
✓ Sterile Technique ( I/V, CVP, I/A lines)
✓ Disposable equipment
✓ Protective gloves, gown, mask
✓ Invasive monitoring – ONLY if indicated
43
Dr.Sravani Vishnubhatla

44. CARE OF FISTULA / SHUNT
✓ DO NOT INJECT
✓ DO NOT CANNULATE VEIN OR ARTERY ON THAT
SIDE
✓ Cover it with a light bandage
✓ Do not apply BP cuff on the side
✓ Hypotension can block the fistula/shunt
✓ Allow adequate circulation in that arm
✓ Do not flex or over extend
Dr.Sravani Vishnubhatla

45. CRF- I/O MONITORING
✓ ECG
✓ NIBP
✓ SpO2
✓ Etco2
✓ Fio2
✓ CVP
✓ Output
✓ PCV
✓ Electrolytes
✓ ABG
✓ Acid-base status
✓ Temperature
✓ Blood loss
✓ Fluid balance
✓ Blood sugar
✓ N-M monitoring
Dr.Sravani Vishnubhatla

46. CRF- ANESTHESIA TECHNIQUE
✓ Pre oxygenation advocated
✓ Rapid Sequence Induction
✓ IV induction- pentothal, Propofol, Fentanyl, Midazolam
✓ Intubation – non depolarising - no contraindication (if K &
Pseudo cholinesterase levels N) / nondepolarizing drug
✓ Narcotic- Fentanyl /Neurolept safe
✓ Abolishing stress response to D/L & intubation
✓ IV fluids- with care
✓ NDMR – Atracurium, vecuronium, rocuronium, pancuronium
✓ IPPV- maintain normocarbia
✓ Reversal with atropine/glycopyrrolate & Neostigmine
46
Dr.Sravani Vishnubhatla

47. CRF - IV INDUCTION AGENTS
Drug Metabolism Mechanism of
action
Remarks
Thiopentone Mainly in liver, <
1% exc
unchanged
60-75% binds to albumin
pKa 7.6- ↑free form in acidosis)
↑ free drug, d.o.a,. Potency,
(altered BBB) in uremia, ↓
dose
Propofol Conjugated in liver Inactive metabolites exc in urine Safe
Ketamine In liver Metabolites exc in urine
Hypertensive effect-
undesirable
Avoided
Etomidate In liver Metabolites exc in
Binds to serum proteins
Enhanced effects, relatively
safe
Droperidol Liver Safe
47
Dr.Sravani Vishnubhatla

48. CRF- INHALATIONAL AGENTS
48
Dr.Sravani Vishnubhatla

49. CRF- MUSCLE RELAXANTS
49
Dr.Sravani Vishnubhatla

50. CRF & Drugs
Drug Metabolism /
excretion
Action Remarks
Anticholinergics
Atropine ,
Glycopyrrolate
To active
metabolite
50% exc by
kidney
Potential for
accumulation
Single dose safe
Scopolamine Less
dependent on
renal excretion
↑ CNS effects in
azotemia
Avoid
Anticholinestrase
Neostigmine
Pyridostigmine
Edrophonium
50-70%
excreted in
urine
prolonged T ½ , &
d.o.a
Safe, useful
even with long
acting NDMR’s
50
Dr.Sravani Vishnubhatla

51. CRF- DRUGS
Drug Metabolism Renal excretion Remarks/action in
CRF
Propranolol Liver Nil Safe
Ca + B Liver Nil Safe
Thiazides ++  Dose
M dopa ++ Dose, MAC,
catechols
MAOI-iproniazide catechols & MAC
Trimetaphan (Arfonad) cholinestrase Nil Safe
NTG Liver Nil Safe
SNP Liver – toxic
metabolite
Thyocynate in urine Unsafe
Hydralazine + Prolonged d.o.a
Dopamine Liver Safe in lower doses
Digoxin, Lanatoside C Unchanged in urine Prolonged d.o.a
Digitalis Narrow therapeutic
index
Arrhythmias – risk of
toxicity, omit preop
Dr.Sravani Vishnubhatla

52. CRF- I/O FLUID THERAPY
Aims
✓ Patients chronically volume depleted & hypovolemic
✓ Need to maintain good output
✓ Maintain CVP ( 8-10cm H2O)/ PCWP
✓ Maintain SBP 130-160 mmHg
✓ Higher Perfusion Pressure for cadaveric donor
✓ K+ containing solutions avoided ( WB, Plasma)
✓ Care in anephric patients (80 ml /h D5) or 2 ml/Kg/h
✓ If febrile – increase to 5 ml / Kg/°C ↑ / h
✓ Post op hemodialysis in case hypervolemia occurs
Advisable Fluids – D5, NS, Mannitol, Packed cells, salt free
Albumen, leucocyte free RBCs
52
Dr.Sravani Vishnubhatla

53. CRF - VASOPRESSORS
Drug  action  action Remarks
Epi, Nor epi +++  RBF- care
Isoprenaline High dose Low dose Myocardial
irritability,
maintains
RBF
Dopamine > 20 g/Kg/
min
<10 g/Kg/
min
Safe
Dobutamine,
Angiotensin
+++  RBF- care
PGE2  ++ Natriuresis
Phenylephrine ++  RBF - care
Dr.Sravani Vishnubhatla

54. RENAL SURGERY
INTRA OP COMPLICATIONS
✓ Bleeding- vascular renal tumours
✓ Fluid overload – dilutional Hyponatremia
✓ Pleural damage –high risk if L Nephrectomy
✓ Bladder perforation
Dr.Sravani Vishnubhatla

55. ANESTHESIA FOR SHUNT / FISTULA
Brachial plexus block (preferable) /LA
Precautions
✓ Care due to coagulation problem
✓ Debilitation- smaller dose of LA
✓ myocardial irritability (acidosis, K,  I/V volume)
✓ Avoid epinephrine in LA- risk of SBP, renal
vasospasm, RBF & arrhythmias, ST changes
✓ Vasoconstriction makes fistula / shunt formation /
cannula insertion more difficult
✓ Epinephrine 1:400,000- dilution if at all
✓ Shorter d.o.a of LA in uremia ( by almost 38%)
Dr.Sravani Vishnubhatla

56. THANK YOU!
Dr.Sravani Vishnubhatla