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CUSTOMISING FLUIDS IN CHRONIC KIDNEY DISEASE
- 1. Chronic renal failure – customizing fluid therapy. Dr. Pallavi Ahluwalia. 1
- 2. Criteria for definition of Chronic Kidney Disease 1. kidney damage for 3 months or more, as defined by structural or functional abnormalities of kidney with or without decreased GFR manifested by either • Pathological abnormalities • Markers of kidney damage, including abnormalities of blood or urine abnormalities in imaging tests. 2. GFR <60ml/min/1.73 m²for≥ 3 month with or without kidney damage. 2
- 3. STAGES OF CK D Modified from National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease:evaluation,classification and stratification. Am J Kidney Dis 39:suppl 1, 2002 . 3
- 5. 5
- 6. 6 Chronic kidney disease Sodium and water balance Potassium balance Elimination of nitrogeneous wastes Erythropoietin production Acid-base balance Activation of vitamin D Phosphate elimination Skeletal buffering Hypocalcemia Hyperparathyroidim Acidosis Osteodystrophies Uremia Coagulopathies Bleeding Heart Failure Edema Impaired immune function Skin disorders Gastrointestinal manifestations Neurologic manifestations Sexual dsyfunction Hypertension Increased vascular volume
- 7. CKD stage & Complications Anemia Electrolyte abnormalities Metabolic acidosis Cardiovascular complications Volume over load 7
- 8. Preoperative assessment CKD - Stage Comorbidities Investigations Surgical procedure Preop dialysis 8
- 9. Investigations & Diagnostic tools • CBC - Anaemia • BT &CT (Particularly neuroaxial anaesthesia) • BUN (10-20 mg/dl) • S.Creatinine (0.6-1.3 mg/dl) • Creatinine clearance(110- 150 mg/dl) • Blood sugar level • Serum electrolytes(hyper kalemia) • Urine analysis • CXR ,ECG& ECHO • ABG- metabolic acidosis,hypoxemia • Imaging Modalities 9 Formula for calculating GFR
- 10. Goals of fluid therapy • Prevent hypo & hyper volemia • Prevent electrolyte abnormalities • Prevent acidosis • Prevent immediate post op dialysis To avoid the progression of CKD to ESRD or Acute on chronic renal failure. 10
- 12. Fasting period Third space loss Maintenance & Blood loss Hypovolemia & Hypotension Acute kidney injury Why we need to give fluids ? 12
- 13. Fasting fluid – should we replace ? • Even prolonged fasting – no decrease in absolute blood volume • Modern fasting guideline – fluids upto 2 hours before surgery 13
- 14. Third space - fact or fiction? No replacement for third space loss Jacob M et al Best Pract Res Clin Anaesthesiol. 2009 Third space Endothelial glycocalyx 14
- 15. Assumption Problems With Assumption The patient is fasted preoperatively and is thus hypovolemic. BUT current fasting guidelines allow water ingestion up to 2 hours prior to surgery. The so-called fluid deficit in elective surgery is negligible Insensible losses continue during surgery and must be accounted for. BUT with laparoscopic and other minimally invasive surgery there is little insensible loss Fluid shifts to the “third space” must be replaced. BUT it is unlikely that the “third space” exists Blood loss must be replaced with three to four times the amount of crystalloid. BUT there should be an assessment of fluid responsiveness to guide administration of fluid after blood loss Hypotension following induction of anaesthesia is due to vasodilation, and the vascular space must be filled. BUT anaesthetic-induced vasodilation is better managed with vasopressors and/or lighter anaesthesia to maintain peripheral vascular resistance Urine output must be taken into consideration and replaced BUT antidiuretic hormone excretion (ADH) during surgery makes urine output as a guide very unreliable. Even if the patient has an excessive intravascular volume, the kidneys will regulate. BUT the kidneys are already stressed by ADH, and it may take days or weeks to excrete large fluid load 15
- 16. ASSUMPTIONS PROBLEMS WITH ASSUMPTIONS PREOPERATIVE FASTING THUS HYPOVOLEMIC CURRENT FASTING GUIDELINES ALLOW WATER INGESTION UP TO 2 HOURS PRIOR TO SURGERY INSENSIBLE LOSSES CONTINUE DURING SURGERY LAPAROSCOPIC AND OTHER MINIMALLY INVASIVE SURGERY THERE IS LITTLE INSENSIBLE LOSS FLUID SHIFTS TO THE “THIRD SPACE” MUST BE REPLACED. IT’S UNLIKELY THAT THE “THIRD SPACE” EXISTS BLOOD LOSS MUST BE REPLACED WITH THREE TO FOUR TIMES THE AMOUNT OF CRYSTALLOID THERE SHOULD BE AN ASSESSMENT OF FLUID RESPONSIVENESS TO GUIDE ADMINISTRATION OF FLUID AFTER BLOOD LOSS HYPOTENSION FOLLOWING INDUCTION OF ANAESTHESIA IS DUE TO VASODILATION, AND THE VASCULAR SPACE MUST BE FILLED. ANAESTHESIA INDUCED VASODILATION IS BETTER MANAGED WITH VASOPRESSORS URINE OUTPUT MUST BE TAKEN INTO CONSIDERATION AND REPLACED ANTIDIURETIC HORMONE SECRETION (ADH) DURING SURGERY MAKES URINE OUTPUT UNRELIABLE EVEN IF THE PATIENT HAS AN EXCESSIVE INTRAVASCULAR VOLUME, THE KIDNEYS WILL REGULATE THE FLUID LOAD KIDNEYS ARE ALREADY STRESSED BY ADH, AND IT MAY TAKE DAYS OR WEEKS TO EXCRETE LARGE FLUID LOAD
