Perioperative care of patients with kidney diseases prof (1). ahmed rabee

1. Perioperative Care of Patients
with Kidney Diseases
By
Dr. Ahmed Rabie El-Arbagy
Prof. of RENAL- MEDICINE
Faculty of Medicine- Menoufia Univ.
Dakahlia Syndicate -2017

2. AGENDA
Introduction( Nature of Renal
dysfunction)
Preoperative Assessment
Investigations
Renal risk Assessment
Surgical Risks in CKD
Perioperative AKI
Conclusion

3. INTRODUCTION( Spectrum of Renal patients)
Renal dysfunction represents a spectrum of disease with
potentially far-ranging consequences on surgical and
anesthetic management due to not only the underlying
disease processes but also from the intervening medical
and surgical therapies.
 Furthermore, optimization of the patient with renal
dysfunction needs to not only consider the preexisting
renal function but also the potential risk of AKI in the
perioperative setting.
Remember that perfect preoperative evaluation
for perfect perioperative outcome in patients with
kidney diseases

4. INTRODUCTION (Changes in Impaired Kidney)
Impairment of excretory & synthetic functions of the
kidney result in multiple complications that must be
identified & corrected preoperative.
In addition, drugs normally excreted by the kidney can
accumulate to toxic levels in patients with CKD.
Therefore, adjusting dosages or avoiding such drugs,
including iodinated contrast in high-risk patients, is a key
management principle in patients with CKD.
CKD can be associated with excess surgical
morbidity, the most important of which include AKI,
hyperkalemia, volume overload, and infections.

5. Preoperative Assessment
A careful history should have been taken initially
from the patient before any examination or
investigations occur.
As should be apparent, patients with CKD may have
complex and overlapping medical problems: loss of
renal function, diabetes, CVD, HTN, anemia,
dyslipidemia, poor nutritional status, MBD, neuropathy,
and an overall decreased quality of life.
These assessments hold true for the preoperative
evaluation but they must be put into context of the
requirement for the underlying surgery and the inherent
surgical risk.

6. Preop. Assessment( Intensive evaluation)
It is common practice to perform routine testing on
patients before they go to theatre.
Given the array of diseases that can affect kidney
function, a patient with kidney dysfunction who
presents for surgery requires a comprehensive
evaluation and care optimization.
Surgery in the Patient with Renal Dysfunction with
CKD may require inpatient admission or coordination
of outpatient nursing services.
Patients with CKD are at higher risk of
complications and prolonged hospital or ICU stay.

7. Concept of Preoperative Diagnostic Tests
Selective routine preoperative diagnostic tests are performed in
patients with CKD.
Avoid excess & unnecessary blood-draw procedures preoperatively
and during hospitalization in this generally anemic patient
population.
Avoid IV line placements and blood-draw procedures in the
nondominant arm of a patient who will be starting dialysis in the near
future. In this situation, the vasculature needs to be protected for the
creation of an AVF or graft.

8. INVESTIGATIONS
The doctor should ask whether the result of the test is
going to alter the patient's management. Ordering
unnecessary tests is neither helpful nor cost-effective.
Several preoperative laboratory studies are
recommended for patients with CKD but the more
important question is what to do with the results?.
The extent of preoperative testing is dependent on a
patient’s comorbid diseases and often includes an ECG
and CXR.
Appropriate counselling is important, so that the
patient realises the implication of both positive and
negative results and is able to give informed consent.

9. INVESTIGATIONS( Renal Function)
Urinalysis: Urine dipstick or analysis is useful to detect
undiagnosed diabetes or UTI. It may also detect haematuria
or abnormal protein loss.
S. creatinin , BUN & eGFR : This detects underlying renal
deficiency and the possibility of developing AKI after major
surgery. It may also influence the choice of drugs given within
the anaesthetic.
An eGFR should be calculated to not only ensure that correct
dosage adjustments are made for renally excreted medications
but also to help quantify perioperative risk.
AKI in the setting of CKD should prompt an evaluation to
identify precipitating factors and elective procedures
should be postponed until resolution.

10. Optimising Management For Patients with known CKD or AKI
** Management of such patients should be optimised prior to
going to theatre.
** Measures include:
* Optimising blood pressure and fluid balance,
* Correcting acidosis or hyperkalaemia.
* Drugs that are excreted solely via the kidney should be used
cautiously and with appropriate dose adjustment.
*Review the drugs that already taken with patients that may put
them at risk of AKI.
* Those with anaemia secondary to CKD should not be transfused
pre-operatively unless there is evidence for ongoing blood losses as
this may precipitate fluid overload & hyperkalaemia--------------

11. Renal Risk Assessment and Interventions
** Patients with CKD ( On conservative treatment)
Rapidly establish the duration of CKD; level of renal dysfunction and
whether the elevation in BUN and creatinine is prerenal, intrarenal, postrenal,
or a combination of these on a background of CKD.
Patients who are euvolemic, responsive to diuretic therapy, and/or have no
significant electrolyte abnormalities or bleeding tendencies have
uncomplicated cases and do not require dialysis before surgery.
Patients with edema, CHF, or pulmonary congestion or those who are
responsive to diuretic therapy require further CV evaluation.
If the results of the CV evaluation are optimal, then fluid overload can be
attributed to CKD. Combination diuretic therapy can help treat these patients
to achieve euvolemia prior to surgery.

