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    Anaesthesia in CKD MAJU

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    Anonymous BQM9271ZX
    This document discusses chronic kidney disease (CKD) and considerations for patients with CKD undergoing surgery. It notes that the prevalence of end-stage renal disease is increasing worldwide. Patients with CKD have some baseline organ dysfunction that makes them more vulnerable to additional acute physiological stress. The stages of CKD are defined based on glomerular filtration rate and evidence of kidney damage. Preoperative evaluation of CKD patients requires optimizing their medical condition with a multidisciplinary team. Intraoperative management focuses on fluid balance, blood pressure control, and avoidance of respiratory acidosis. Postoperative care includes adequate analgesia and increased risk of infection for transplant patients. Pharmacokinetics of many drugs are altered in kidney disease requiring dosage adjustments.

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    Anaesthesia in CKD MAJU

    Uploaded by

    Anonymous BQM9271ZX
    67 views21 pages
    This document discusses chronic kidney disease (CKD) and considerations for patients with CKD undergoing surgery. It notes that the prevalence of end-stage renal disease is increasing worldwide. Patients with CKD have some baseline organ dysfunction that makes them more vulnerable to additional acute physiological stress. The stages of CKD are defined based on glomerular filtration rate and evidence of kidney damage. Preoperative evaluation of CKD patients requires optimizing their medical condition with a multidisciplinary team. Intraoperative management focuses on fluid balance, blood pressure control, and avoidance of respiratory acidosis. Postoperative care includes adequate analgesia and increased risk of infection for transplant patients. Pharmacokinetics of many drugs are altered in kidney disease requiring dosage adjustments.

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    pembiusan pada pasien ckd, regional atau general anestesi

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    This document discusses chronic kidney disease (CKD) and considerations for patients with CKD undergoing surgery. It notes that the prevalence of end-stage renal disease is increasing worldwide. Patients with CKD have some baseline organ dysfunction that makes them more vulnerable to additional acute physiological stress. The stages of CKD are defined based on glomerular filtration rate and evidence of kidney damage. Preoperative evaluation of CKD patients requires optimizing their medical condition with a multidisciplinary team. Intraoperative management focuses on fluid balance, blood pressure control, and avoidance of respiratory acidosis. Postoperative care includes adequate analgesia and increased risk of infection for transplant patients. Pharmacokinetics of many drugs are altered in kidney disease requiring dosage adjustments.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    67 views21 pages

    Anaesthesia in CKD MAJU

    Uploaded by

    Anonymous BQM9271ZX
    This document discusses chronic kidney disease (CKD) and considerations for patients with CKD undergoing surgery. It notes that the prevalence of end-stage renal disease is increasing worldwide. Patients with CKD have some baseline organ dysfunction that makes them more vulnerable to additional acute physiological stress. The stages of CKD are defined based on glomerular filtration rate and evidence of kidney damage. Preoperative evaluation of CKD patients requires optimizing their medical condition with a multidisciplinary team. Intraoperative management focuses on fluid balance, blood pressure control, and avoidance of respiratory acidosis. Postoperative care includes adequate analgesia and increased risk of infection for transplant patients. Pharmacokinetics of many drugs are altered in kidney disease requiring dosage adjustments.

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    MODUL R3

    CKD
    CKD
     Incidence of ESRD (aka CRF) increasing worldwide – in USA
    prevalence of ESRD more than doubled between 1990 and 2001
     4 –Year survival for ESRD patients in UK only 48%
     Approximately 26 million Americans have some form of CKD
    (pre-dialysis kidney disease) and many remain undiagnosed
     The CKD patient population fits the “2nd hit injury” paradigm
    because they have some stable chronic baseline organ dysfunction
    that is disproportionately worsened when exposed to acute
    physiologic stress such as hypotension, hypovolaemia, or drug
    toxicity
    Definition CKD
     2002 National Kidney Foundation Kidney Disease Outcomes
    Quality Initiative (K/DOQI) guidelines proposed a 5 stage
    classification for CKD based on GFR
     GFR < 60mL/min/1,73m2 for > 3 months where there is
    evidence of kidney damage or
     Evidence of kidney damage for > 3 months based on pathologic
    specimen, imaging or laboratory tests (e.g proteinuria)
    irrespective of GFR
    RIFLE criteria
    Aetiology of CKD

