peri operative renal dysfunction by prof.mridul m panditrao
DESCRIPTION
Prof. Mridul M. Panditrao explains the problem of Peri-operative renal dysfunctionTRANSCRIPT
PERI-OPERATIVE
RENAL
DYSFUNCTION
Dr. M.M.PANDITRAO
CONSULTANT DEPARTMENT OF ANAESTHESIOLOGY &
INTENSIVE CARERAND MEMORIAL HOSPITALFREEPRT, GRAND BAHAMA
COMMONWEALTH OF THE BAHAMAS
PERI-OPERATIVE RENAL DYSFUNCTION
Peri-operative Acute Renal Failure
i. Pre-existing pre-op risk factor
ii. Intra-operative event
ESRD /CRF Patient requiring care
POARF : Principles
• Pre-disposing pre-op risk factors
• Physiology of Urine Production
• Differentiate and Manage causes
• Effects of Anaesthetics and Surgery
• Prevent insults of these on Kidneys
RISK FACTORS
• Systemic Diseases: CRF, DM,• Jaundice• Advanced Age• Poor Myocardial Function• Nephro-toxic drugs: recently used• On CPB
•
PHYSIOLOGY OF URINE PRODUCTION
AETIOLOGY OF POARF
• Pre-Renal
i. Ac.hypovolemia & hypotension
ii. Poor cardiac function
iii. Hepatic Failure
• Post-Renal : Obstructive Pathology
AETIOLOGY OF POARF ( CONTD.)
• INTRINSIC ARF (RENAL)
i. Prolonged ischemia: aortic cross-clamping
ii. Myoglobinuria
iii. Haemoglobinuria : transfusion reaction
iv. Nephro-toxics
v. Renal Artery Thrombosis/ embolism
vi. Renal Vein Thrombosis
vii. Interstitial Nephritis/ Ac. GN/ Vasculitis
PATHOPHYSIOLOGY OF RENAL ISCHEMIA
RENAL ISCHEMIA
>Decreased renal perfusion
Hypoxic injury to renal tubules
Tubular endothelial swelling
Vascular congestion within outer medulla
Sloughing of tubular necrotic debris
Tubular obstruction
Increased backpressure in Bowman’s capsule
decreased GFR increased backleak of ultra-filtrate
OLIGURIA
Diagnosing aetiology of ARFurinary indices of ARF
• *FeNa = Urine Na/ Plasma Na X 100 ** RFI = Urine Na Urine creat/ Plasma Creat Urine creat/ Plasma creat
PRE INTRINSIC
Urine Na+ (meq/ lit.) <20 >40
Urine Osmo.(mosm/ lit.) >500 <350
Fractional excretion of Na ( FeNa)*
<1 >2
Renal Failure Index(RFI)** <1 >2
Urine sediments Clear/ casts
Brown granular casts
Management of Intra-op Oliguriaprevention & treatment
• Euvolemic state + stable haemodynamics• Patent Foley and adequate BP• CVP• Review Blood loss• Expand Blood volume• PA catheter & PCWP• Check Hb / Haematocrit / Urine for indices
Management of Intra-op Oliguriaprevention & treatment ( cont.)
• If no Invasive --- 2 simple tests• Inspite of Volume loading low C. O.
Dopamine / Dobutamine / adrenaline• Loop Diuretics• Mannitol ?????• Under Trial : ANP & Urodilatin• Vasoactive renal protective drugs:
PGs, Endothelin antagonists, Theophylline,
Calcium Channel Blockers
PERIOPERATIVE MANAGEMENT OF
ESRD/ CRF
End Organ Effects of ESRD NS – Uremia : sedation, fatigue, encephalopathy - Ch. Dialysis : dementia, dialysis diseqilibrium ** Sensitivity to sedatives/hypnotics/IVAs/ Inhalationals - Uremia : Peripherral & autonomic neuropathy*** autonomic Neuropathy - Haemodynamic instability$$ Medico-legal implications CVS – Hyperlipidemia—atherosclerosis ---
hypertension—DM---IHD/ LVH/ LVF/ CHF Pericarditis “Leaky Pulm. Capillary Syndrome”--- Pulm.Oedema
End Organ Effects of ESRD (cont.)
• BLOOD: Anemia, Platelet dysfunction,
Blood Transfusion – Caution
Uremic toxins• ELCTROLYTES: K+
: Ca+, PO4---, Bone
“Renal Osteodystrophy”• ACIDOSIS : HCO3
- ???
• INFECTIVE : A-V Grafts / antibiotics
Hepatitis
Pre-op. Concerns of ESRD
• Strict evaluation of End-Organ damage
• Review of last Dialysis record
• Review of Aetiology of C R F
• Avoid K+ containing I V fluids : R L
• Review recent electrolytes, urea.
Creatinine
• Care and safety of A V Fistula
Intra-operative
• INDUCTION: Sensitivity to IVAs, etc.
multifactorial --- * hypoproteinemia
* uremia
* Free active metabolites
* Met.acidosis… free fraction
Dose, Route, Speed, Concentration etc. of Inj.
Intra-operative (cont.)
• INTRA-VASCULAR VOLUME• AUTONOMIC NEUROPATHY• L V DYSFUNCTION• INHALATIONALS• OPIOIDS• NMBDs : Benzylisoquinoliniums
Vs.
Amino-steroids
Succinyl Choline
Post-operative
• Reversal• Ventilatory Support ????• Nursing Care
CONCLUSION
• RENAL DYSFUNCTION IS A PROBLEM• ESPECIALLY PERI-OPERATIVE ARF• UNDERSTANDING AETIO-PATHO• DIAGNOSING THE CAUSE• INVESTINGATING & MANAGING• ESRD / CRF VERY CHALLENGING