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When and How should we ask pts about kidney disease?

  • During the Pre-op interview
    • 1. Have you ever had any kidney problems?
    • 2. Have you ever had any changes in bladder function in the last year?
    • 3. Have you ever had any kidney stones?
    • 4. Have you ever had kidney failure, dialysis, or two or more kidney infections?


pts answer answer yes to having If kidney problems what should you ask about next?

  • 1. What is your kidney problem?
  • 2. Do you make urine?
  • 3. Are you on dialysis?


If they answer yes to dialysis what do you need to ask/ do?

1. Ask what kind of dialysis (Hemodialysis, Peritoneal)

2. When was the last time you had dialysis?

3. What was your last potassium? 4.


What should you always document if a patient undergoes dialysis?

POTASSIUM! Pull it over in the chart and document that you have seen it!


What is the measurement for Chronic Kidney Disease? Chronic Renal Failure?

  • CKD- GFR of less than 60 ml/min/1.73m2 for 3 months
  • CRF- GFR less than 15 ml/min/1.73m2


Most common reasons we will see Chronic Renal Failure patients

AV fistula creation or revision

GI Bleeding


Tidbits about IV placement and solutions to use

  • No brachiocephalic veins! ---- needed for fistula placement
  • Do not place IV or BP cuff on operative side
  • No LR (K+) or D5W
  • 500 ml bag
  • microgtt tubing


Situations where dialysis will be required

  • Oliguria
  • Fluid Overload
  • Hyperkalemia
  • Severe Acidosis
  • Metabolic Encephalopathy
  • Pericarditis
  • Coagulopathy
  • Drug Toxicities


Before taking dialysis pts for surgery what should the patient look like?

  • OPTIMIZED! --Surgery that day
  • Review fluid removed
  • Note post dialysis K+ (should be < 5.5)
  • Pre/post dialysis weights


When should scheduled meds be administered? Why?

  • After Dialysis
    • Dialysis removes many medications from the blood.
  • Medications more likely to be removed if they are low-molecular weight, water soluble, and non protein bound


How can uremic encephalopathy present?

1. Asterixis

2. Myoclonus

3. Lethargy

4. Confusion

5. Coma

6. Seizures


Should we regularly administer regional anesthesia to these patients?

Avoid if possible, lower dose d/t peripheral neuropathy


Disequilibrium Syndrome

Dialysis Related --Transient CNS disturbance after rapid shifts in ECF and ICF


What would you assess for neurologically that could be associated with renal disease?

1. Uremic Encephalopathy

2. Autonomic Neuropathy

3. Peripheral Neuropathy


5. Disequilibrium Syndrome


Hematological assessment of the renal patient: What to look for and why

  • Anemia (Hgb 6-8 g/dL)
  • 1. Decreased EPO production- (See Garmins Lecture)
  • 2. Decreased RBC production
  • 3. Bone Marrow Suppression (excess PTH)
  • 4. Impaired platelet function
  • 5. Impaired WBC function
  • Why do they tolerate this?
    • Increased 2.3 DPG (Right shift on oxydis curve)
    • Metabolic Acidosis (Also R shift on oxydis curve)


How do Renal patients tolerate anemia well?

  • Increased 2.3 DPG (Right shift on oxydis curve)
  • Metabolic Acidosis (Also R shift on oxydis curve)


Cardiac Assessment for renal pt: What will you look for?

1. Increased CO (Compensate for low O2 capacity)

2. HTN (RAAS activation)

3. L Ventricular Hypertrophy

4. CHF w/ Pulm Edema (after compensation reached)

5. Deposits of Calcium (on heart valves and on conduction system

6. Arrhythmias (Electrolyte imbalance)

7. Uremic Pericarditis (Chest pain, tamponade)

8. CAD, PVD (From triglycerides (osmotic from Liver))


Pulmonary Assessment of the Renal Patient: What to look for

1. Increased MV (Compensate for Acidosis)

2. "Butterfly Wings" on CXR (Pulm Edema)


Endocrine Assessment of the renal patient: What to look for

1. Diabetic (Poor glucose tolerance)

2. Hyperparathyroidism ----Prone to fractures from bone degredation

3. High Triglycerides

4. No degredation of hormones (increased amount in circulation)


GI/Liver Assessment of the Renal Patient: What to look for

1. GI Hemmhorage

2. N/V ------Hypersecretion of Gastric Acid--Possible RSI

3. High Hep B and C Incidence


Renal Failure impact on drugs, and what to do about it

  • Drug effects or pharmacokinetics altered d/t
    • 1. Anemia- (Decrease MAC of Volatile agents) -----No enflurane!!!
    • 2. Decreased total Protein (Decrease all protein bound drugs)
    • 3. Electrolyte Abnormalities
    • 4. Fluid Retention
    • 5. ANY drugs eliminated UNCHANGED by the kidneys are CONTRAINDICATED (Gallamine, Phenobarb, LMWH)


LMWH- unique consideration

Cleared by the kidney but NOT by dialysis == prolonged duration


Lab tests that could be useful

1. CMP

2. GFR

3. CBC


5. ABG


Tests that could be useful and what are they looking for?

  • 1. CXR
    • Uremic pneumonitits
    • Pericardial Effusion
    • Fluid Status
  • 2. EKG
    • Ischemia
    • Conduction Blocks
    • Left Vent Hypertrophy
  • 3. Echo
    • Hypertrophy
    • EF
    • Pericardial Fluid


Why is BUN not reliable as a sole lab value? What value BUN is indicative of a low GFR

It can vary with protein dietary intake. >50 mg/dL is indicative in pts with normal diet


What is the most common cause of increased BUN?

CHF secondary to the reabsorption of BUN????? (I don't know what this means)


Plasma Creatinine

1. Source?

2. Lag Time?

3. Elderly Patients?

4. 50% increase in plasma creatinine=

1. Skeletal Muscle

2. 8-17 hr lag time after a change in GFR

3. Elderly pts Cr levels stay normal constantly -----If elevated, very indicative of renal failure

4. Coresponding 50% decrease in GFR


Creatinine Clearance Values 1-6

1. Normal 100-120 ml/min

2.Decreased Renal Reserve 60-100 mls/min

3. Mild Renal Impairment 40-60 mls/min

4. Moderate Insufficiency 25-40 mls/min

5. Renal Failure < 25 mls/min

6. ESRD < 10 mls/min


Common renal pt lab abnormalities

1. Hyponatremia

2. Hyperkalemia

3. Metabolic Acidosis (high anion gap)

4. Hypermagnesemia

5. Hypocalcemia (If pt hypotensive and not responsive to pressors, give Ca++)

6. Hypoalbuminemia

7. Hyperglycemia


3 treatments we use to lower K+

1. Calcium Gluconate 10% (10-20ml)

2. Sodium Bicarb (50-100 mEq/L)

3. Glucose (50 ml of 50%) and Insulin (10 units regular)