Post on 03-Dec-2014
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RENAL PATIENTS FOR VASCULAR ACCESS :
PERI-OPERATIVE MANAGEMENT
CHALLENGES, LESSONS LEARNT &
RECOMMENDATIONS!
PROF. MRIDUL M. PANDITRAO
CONSULTANTDEPARTMENT OF ANESTHESIOLOGY
PHA’S RAND MEMORIAL HOSPITALFREEPORT
GRAND BAHAMATHE BAHAMAS
Challenge Oriented Approach
• Related to the Primary pathology
• Related to the Surgical procedure
• Related to Anesthesia
• Related to Logistical/Infrastructural facilities
Primary Pathology:• CRF/CRD/CKD/ESRDS/Uremia• Defined as
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm
Primary Pathology: Chronic Renal Failure
• One of the commonest problems we face• Variety of etiopathogenesis• Varied age group belonging to both the sexes• Most commonly elderly age group• Associated multiple co-morbidities• Multiple pharmacological agents• Multiple exposures for surgical procedures
Primary Pathology: Chronic Renal Failure
• Multi-systemic pathology
• Accumulation of CNS depressing substances
• Very large distribution volume
• Compromised excretory function
• Delay in the excretion of pharmacological agents
• Actions of all the drugs significantly prolonged
Systemic Effects of CRD• Cardiovascular system: Hypertension, ischemic heart disease, cardiac failure,
pericarditis (severe uremia)
• Respiratory system :Pulmonary edema, pleural effusion, respiratory infection
• Gastro-intestinal: Stress ulceration, delayed gastric emptying, malnutrition
• Central Nervous System :Peripheral neuropathy, autonomic neuropathy,
mental slowing, convulsions, coma
• Renal :Fluid and electrolyte imbalance, altered drug handling
• Haematological : Anemia, Coagulopathy
• Immunological : Immunosupression (physiological, pharmacological)
S.Rang, NL. West , J. Howard, J Cousins : Anaesthesia for Chronic Renal Disease and Renal Transplantatione a u - e b u update s e r i e s 4 ( 2 0 0 6 ) 246–256 www.europeanurology.com
Pharmacological effects of CRD
• Non-depolarizing neuromuscular blocking drugs– Unpredictable duration of action– Incomplete reversal of paralysis
• Antibiotics :Unwanted side effects: e.g. – Aminoglycosides: ototoxicity or nephrotocity
• Opioids: Unwanted side effects of active metabolites: e.g. – Morphine-6- glucuronide: respiratory depression
Dialysis
• Anesthesia and surgery should take place in a near normal physiological environment
• Therefore seems logical that dialysis should take place just before surgery.
• However, the dialysis process may itself cause physiological disturbance viz; – Fluid depletion and redistribution to extravascular
spaces resulting in depletion of intravascular volume– Electrolyte disturbance, especially hypokalaemia– Residual anticoagulation from heparinization of the
haemodialysis circuit.
Post- Dialysis
• Hypotension (Volume constriction) — 25 to 55 %– Acute episodic hypotension– Chronic persistent hypotension
• Cramps (Electrolyte disturbances)— 5 to 20 % • Nausea and vomiting — 5 to 15 % • Headache — 5%• Itching — 5 %• Petechiae/Oozing (Coagulopathy) — 2 to 5 %• Chest pain — 2 to 5 %• Back pain(Hemolysis) — 2 to 5 %• Fever and chills — Less than 1 %
Surgical Procedures
• Related to Primary pathology/Intervention – Vascular access for hemodialysis*
– Procedures for peritoneal dialysis– Renal transplantation
• Unrelated co-incidental pathology
Vascular Access:
• Temporary
• Permanent
Temporary
• Peripheral – Short • Peripheral – Midline • Central – Peripherally Inserted Central Catheter
(PICC) • Central – Tunneled Central Venous Catheter • Central – Percutaneous Non-Tunneled Catheter • Central – Implanted Port • Subcutaneous Infusions (Hypodermoclysis)
Temporary Catheter
Permanent:AV Fistula & Graft
AVF/AVG
Challenges
• Leading normal life is a stress
• Added stress of anesthesia and surgery
• Decompensate the patients
• Avoidable errors of judgment
• High Morbidity and Mortality
Challenges!
• Repeated/ multiple surgeries
• Increased degree of difficulty for surgery, successively
• Multiple procedures needed at the same time
• Increased surgical time ∞Increased anesthesia time
• Increased complications/ challenges
• Multiple exposure to GA: enzyme induction
Systems review & pre-operative preparation• GI Reflux: Delayed gastric emptying
– Antacid prophylaxis– Alteration of anaesthetic technique to protect airway
• Neurological: Peripheral neuropathy – Positioning on operating table– Pressure area care
• Autonomic neuropathy:– intraoperative hemodynamic instability– ???Intraoperative invasive blood pressure monitoring
• Anaesthetic drug/ dose alteration• Haematological : Anaemia
– Consider acceptable perioperative haemoglobin concentration• Immunological: Immunosupression
– Antibiotic prophylaxis• Steroid supplementation• Minimize invasive procedures
AnesthesiaAims& Objectives: • Ensure intraoperative patient comfort• Optimize surgical conditions• Minimize risk of anaesthetic complications,
e.g. Perioperative cardiac events,• Optimize postoperative state – avoidance of prolonged sedation, – minimize strong postoperative analgesia– avoid all possible complications
Anesthesia
• Two choices– General Anesthesia
– Regional technique: Supra-clavicular brachial Plexus Block
GA
• Anesthetic agents: IV or Inhalationals– Cardio-depressants– Arrythmogenic– Peripheral vasodilatation– Negative inotropism– No chance of poly-pharmacy– Fluid restriction– Co-morbidities
GA
• Conventional technique:– Pre-anesthetic medication: H2 blocker, pro-kinetic, – Intra-venous induction: Propofol, thiopentone– Neuro-muscular paralysis: Depolarizing/ Non-de– Airway management: ET intubation, LMA– Intra-op: Monitoring, fluid restriction– Reversal/ extubation– Post-operative analgesia– Recovery room: monitoring
Complications of GA
• Disrrythmias• Hypotension• Inability to use vasoconstrictors • Dependency on Inotropic support• Delayed recovery• Persistent neuro-paralysis• Difficulties in choice of Post-operative Analgesia
Regional
• Useful for temporary/ peripheral placement• Supra-clavicular Brachial plexus Block:• Single shot or Continuous catheter technique• Modalities– Ultra-sound Guided– Peripheral Nerve Locator guided– Blind technique
Limitations!
