Anesthesiology

Lec:-

Anesthesia for patient with renal disease

INTRODUCTION

&.Anesthesia and surgery carry some risk to renal function and some
patient presented to surgery with renal disease.

&.Our job is preserve renal function and dealing with complication

related to renal impairment.

 Renal blood flow (RBF)

&.RBF of about 1200 ml/min is well maintained (autoregulated) at blood
pressures of 80 ton180 mm Hg.

&.Principal goal of blood flow regulation is to maintain GFR.

 Glomerular filtration rate (GFR).

&.Is Volume of plasma filtered by the kidneys per unit time. Normally
120 ml/ min (173 l/day).

&.Renal hypoperfusion results in active absorption of sodium and passive

absorption of water.

&.If renal hypoperfusion persists or worsens the GFR is decreased and

The result is oliguria.

&.The euvolemic, nonstressed state has little baseline sympathetic tone is

essential factors affect renal blood flow and GFR.

&.Under mild to moderate stress, RBF decreases slightly, but,

maintaining GFR.

&.During periods of severe stress (e.g., hemorrhage, hypoxia, major

surgical procedures), both RBF and GFR decrease secondary to
sympathetic stimulation.

 Functions of the kidney.

 1. Regulation of body fluid volume and composition
2. Acid-base balance
3. Detoxification and excretion of nonessential materials, including
drugs
4. Endocrine and metabolic functions such as erythropoietin
secretion, renin, vitamin D conversion, and calcium and phosphate
homeostasis

 Risk factors of postoperative kidney injury

Which presented as (increased blood urea nitrogen [BUN]) and
(Oliguria) include :-

1.. Left ventricular dysfunction,

2..Advanced age, over 55 years

3.. Jaundice.

4..Diabetes mellitus .

5.. Patients undergoing cardiac or aortic surgery are particularly at risk

for developing postoperative renal insufficiency.

6.. sepsis.

8.. Nephrotoxins include radiocontrast media, aminoglycosides,

angiotensin-converting enzyme (ACE) inhibitors, and fluoride associated
with volatile anesthetic metabolism.

7..Hemolysis and muscular injury (producing hemoglobinuria and

myoglobinuria) .

9.. Obstructive nephropathy in men with conditions such as prostatism

and ureteral obstruction from pelvic malignancies. (Called Postrenal
causes 10% of cases) .

10.. Hypertension,

11.. Trauma,
&.Whereas Patients have uremia (chronic renal failure ) presented with

1. (elevation of BUN and creatinine),

2. Hyperkalemia,
3. Hyperphosphatemia,
4. Hypocalcemia,
5. Hypoalbuminemia, and
6. Metabolic acidosis.
7. They are also anemic and have platelet and leukocyte dysfunction,
rendering them prone to bleeding and infection.

&.Acute kidney injury (AKI) is a common problem, with an incidence of

up to 5% in all hospitalized patients and up to 8% in critically ill patients.

&.Postoperative AKI may occur in 1% or more of general surgery

patients, and up to 30% of patients undergoing cardiothoracic and
vascular procedures.

 Complication of AKI:-
Perioperative AKI greatly may cause :-

1. increases hospitalization costs,

2. mortality rate, and
3. perioperative morbidity, including
4. fluid and electrolyte derangements,
5. major cardiovascular events,
6. infection and sepsis, and
7. gastrointestinal hemorrhage.

 Evaluating Renal Function

&.In addition to history and physical examination , abnormalities of
glomerular function cause the greatest derangements and are most readily
detectable, the most useful laboratory tests utilized currently are those
related to assessment of glomerular filtration rate (GFR) or what we
called renal function test, which include as example .

i. BLOOD UREA NITROGEN

&.The primary source of urea in the body is the liver. Hepatic conversion
of ammonia to urea prevents the buildup of toxic ammonia levels:

2NH3 + CO2 → H2N − CO − NH2 + H2O

&.Blood urea nitrogen (BUN) is therefore inversely related to glomerular

filtration rate .

&.As a result, The normal BUN concentration is 10–20 mg/dL. elevations

usually result from decreases in GFR or increases in protein catabolism.
BUN concentrations greater than 50 mg/dL are generally associated
with impairment of renal function.

ii. SERUM CREATININE

&.Creatinine production in most people is relatively constant. Creatinine

is then filtered (and to a minor extent secreted) but not reabsorbed in the
kidneys.

&.Serum creatinine concentration is therefore inversely related to

glomerular filtration and generally reliable indices of GFR in the healthy
patient.

The normal serum creatinine concentration is 0.8–1.3 mg/dL in men

and 0.6–1 mg/dL in women.

Doubling of the serum creatinine represents a 50% reduction in GFR.

iii. URINALYSIS

&.Urinalysis routinely performed for evaluating renal function.

&.Urinalysis can be helpful in identifying some disorders of renal tubular

dysfunction as well as some nonrenal disturbances.

&.A routine urinalysis typically includes:-

 A. specific gravity; Specific gravity is related to urinary osmolality;
1.010 usually corresponds to 290 mOsm/kg. A specific gravity
greater than 1.018 after an overnight fast is indicative of adequate
renal concentrating ability.

&.A lower specific gravity in the presence of hyperosmolality in plasma

is consistent with diabetes insipidus.

B. Glucose, Glycosuria is the result of hyperglycemia (normally 180

mg/dL).
C. protein, Proteinuria detected by routine urinalysis should be
evaluated by means of 24-h urine collection. Urinary protein
excretions greater than 150 mg/d are significant.
D. Bilirubin content; Elevated levels of bilirubin in the urine are seen
with biliary obstruction.
E. microscopic examination of the urinary sediment to detects the
presence of red or white blood cells, bacteria, casts, and crystals.
Red cells may be indicative of bleeding due to tumor, stones,
infection, coagulopathy, or trauma.
White cells and bacteria are generally associated with infection.
Disease processes at the level of the nephron produce tubular casts.