12. Renal Risk Assessment and Interventions( Dialysis)
** Patients with CKD and May need dialysis
Patients with diabetes have a greater tendency of having
volume overload or CVD.
CKD may be so advanced that the patient develops diuretic
resistance, with progressive edema. Preoperative dialysis may be
considered in these patients.
If postoperative dialysis is imminent, the surgeons should be
advised to place a temporary catheter intraoperatively. This
avoids the use of femoral cannulation, which carries a higher risk
of infection. Permanent vascular access placement can then be
arranged when the patient is more stable.

13. Renal Risk Assessment and Interventions
Further deterioration in renal function can be avoided by
identifying and eliminating potential nephrotoxic agents.
These include substitution or dosage adjustment for antibiotics
(eg, aminoglycosides, acyclovir, amphotericin), sedatives, and
muscle relaxants. NSAIDs should be avoided, as should
radiocontrast .
Electrolyte abnormalities must be identified and corrected
perioperatively.
Use of pethidine{ demerol (meperidine) }for postoperative pain
control should be avoided because accumulation of its
metabolite normeperidine can cause seizures in patients with
CKD, especially those on dialysis.

14. Renal Risk Assessment and Interventions
( Dialysis patients)
** CKD patients already on dialysis, the following need to
be determined:
*Dialysis adequacy * Preoperative dialysis needs
*Postoperative dialysis timing
*Dosage requirements for all medications
Patients on HD usually require preoperative dialysis within
24 hours before surgery to reduce the risk of volume
overload, hyperkalemia, and excessive bleeding.
Patients on PD who are undergoing abdominal surgery
should be switched to hemodialysis until wound healing is
complete. PD should be continued for those undergoing
nonabdominal surgery.

15. Renal Risk Assessment and Interventions
** Transplanted patients( Kid. Tx.)
Because of complicated interactions and immunosuppressive (IS)dosing,
monitoring, and adjustment, a nephrologist with specialized knowledge of
renal transplantation should be involved in the preoperative evaluation of
patients with CKD who have received Kid. Tx.
* Drug- Drug interactions :
Cyclosporine or tacrolimus taken by renal transplant recipients for IS are
metabolized by the cytochrome P-450 system in the liver and, thus, interact
with a wide variety of agents. Diltiazem, hepatic 3-methylglutaryl coenzyme A
reductase inhibitors (statins), macrolides, and antifungal drugs inhibit the P-
450 system, elevate levels, and can precipitate nephrotoxicity. Others, such as
carbamazepine (Tegretol), barbiturates, and theophylline, induce the P-450
system, reduce levels, and can precipitate rejection.
* Drug levels must be monitored in this setting. IV cyclosporine or tacrolimus
should be given at one third the oral dose until the patient is able to tolerate
oral medications.

16. SURGICAL RISK IN CKD
Surgical risk with CKD, as in all other patients, depends on:
The type of surgery and whether the procedure is routine or
performed on an emergency bases.
The extent of renal impairment and the use of dialysis also affect
outcome and subsequent morbidity.
Overall surgical mortality rates in patients with ESRD range from 1 to 4
percent.
Emergency surgery is associated with an even five times greater risk
of death.
In patients with ESRD who undergo cardiac surgery, estimated
mortality rates range from 10 to 20 percent, and concomitant DM and
patient age > 60 years further increase the risk of death.
In these patients, cardiac arrhythmias and sepsis are the most
common causes of perioperative mortality.

17. Surgical Risk & CKD
Surgical risk as related to CKD can be divided
into the following areas:
 Need for surgery,
Specific surgical techniques,
 Fluid shifts & blood loss,
 Analgesic requirements,
 Intravenous access and
Anesthetic techniques.

18. Surgical risk(The need for surgery )
** The need for surgery can be stratified as elective, urgent, or
emergent:
As discussed previously, emergent surgery is associated with
increased morbidity and mortality for patients with CKD.
Urgent and elective surgery can be deferred until the patient’s
status is optimized, particularly if they have concomitant AKI.
Surgery can help to enhance the resolution of AKI if it is treating the
underlying precipitating event.
 Again, communication between primary care and perioperative
physicians is crucial to make this determination and to plan an
appropriate course of action.

19. Surgical risk, specific techniques & Contrast media
** Surgical techniques include the use of
nonionic contrast agents or the use of intraabdominal
laparoscopy and they may need to be modified for patients
with CKD or AKI. Earlier studies on patients with CKD
suggested that nonionic contrast agents might increase the
risk of death in patients with CKD. However, others show
clinically insignificant changes, when preoperative
prevention strategies are employed.
The ideal strategy to prevent contrast-induced
nephropathy (CIN) is unknown but current
recommendations include hydration, avoidance of other
nephrotoxic medications, prevention of hypotension,
and possibly use of adjuvants such as sodium bicarbonate
or N-acetylcysteine.