• Limited applicability• Useful only if distal/Forearm vessels planned• Relative contra-indications– Patient acceptability– More proximal vessels– Coagulopathy– Anticipated longer time required
Logistical/ Infrastructural
• Time constraints
• Human resources/ manpower
• Perception related
• Overall team approach
Time management
• Routine elective surgical hours: 6-8 hours/day• Average time required for one case: 90-120
minutes• Additional time lost between cases: 10-15
minutes• Effectively the number of case can be safely/
practically done : 3 major (GA)± 1 minor (LA)
Human resources/ manpower
• The multiple teams of health providers involved
• Limitations of staffing/ number
• Limitation of the available OR slots
• Excessive loading: errors/ morbidity &
mortality!
Consumables!
• Anesthetic medications/Equipment– Centrally acting α2 agonists : dexmedetomidine– Cardio-stable NMBDs : Rocuronium– “Turn on-Turn off’ Opioids: Remifentanil– Specific anti-cholinergics : Glycopyrrolate
• Other consumables: surgical/miscellaneous
Teams!!
• Co-ordination between the team members– The Renal team– The Admitting/Medical team– The Surgical team– The Anesthesiologists– The Nursing team• The Ward• The OR
– The Ancillary staff team
Our Experience/ evidence
1st April 2012 - 30th September 2013(18 Months)• Total Number of surgical procedures: 2661
• Day cases: 635• Inpatients: 2026
• Total number of renal cases:201• Percentage: 7.5%• Total number done under GA:103• Percentage: 3.9%• Morbidity/Mortality: 1 Death
Lessons learnt!
• Proper considerations to the “ground realities!”• Communication-communication-communication!• “Renal patients do not behave like normal patients• “ All Renal patients for LA/Regional/GA must have
pre- anesthesia assessment/optimization”• “Pre-operative dialysis not necessarily means
everything is OK!”
More Lessons learnt!
• “Over-enthusiasm is more harmful than having any benefits” especially : number of patients postings for surgery
• Intra-operatively:“ Anticipate the most unanticipated and be forewarned/ forearmed”
• “Mutual respect between team members/ specialties is of paramount importance”
• “This is an ongoing process and not the endpoint”
Recommendations!
General:• Practicality based planning for number of
patients to be posted for surgeries• Proper and in-depth preparation• Mandatory pre-anesthetic assessment • Post-dialysis review• Electrolytes/coagulation profile• Pre-anesthetic medication
Recommendations!General:• Co-ordination between the teams• Confirmation of the vascular access site before
siting IV cannula• Reserving the specific OR day exclusively for
vascular access cases• Having adequate infra-structural/ Human
resources support
Recommendations!Timing of preoperative dialysis :• Dialysis is usually scheduled about 12–24 hours prior
to surgery. • The ionic content of the dialysate may be altered to
influence the amount and composition of fluid removed
• Co-ordination between anesthesia and renal physicians pre-preoperatively is very important.
• A post-dialysis measurement of serum electrolytes is required before surgery – as dialysis induced electrolyte disturbance can predispose
to intraoperative cardiac dysrhythmias.
Recommendations!
Intra-operative (specific):
• Modifications in anesthetic approach
– Avoiding Cardio-inhibitory anesthetic agents!
• Intravenous induction to be voided; propofol/thiopentone
• Volatile Induction Maintenance Anesthesia(VIMA): sevoflurane …
3MAC →1-1.3 MAC
– Laryngeal Mask airway(LMA)/ Avoiding ETT
– Avoiding depolarizing/ Non-depolarizing NMBDs
Recommendations!– Balanced/ adequate intra-operative analgesia
(Avoiding excessive Intra-operative Use of Opioids)– Intra-operative Volume- restriction– Intra-operative Eternal vigilance/ excellent
monitoring and treatment• Hypotension: ephedrine in successive boluses/ avoiding
vasoconstrictors • Arrhythmias: good depth of anesthesia, Watchful Non-
intervention!
– Watch for surgical complications: hemorrhage/ oozing!
Recommendations!
Post-operative
• Impeccable Post –operative care:
– In Post-operative recovery room
• Continued same level of vigilance as in OR
• Balanced post-operative analgesia
– In the wards
• Intuitiveness on the part of staff/ doctors
• Promptness of action
Conclusion!
• CRF/ESRDS patients pose multiples of challenges
• Especially in peri-operative period• Whether for Vascular access/ Renal transplant
or co-incidental surgical procedure• Well coordinated team approach is an
absolute necessity• Communication is the key issue
Conclusion!
• Vascular access is an absolute necessity• With functioning temporary access in place• Permanent access must be achieved in
planned/elective manner• Logistical and ‘ground realities’ need to be
taken in to consideration• Well planned protocol based peri-operative
management is desirable/ mandatory
Take Home Message!!!!
No Justification in having additional Morbidity/ mortality, than inherent
to the primary pathology due to inadequate/improper planning,
Overzealousness &
Non-coordination!!
Thank
You!