    Diabetic Hypertensive Glomerular


    Nephropathy Nephrosclerosis Disease

    Interstitial Vascular Inherited


    Diseases of the Diseases of the Kidney
    Kidney Kidney Diseases
    Pathophysiology of CRF
    Preoperative Evaluation

     Multidisciplinary approach involving anaesthetists, surgeons


    and renal physicians
     Optimise medical condition & address potentially reversible
    manifestations of uraemia
     Cardiorenal syndrome & Cardiovascular Risk
     Renal Risk Assessment and Interventions
     Dialysis and Renal Transplant Patients
    Basic outline of the “Premed”
     History & Physical Examination
     CVS & Respiratory system evaluation ?? Fluid overload
     diabetic patients
     Basic bloods
     (Hb), postdialysis, INR/PTT, platelet dysfunction in uraemia – count may
    be normal)
     CXR (clinical impression)
     ABG
     Acid-Base status (Resp. distress);oxygenation; ventilation
     ECG
     Echo -
     Blood transfusion – only in severe (symptomatic) anaemia
     Consider Anaesthetic Technique
    Cardiorenal Syndrome

     Pathophysiological disorder of the heart and kidneys wherein


    the acute or chronic deterioration of one organ results in
    acute or chronic deterioration of the other
     Classified into 5 types
    Cardiovascular Risk
     High prevalence of cardiovascular disease and increased perioperative
    morbidity
     Cardiovascular risk assessment according to ACC/AHA guidelines
     Surgical risk for noncardiac procedures
     Major risk factors (before elective surgery)
     Risk profile for surgery
     Risk with intended procedure
     Decompensated HF or unstable coronary syndromes  postpone procedure until
    medical management optimised
     Intermediate/Minor risk factors (before elective noncardiac surgery)
     Functional capacity (METs- metabolic equivalents or tasks)
     Self-reported/treadmill testing
     6 METs – better prognosis; good functional capacity – proceed to surgery
     Poor functional capacity – investigate and optimise prior surgery
     Type of surgery
    Intraoperative considerations:
    Kidney Failure
     Monitoring
     Risk thrombosis – BP cuff not on arm with AV fistula
     Continuous intraarterial BP in uncontrolled HPT
     Induction
     RSI in patient GI bleed
     Induction dose adjustment
     Anaesthesia maintenance
     Control BP with minimal deleterious effect on CO
     Volatile agents, propofol & opioids (NB morphine effect prolonged)
     Ventilation control to avoid respiratory acidosis and alkalosis
     Hypercarbia may exacerbate existing acidaemia  circulatory depression & increase in
    serum potassium
     Fluid therapy
     Replace insensible losses in superficial operations involving minimal tissue trauma
     Procedures associated with major fluid losses
     Isotonic crystalloids, colloids or both
     Ringers Lactate contains potassium  NB Hyperkalaemic patients
     Bloodtransfusions only as indicated
    Postoperative Considerations
     Emergency surgery
     Postoperative cardiac assesssment
     Lack preoperative evaluation
     Diagnosis of postoperative MI should be based on combination of clinical,
    laboratory & ECG evidence
     Environment
     Normal ward
     High Care/ICU
     Analgesia
     Regional anaesthesia reduces requirement for systemic analgesic drugs
     Epidurals potentially reduced incidence of postop respiratory complications and
    VTE events
     Systemic anaglesia
     WHO pain ladder
     PO vs IMI vs PCA (IV)
     Immune Suppression with transplants – postoperative sepsis risk increase
    Pharmacological Considerations
     INTRAVENOUS AGENTS
     Induction Agents
     Muscle Relaxants
     Reversal Agents
     Benzodiazepines
     Opioids
     INHALATION AGENTS
     Volatile Agents
     Nitrous Oxide
     OTHER
    Induction Agents
    PROPOFOL & Pharmacokinetics minimally affected and
    ETOMIDATE pharmacodynamics unchanged
    Changes in volume distribution and mental state
    Decreased induction dose required