- 17. How to customize fluids ? 17
- 18. Monitoring urine output GFR of individual nephrons No.of functioning nephrons GFR • Essential to maintain volume and hemodynamics • To prevent acute on chronic renal failure • NOT a reliable marker of renal function 18
- 19. Monitoring & Goals High risk Moderate Low risk < 180 min > 180 min Surgical time Patient risk HR, NIBP Urine output SVV, PPV SV, CI, DO2 GDT Restrictive Liberal Della Rocca et al, BMC Anesthesiol. 2014 19
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- 21. Enhanced recovery after surgery (ERAS) protocol Fluids targeting cardiac output – strongly recommended Fluid management – independent predictive factor for post-op. outcome 21
- 22. Compared with the liberal fluid approach, GDT is superior in terms of riskof postoperative complication. GDT is a term used to describe use of cardiac output or similar paremeters to peri-operatively guide I.V. Fluids & inotropic therapy. 22
- 24. CLINICAL PARAMETERS PARACLINICAL PARAMETERS STATIC MEASURES DYNAMIC MEASURES BODY WEIGHT CHANGES URINARY INDICES (UNa, FeNa, FeUrea, sp. Gravity, osmolarity CVP, IVC diameter Stroke volume and pulse pressure variation INPUT/OUTPUT BALANCE Hematological changes PAOP Aortic flow velocity and SV BLOOD PRESSURE, HEART RATE AND ORTHOSTASIS Bio-electrical impedence RV-end diastolic volume PPV induced changes in IVC diameter URINE VOLUME Lactates, SVO2 LV- end diastolic area Micro circulation evaluation CAPILLARY REFILL, SKIN TURGOR Extravascular lung water index Intra- aortic blood volume index ORGANOMEGALY Global end diastolic volume index PULMONARY EDEMA
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- 26. Which fluid ? Normal saline Ringer’s lactate Plasmalyte Colloids 26
- 27. Malley et al, Transplantation Proceedings 2002 • 49 transplant centers • 5544 kidney transplants • Year 1999 27
- 28. Preference of IV fluids 0.9 % NS NS Based RL Others > 90 % of patients > 60 % of patients < 30 % of patients 20 40 60 80 Malley et al, Transplantation Proceedings 2002 28
- 29. Avoid potassium Malley et al, Transplantation Proceedings 2002 Reasons for the choice 29
- 30. Hyperchloremia - consequences Afferent arteriole constriction Renal blood flow GFR Urine output Chloride 30
- 31. • 12 healthy adult • 2 L of NS / Plasmalyte over 1 hour(contains sodium acetate & gluconate instead of sodium lactate) • Cross over after 7-10 days • Renal artery blood flow & renal cortical perfusion • Electrolyte & ABG upto 4 hours Chowdhury et al, Ann Surg 2012 31
- 32. Chowdhury et al, Ann Surg 2012 Sodium Potassium Saline Plasmalyte Saline Plasmalyte 32
- 33. Chowdhury et al, Ann Surg 2012 Chloride Bicarbonate Saline Plasmalyte Saline Plasmalyte 33
- 34. Anesthesia & Analgesia: 2015: 120 (1), 123–129. Potura et al, Anesth Analg 2015 34
- 35. Serum chloride level 102 104 106 108 110 0 24030 60 90 120 180 Minutes after start of the surgery Saline Acetated solution • 150 patients • 4 ml/kg/hr • Fluid bolus Potura et al, Anesth Analg 2015 35
- 36. Serum potassium 4.0 4.5 5.0 0 24030 60 90 120 180 Saline Acetated solution • 150 patients • 4 ml/kg/hr • Fluid bolus Minutes after start of the surgery Potura et al, Anesth Analg 2015 36
- 37. pH 7.40 7.42 0 24030 60 90 120 180 Acetated solution 7.38 7.36 7.32 7.34 Saline • 150 patients • 4 ml/kg/hr • Fluid bolus Minutes after start of the surgery Potura et al, Anesth Analg 2015 37
- 38. Base excess5 0 - 5 0 24030 60 90 120 180 Saline Acetated solution • 150 patients • 4 ml/kg/hr • Fluid bolus Minutes after start of the surgery Potura et al, Anesth Analg 2015 38
- 39. My experience Ringer’s lactate Normal saline Plasmalyte 39
- 40. Role of colloid in renal failure HES use Acute kidney injury Critical careIntraoperative use No RCT Avoid in CKD 40
- 41. 6.88 6.67 6.6 6.52 6.37 2.2 14.8 22.8 29.9 44.2 1.4 6.2 9.8 11.6 12.6 0 5 10 15 20 25 30 35 40 45 50 Category 1 Category 2 Category 3 Category 4 Chart Title #REF! pH K Lactate Column1 pH Lactate Potassium Day 0 Day 42Day 7 Day 14 Day 21 1.4 Biochemical changes – Blood storage 41
- 42. Conclusion No prolonged fasting Plasmalyte Individualized goal directed fluids 42
- 44. Monitoring & Goals High risk GFR-30-60 Moderate GFR-60-90 Low risk GFR-90 < 180 min > 180 min Surgical time Patient risk HR, NIBP Urine output SVV, PPV SV, CI, DO2 GDT Restrictive Liberal 44