6.4 CKD - Tplx , Systems, Pain Flashcards
A patient is to receive a cadaveric renal transplant.
a) Detail the aspects of your preoperative assessment specific to chronic kidney disease (CKD).
11 marks
Issues relate to: >> CKD itself. >> Underlying cause of the CKD. >> Management of CKD. >> Implications of possible previous transplant (and I will freely admit I would never have thought of this issue if it hadn’t been in the Chairman’s Report!).
Airway:
» Some causes of CKD may contribute to a difficult airway, e.g. scleroderma.
Respiratory:
> > Assess for fluid overload.
> > Patient may be immunosuppressed due to drugs or disease – assess for possibility of respiratory infection.
> > Continuous ambulatory peritoneal dialysis (CAPD) fluid should be drained preoperatively as it may cause diaphragmatic splinting, basal atelectasis, shunt.
A patient is to receive a cadaveric renal transplant.
a) Detail the aspects of your preoperative assessment specific to chronic kidney disease (CKD).
(11 marks)
C
Cardiovascular:
> > Patients with CKD at risk of accelerated coronary artery disease. Assess symptoms, check recent ECG.
> > Hypertension may be underlying cause or result from CKD. Check for end-organ damage in the form of left ventricular hypertrophy on ECG and echo.
> > Fistulae/vascaths must be preserved. Do not cannulate or take blood pressure on fistula arm, avoid pressure on it intraoperatively.
> > At risk of calcified valvular lesions resulting in stenosis – assess symptoms, auscultate heart sounds, echo if indicated.
> > Up-to-date ECG, echo and exercise testing should be done in work-up for transplant list.
a) Detail the aspects of your preoperative assessment specific to chronic kidney disease (CKD).
(11 marks)
Neuro
Neurological:
» Autonomic neuropathy related to uraemia and diabetes mellitus.
Risk of delayed gastric emptying and
possible need for proton pump inhibitor
premedication and rapid sequence induction.
Endocrine:
» If patient has diabetes mellitus, use variable rate insulin infusion.
> > In the absence of diabetes, the patient may still have impaired glucose tolerance due to steroid treatment.
> > If having steroid treatment, may need perioperative supplementation.
> > Patient may have secondary hyperparathyroidism: check calcium and phosphate levels.
a) Detail the aspects of your preoperative assessment specific to chronic kidney disease (CKD).
(11 marks)
Farm
Pharmacology:
» Suxamethonium for rapid sequence induction may be contraindicated in the presence of elevated serum potassium.
> > Variable rate insulin infusion if diabetic, or management of oral hypoglycaemic agents according to AAGBI guidelines.
> > Omit angiotensin converting enzyme inhibitor or angiotensin II receptor antagonist prior to surgery to avoid hypotension.
All other antihypertensives to be continued.
> > If patient has previous transplant, may be taking steroids and other immunosuppressive drugs
(e.g. tacrolimus, cyclosporin).
Even if transplant has failed, these drugs need to remain therapeutic to avoid rejection, so seek advice from renal physicians regarding dosing perioperatively, whilst nil by mouth.
A patient is to receive a cadaveric renal transplant.
a) Detail the aspects of your preoperative assessment specific to chronic kidney disease (CKD).
11 marks
Gastrointestinal:
» Consider autonomic neuropathy due to chronic kidney disease (or diabetes mellitus).
Premedication with proton pump inhibitor and rapid
sequence induction should be considered.
Haematological:
» May have anaemia due to a variety of underlying reasons: chronic disease, impaired erythropoiesis, blood loss from dialysis, gastrointestinal loss.
> > Check full blood count, ensure up-to-date group and save.
> > Thrombocytopathy associated with renal failure may contraindicate regional anaesthesia, but this is improved by dialysis and therefore unlikely to be an issue.
A patient is to receive a cadaveric renal transplant.
a) Detail the aspects of your preoperative assessment specific to chronic kidney disease (CKD).
(11 marks)
Immune Infection
Renal
Immune, infection: >> Susceptible to infection due to immunosuppression of disease state and/ or drugs. Check white cell count; consider urinary tract, respiratory system, and vascular or peritoneal access as possible sources of infection.
Renal: >> Assess fluid status. Some patients with CKD are anuric, some still pass urine. Ensure patient is not hypovolaemic if recent haemodialysis as this increases risk of perioperative hypotension.
> > Check electrolytes –
may require haemodialysis preoperatively.
Abnormalities predispose to arrhythmia
A patient is to receive a cadaveric renal transplant.
b) How can the function of the
transplanted kidney be optimised
intraoperatively? (3 marks)
Airway, respiratory:
» Optimise gas exchange to support oxygen delivery, minimise risk of respiratory acidosis.
Cardiovascular:
» Optimise filling with cardiac output monitoring, central venous pressure monitoring (12–14 cm H2O).
> > Aim for normotension
(MAP 90 mm Hg or more in hypertensives).
> > Adequate patient warming to
avoid vasoconstriction.
Endocrine:
» Glucose control if indicated.
Pharmacology:
» Do not give nephrotoxins including starch solutions.
Immune, infection:
» Early commencement of immunosuppression.
c) How may this patient’s
postoperative pain be optimally
managed? (3 marks)
> > Regular pain assessment and management of anxiety through explanation and reassurance.
> > Regular paracetamol.
> > NSAIDs contraindicated due to
effect on renal perfusion.
> > Wound catheters.
> > PCA: fentanyl and oxycodone
do not accumulate in renal failure
(graft may not function immediately).
> > Epidural: used in some centres,
may be contraindicated by recent
heparin administration for dialysis.
Need to ensure that hypotension does not result.
d) Explain why some common
postoperative analgesic drugs
should be avoided. (3 marks
> > NSAIDs: reduce renal perfusion, poor perfusion results in reduced function, and can be directly nephrotoxic.
> > Morphine: metabolised primarily in the liver to active metabolites that are excreted by the kidney.
Postoperative renal impairment
(i.e. a graft that is not immediately fully functional)
might result in accumulation of these metabolites and cause drowsiness, hypotension and respiratory
depression. Smaller doses with longer dosing intervals for short time periods are acceptable.
> > Codeine and dihydrocodeine:
active metabolites renally excreted so increased risk of sedation, respiratory depression and hypotension in
renal failure.
