Administration of Anesthesia to Patients with Renal Failure

1. Never place a central line in the same extremity where the arteriovenous access (primary AV fistula or GORE-TEX® graft) is present. 2. Do not administer large amounts of intravenous (IV) fluids to patients with end-stage renal disease (ESRD) or acute renal failure (ARF)-oliguric patients (i.e., no more than 1 mL/kg) for minor procedures and during stable clinical conditions. 3. Choose the proper IV solution during anesthesia (0.9% or 0.45% NaCl) according to the following serum electrolyte levels: • normal saline (NS) if NA + 140 mEq/L or in patients receiving large amounts of exogenous NA + in the form of fresh, frozen plasma. May alternate one liter of each during prolonged surgical procedures, particularly if large amounts of volume are needed. Add 5% dextrose in NS or 1⁄2 NS in nondiabetic patients or in diabetics who receive pre-op insulin. 4. Severe intraoperative hyponatremia can frequently happen while receiving hypotonic solutions ( 200 mg/dL. Use regular insulin alone; correction of hyperglycemia results in improvement of hyperkalemia. May use sliding scale for blood sugar as follows (using Accu-Chek® every 15 min): • 201-250 mg/dL 3 U regular insulin IV • 251-300 mg/dL 5 U regular insulin IV • 301-350 mg/dL 7 U regular insulin IV • 351-400 mg/dL 10 U regular insulin IV • 400 mg/dL 15 U regular insulin IV Conversely, if blood sugar 7.48), in which case do not administer. c. Calcium gluconate 1 gm IVP, particularly if EKG findings of hyperkalemia are present. Watch for hyperkalemia intra-op if: • radiographic contrast is used (particularly in ARF-oliguric patients, as a consequence of “solvent drag effect”), • large amounts of mannitol are given under the same circumstances as above, or • cardiovascular collapse develops with ensuing lactic acidosis (resulting in acidemia, “shifting,” and hyperkalemia). 6. For intra-op hypertension in ESRD and ARF patients, avoid ACE inhibitors and beta-blockers as antihypertensive drugs since they can lead to hyperkalemia. Instead use calcium channel blockers, which may have a nephroprotective effect in ARF patients. 7. In patients with acute ongoing metabolic acidosis and acidemia (pH 150 mEq/L), tris-hydroxymethyl aminomethane (THAM) is the preferred solution to provide buffer and prevent further worsening hypernatremia obligated by NaHCO3 infusion. 8. Large amounts of citrate administered via multiple blood transfusions can lower Ca++ levels, for which calcium gluconate 1 gm IV should be administered for every 3 U of blood. Ca++ levels need to be followed closely to prevent high calciumphosphorus double product and risk for calcium-phosphorus precipitation in vital organs. 9. In the unusual event of severe hypophosphatemia (P < 2.0 mg%), replace NaHPO4 10 mmol IV over 1 hour or KHPO4 10 mmol over 1 hour according to the situation. 10. Avoid drugs with potential nephrotoxicity in ARF patients; modify doses of medications according to reduced renal function (glomerular filtration rate (GFR) < 5 mL in ESRD). Formulas such as MDRD eGFR and Cockroft-Gault (140 – age in years) x (weight in kg)/SCr x 72 are of no use in ARF to calculate GFR since anuria is GFR 0 regardless of serum creatinine levels; this formula is only useful when renal function is at a steady state and not changing daily as with ARF. P O I N T S T O R E M E M B E R