Anesthesia

Management in Renal
Failure
By :
dr. Yudi Hadinata
Consultant :
dr. Wiwi Jaya Sp.An

NEPHRON
NEPHRON

Renal Functions
Acid Base
Acid Base
Homeostasis
Homeostasis
Excretion of
Excretion
wastes of
wastes

Osmolality
Osmolality
Regulation
Regulation

Hormone
Hormone
Secretion
Secretion

Blood pressure
Blood
pressure
regulation
regulation
(Morgan, 2006)

Definition
Acute Renal Failure :

Deterioration of renal function over a period of hours to days (24-72hrs)

Chronic Renal Failure

Deterioration persist more than 3 months with GFR < 60 (mL/min/1.73

m2)

(Morgan, 2006; Hines, 2008)

Diagnosis
Anamnesis

Physical exam

Anamnesis

Physical exam

Laboratory
findings
Laboratory
findings

Pulmonary

dyspnea, Lung edema, hypoxemia

Cardiovascular

Hypertension, CHF, LVH, arhytmia

Neurological

uremic encephalopathy, neuropathies

Gastrointestinal

anorexia, nausea, vomiting, peptic ulcer, haemorrhage, delayed gastric

emptying

Hematologic

Anemia, platelet dysfunction

Endocrine

hyperparathyroidism

Metabolic

Hyperkalemia, hyperphosphatemia, hypermagnesium, hypoeruricemia,

hypocalcemia, metabolic acidosis.

Renal

Back pain, olygouria, diuresis, anuria, urogenital sign & symptom

(Hines, 2008)

RENAL
FAILURE

Diagnosis
Creatinine level

Male >< Female (0.8-1.3 >< 0.6-1) gr/dl

Reduce GFR (Glomerular Filtration Rate)

GFR decrease 1% every year after 2nd decade

Creatinine clearance :
(140-age) x lean
body weight
Creatinine clearance :
(140-age) x lean
72 x plasma creatinine
body weight
Female ( 0.85)
72 x plasma creatinine
Female ( 0.85)

(Morgan, 2006)

Correlation between Creatinine and GFR

(Morgan, 2006)

Fluid Overload
Fluid
Overload
Hyperkalemia
Hyperkalemia
Severe
Acidosis
Severe Acidosis
Encephalopathy
Encephalopathy

Pericarditis
Pericarditis
Coagulopathy
Coagulopathy
Refractory
GIT
Refractory
symptomGIT
symptom
Drug
Toxicity
Drug Toxicity
(Morgan, 2006)

Preoperative Evaluation
Progressing
Progressing
Renal
Renal
Diseas
Diseas
e
e

Stable
Stable
Diminishing
Diminishing

(Morgan, 2006;Hines, 2008)

Hemodialy
sis
Hemodialy
sis

Clinical Evaluation
Respiratory
Clinical
Evaluation
Hemodynamic
Respiratory
Urine Production
Hemodynamic
Urine Production

Laboratory Result
Hb,
Electrolyte, BT/CT,
PT/APTT
Laboratory
Result
Hb, Electrolyte, BT/CT, PT/APTT

Ureum/Creat
inine
Ureum/Creat
inine

Fluid Management in Renal Failure

Input
Input

Outpu
Outpu
t
t

Dietary
Dietary
intake
intake

Urine
Urine

IV fluid
IV fluid

Insensible
Insensible
water
loss
water loss

Blood
Blood
products
products

Bleeding
Bleeding

Choosing the drug for anesthesia ?

Class of drug

Renal excretion

Partially renal
excretion

Induction drug

Barbiturates

Muscle relaxant

Gallamine, metocurine

Pancuronium,
vecuronium

Neostigmin,
Edrophonium

Cardiovascular drugs

Digoxin, Inotropes

Atropine,
Glycopyrollate,
milrinone,
ydralazine

Antimicrobials

Aminoglycosides, vancomycin,
cephalosporin, penicillin

Sulfonamides

Cholinesterase
inhibitor

(Millers anesthesia, 2005)

Intravenous & Inhalation Anesthesia

Drugs in Renal Failure
Type of Drugs

Drugs

Warning

Dose

Intravenous

Propofol

adjustment

1-2 mg/KgBW

Etomidate

adjustment

0.20.4mg/KgBW

Thiopenthal

adjustment

2-3mg/KgBW

Ketamine

!Hypertension

Isofluran

safe

Desfluran

safe

Sevofluran

Toxic (Compound A)

Halotan

Toxic (Fluoride)

Enfluran

Toxic (Fluoride)

N20

Carefull with anemia

Lidocain

depends

Benzodiazepin

Accumulation

Inhalation

Other drugs

1-1.5 mg/KgBW
(Morgan, 2006; Hines, 2008)

Type of Drugs

Drugs

Warning

Dose

Opioid Analgetics

Fentanyl

Hepatic clearance

2 - 150 ug/Kg

Remifentanyl

Hepatic clearance

1 uq/Kg

Sulfentanyl

Hepatic clearance

0.25-30 ug/Kg

Alfentanyl

Hepatic clearance

8-100 ug/Kg

Morphine

Metabolic Accumulation

0.1 - 1 mg/Kg

Meperidine

Metabolic Accumulation

2.5-5mg / Kg

(Morgan, 2006; Hines, 2008)

Muscle Relaxant
Muscle
relaxant

Renal excretion
Dose (Mg/KgBW)
(%)

Mivacurium

< 10

0.15

Atracurium

10

0.4

Rocuronium

10

0.6

Vecuronium

15

0.1

Doxacurium

30

Pipecuronium

38

Pancuronium

40

Metocurine

43

Tubocurarine

45

Gallamine

90

Succinylcholin

1.5 (if K+ < 5 mEq/L)

(Duke, 2006; Morgan, 2006)

Conclusion
Preoperative
Preoperative
evaluation
evaluation

Safe Drugs
Safe Drugs
Good
Good
Outcome
Outcome

Monitoring
Monitoring

Post operative
Post
operative
Management
Management

THANK YOU

Hyperkalemia

Mild 5.5 - 6 mmol/L

Moderate 6.1-7 mmol/L

Severe > 7 mmol/L

Signs :

Fatigue, weakness, parasthesia, paralysis

ECG : Peaked T wave, prolonged PR, widened QRS, loss P

wave, asystole

Treatment :

Calcium gluconate 10% (10 cc over 2 minutes)

Insulin 10 U + D50% 50cc --> over 30-60 minutes

Dialysis