    BARBITURATES Pharmacokinetics unchanged but


    Increased sensitivity dt increased free circulating barbiturates
    (decreased protein binding) and acidosis increases entry into brain
    by increasing nonionised fraction

    KETAMINE Pharmacokinetics minimally changed


    Hepatic metabolites may depend on renal excretion and can
    potentially accumulate
    Muscle Relaxants
    SUCCINYLCHOLINE Safe if HYPERKALAEMIA absent
    CISATRACURIUM & DRUG OF CHOICE; plasma ester hydrolysis, nonenzymatic
    ATRACURIUM Hoffman elimination
    VECURONIUM Primary hepatic metabolism, 20% eliminated by kidneys. If use
    >0,1mg/kg dose prolonged effect
    ROCURONIUM Hepatic elimination but prolonged action in kidney disease
    reported. Can be used if appropriate NM monitoring available
    PANCURONIUM 60 – 90% dependant on renal excretion

    Reversal Agents
    NEOSTIGMINE Renal excretion. Halflife prolonged. Inadequate reversal
    often related to other effects (“recurarizaton’)
    ATROPINE & Safe for use.
    GLYCOPYROLLATE Repeated doses potential for accumulation (50% drug excreted in
    urine)
    Opioids
    MORPHINE Active metabolites (morphine-6-glucoronide) may have
    greater activity than parent drug and may accumulate
    Start at lower suggested dosage and titrate dosage
    upwards slowly and increase dose intervals
    FENTANYL Inactivated by liver and excreted by urine
    REMIFENTANYL Significant accumulation does not occur
    ALFENTANYL No active metabolites

    Benzodiazepines
    MIDAZOLAM & Hepatic metabolism with urine elimination
    DIAZEPAM Active metabolites accumulate
    Protein bound ; increased sensitivity in
    hypoalbuminaemic patients
    Dose reduction 30 – 50%
    Inhalation Agents

     Not dependent on renal function


     Sevoflurane and Enflurane may produce nephrotoxic fluoride
    ions
     Some physicians avoid use in lengthy procedures
    Other
    PHENOTHIAZINES Pharmacokinetics minimally altered but potentiation of
    central depressant effect can occur
    H2 RECEPTOR Depend on renal excretion
    BLOCKERS Dose reduction required
    PPI Dose adjustment not required
    METOCLOPRAMIDE Accumulates in kidney failure
    DOLASETRON Dose adjustment not required
    NSAIDS Avoid in kidney disease
    LOCAL ANAESTHETICS Decreased duration of action
    Maximum dose to be decreased by 25% due to decreased protein
    binding and lower CNS seizure threshold
    Renal Protection: Pharmacological
    Interventions
     Dopamine
     Volume management by increasingUO
     Evidence does not support “renal protective effect”

     Loop Diuretics – Furosemide


     Used to preserve intraoperative UO – high doses in ARF reduce need for dialysis (no improvement in
    mortality)
     “Protective effect” only demonstrated in rodent models

     Osmotic Diuretic Mannitol


     Old data in kidney transplants – impaired renal perfusion with goal of renal protection and maintenance of
    adequate UO
     Recent randomised trial failed to show protective benefit patients undergoing major vascular surgery

     ACE inhibitors
     No data to support benefit

     CCB’s
     Data insufficient to support benefit

     N -Acetyl Cysteine
     Prevention of contrast nephropathy (high risk in CKD)
     Combination with adequate hydration
     Data fails to show benefit when used as renoprotective agent during major surgery
    TERIMA KASIH

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