Perioperative Management of the Patient With Chronic Renal Failure Publications (22)
Perioperative Management of the Patient With Chronic Renal Failure Publications
Perioperative management requires an understanding of the physiologic perturbations associated with each disease process. This article elucidates the goals in the management and treatment of this complex patient population.
e., heart failure and chronic kidney disease) accumulates in the legs due to gravity, and when a person lies supine at night, the fluid shifts rostrally to the neck, also owing to gravity. The fluid in the neck can increase the extraluminal pressure around the upper airways, causing the upper airways to narrow and predisposing to upper airway collapse. Similarly, surgical patients also incur large fluid and salt balance shifts, and when recovered supine, this may promote fluid redistribution to the neck and upper airways. In this commentary, we summarize the sleep medicine literature on the impact of fluid and salt balance on obstructive sleep apnea severity and discuss the potential anesthetic implications of excessive fluid and salt volume on worsening sleep apnea.
Due to the lack of perioperative studies with CKD patients there are only level 2 recommendations. First of all, this requires the identification of CKD patients through risk assessment and preoperative laboratory tests. In this regard, biomarkers, such as cystatin C may facilitate the detection of chronically impaired renal function. Secondly, particular attention should be paid to the maintenance of hemodynamic stability, including an adequate blood pressure and cardiac index and the preservation of intravascular volume. There is clear evidence that an unimpaired renal perfusion, guaranteed through hemodynamic stability, and an undisturbed fluid balance both reduce the incidence of acute kidney injury (AKI) and consequently the further deterioration of renal function. Thirdly, several studies demonstrate that tight glycemic control is associated with less renal impairment and better survival for patients with CKD. Lastly, the highest priority for the patient with CKD should be assigned to the prevention of AKI, which is an action of proven efficacy.
Identification and risk stratification is crucial for the perioperative management of patients with CKD. To improve clinical outcomes, nonemergent procedures should be postponed, renal function optimized, nephrotoxic drugs avoided, and AKI prevented.
We show that a structured palliative approach which has been proposed for cancer patients may also be feasible in palliative situations concerning nononcologic patients.
It is therefore critical that children with this uncommon condition be identified early when medical or surgical management can potentially improve outcome. We describe a 15-year-old patient with multiple aortic aneurysms with dissection whose presentation includes chronic anemia, acute-on-chronic renal failure with hyperkalemia, and liver injury.
A minimally invasive procedure may progress safely by laparoscopic intervention. However, dysfunction of the catheter during a laparoscopic intervention is a common complication related to CAPD. This usually involves intra-abdominal migration of the catheter, even with one intra-abdominal fixation. In an effort to increase catheter survival, we tested a modified laparoscopic technique with two intra-abdominal fixations of a Tenckhoff catheter.
Forty-one consecutive ESRD patients (mean age, 53.4 y; range, 31 to 84 y) underwent modified laparoscopic Tenckhoff catheter implantation with 2 intra-abdominal fixations between September 2009 and January 2013. The same perioperative protocol and surgical technique were used in all patients. Another 49 ESRD patients who had received laparoscopic Tenckhoff catheter implantation with 1 intra-abdominal fixation performed by the same surgeon were retrospectively recruited for comparison.
The modified laparoscopic procedure with two intra-abdominal fixations of a Tenckhoff catheter was successfully performed in all patients. The mean operating time was 24.3 minutes (range, 15 to 37 min). The mean blood loss was 5.6 mL (range, 5 to 20 mL). Catheter survival was 100% until February 2013. No major perioperative complications were found. A Kaplan-Meier Survival Analysis found no significant difference between the 2 groups in sex, age, operative time, or blood loss. The catheter survival rate was significantly higher in the patients with two intra-abdominal fixations. Most patients were satisfied with the functional results of the Tenckhoff catheter.
The laparoscopic 2-site fixation technique is an effective and safe procedure but long-term follow-up and more cases are necessary.
5% ropivacaine 20 ml under ultrasonographic visualization on right side, and after sixty-minutes the other side injection was performed through the indwelling catheter. During the operation, the patient received a target-controlled infusion of 0.4-0.6 microg x ml(-1) propofol. The perioperative courses were uneventful and there was no adverse effect including central nervous system (CNS) symptoms.
4-7.8-fold higher than the general population. These patients may present electively or emergently for surgery related to, or remote from, the CKD. In any perioperative setting, the patient with hemodialysis-dependent CKD represents a significant clinical challenge, and successful management of these patients requires effective cooperation and communication between nephrology, anesthesia, and surgical staff. The ESRD patient's nephrologist will have the best knowledge of their medical history, comorbidities, and future management goals and may have been the clinician who instigated the referral for the surgery, e.g., for parathyroidectomy, vascular access surgery, nephrectomy or renal transplantation. As such, they are in an ideal position to contribute to, or coordinate, early preoperative medical optimization of the patient and also to provide advice during postoperative recovery and rehabilitation. In this article, we provide an overview of some of the key aspects of managing these patients successfully during the perioperative period. We propose the integration of cardiopulmonary exercise testing and cardiovascular optimization into the care of these high-risk patients and provide an overview of the importance of maintaining microvascular perfusion and the role of viscosity in preserving the capillary perfusion network.
We collected epidemiological data on demographics, type and site of infection, bacteriology, surgical treatment, complications and mortality.
Forty-seven out of 803 (6%) patients with surgically managed upper limb infections in the study period had ESRF. The average age was 59 years. ESRF was secondary to diabetes in 88% of cases. Patients presented on average 7 days after onset of symptoms. Abscesses (34%), wet gangrene (26%) and osteomyelitis (11%) were the commonest infections. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest pathogen (29%), occurring either in isolation or with other organisms. Eighteen percent of single organisms cultured were gram-negative. Multiple organisms occurred in 29%. A median of 2 operations were required. Thirty-six percent of all cases required amputation. Twenty-fi ve percent of patients had a life-threatening event (myocardial infarction or septic shock) during treatment.
ESRF patients present late with severe upper limb infections. Nosocomial infections are common. Initial empirical antibiotic treatment should cover MRSA and gram-negative bacteria. Immediate referral to a hand surgery unit is recommended. Multi-disciplinary management of the patient with input from physicians and anaesthetists or intensivists in the perioperative period is necessary to optimise the patient for surgery and to manage active medical comorbidities and complications after surgery.
5 kg for a month increasing the intravascular volume. Neither did the patient develop pulmonary edema nor congestive heart failure preoperatively. Tumor resection was successfully completed under general anesthesia. Although noraderenaline was required to keep adequate blood pressure during surgery and the first day of intensive care unit stay, there was no adverse event during perioperative period. The increasing intravascular volume before pheochromocytoma surgery in a patient on hemodialysis might make the perioperative management safer, although further study is required to determine the adequate level of increment in the preoperative dry weight.