20. Surgical risk, Contrast media
IV Contrast Agents These may cause pathological VC
in a vulnerable kidney. In susceptible patients, pre-
hydration with IV crystalloid may be of benefit and
where possible, the use of lower volumes of contrast.
 Senior Support Doctors managing patients at risk of
significant peri-operative KI should liaise with support
services for peri-operative management, including
nephrology services and high dependency or critical
care units where increased monitoring or RRT can
be offered.

21. Surgical Risk& Laparoscopy
Laparoscopic surgery with abdominal
pneumoperitoneum is a common technique favored for
its noninvasive nature, faster wound healing, and
reduction in postoperative pain. However, laparoscopy is
also associated with a reduction in renal perfusion. To
preserve renal blood flow, abdominal insufflation
pressures > 15 mmHg are not recommended.
 Laparoscopy can also cause hypotension, which will
further aggravate reductions in renal perfusion.
To mitigate these changes, adequate fluid replacement
is recommended.

22. Surgical risk, fluid balance
Maintenance of euvolemia and renal perfusion seem like obvious goals for patients
with CKD or AKI. However, assessing their adequacy in the perioperative period is not a
simple task.
Features of hypovolemia can be masked by anesthesia and surgery.
Invasive monitoring may improve assessment but disease states, such as sepsis, can cause
maldistribution of intravascular volume due to VD and altered capillary permeability.
Intraoperative blood loss and fluid shifts during surgery can compound these problems.
Typically the anesthesia team will aim for a mean arterial pressure > 65 to 70 mmHg, or
higher for the uncontrolled HTN patient, UO >0.5 ml/kg/h as applicable, CVP 10 to 15
mmHg, and pulmonary artery wedge pressure of 10 to 15 mmHg.
Intraoperative transesophageal ECHO and newer monitors of stroke volume may also be
used to assess adequacy of cardiac preload.

23. Surgical risk, fluid balance& Resuscitation
Fluid resuscitation is typically with either crystalloids
or colloids or blood products as indicated. The ideal
crystalloid is debatable and many texts continue to
recommend normal saline as the choice of IV fluid for
patients with kidney dysfunction.
Normal saline is hypertonic and hyperchloremic
compared with plasma and volumes of > 30 ml/kg can
lead to hyperchloremic metabolic acidosis and
exacerbation of hyperkalemia.
Over hydration and goal-directed therapy to
supranormal values can have a negative effect on
patient outcome such as ileus, pulmonary edema, and
prolonged hospital admission.

24. Surgical risk, Analgesic requirement
Analgesic requirement in the perioperative period is
an important area to consider given that opioids may
accumulate in patients with CKD, placing them at
higher risk of respiratory depression.
 NSAIDs are not recommended for patients with
CKD or AKI. Other options for moderate to severe
postoperative pain include indwelling peripheral nerve
catheters, long-lasting peripheral nerve blocks, or
epidural catheters, as applicable.

25. Surgical risk, Vascular access
IV access is not a trivial matter for patients with CKD.
 HD fistulas, previous blood draws, and previous surgeries
all contribute to making intravenous access more difficult
in this patient population.
 Central line placement may be required or a peripherally
inserted central catheter (PICC) can be placed
preoperatively for cases not associated with significant
fluid losses or for cases requiring ongoing postoperative IV
medical therapies.
If future vascular access grafting is contemplated, IV
line placement and blood draws should be avoided in
a patient's nondominant arm.

26. Surgical risk, Anesthetic techniques
Anesthetic techniques for surgery can be grouped
into general anesthesia, neuraxial anesthesia, peripheral
nerve blockade, or sedation.
The ideal anesthetic technique for a patient with
CKD or AKI having a particular procedure is
unknown.
Ultimately the selected anesthetic technique will
be determined by the patient’s coexisting disease,
surgical approach, and desired anesthetic goals.

27. Anesthetic techniques( Induction)
 All commonly used anaesthetic agents except (ketamine) decrease systemic
vascular resistance, reduce both cardiac contractility and cardiac output and
attenuate the normal response to hypovolaemia.
The haemodynamically unstable patient is therefore at risk of CV collapse.
The dose of induction agent should be carefully considered. Many patients at
risk of AKI will need a reduced dose. Prior to renal excretion, induction agents
undergo redistribution and biotransformation into inactive products. However in
hypovolaemia there is a diversion of blood to essential organs and across the blood
brain barrier, therefore effects of induction agents may be exacerbated.

28. Anesthetic techniques( INDUCTION)
Volatile anaesthetic agents such as isoflurane and
sevoflurane contain nephrotoxic flouride, which poses a
theoretical risk for AKI although there is little evidence
for avoidance of these agents.
Opioids :AKI prolongs the action of opioids as they are
renally excreted. The administration of lower doses is
recommended in these patients.
 Muscle relaxants Suxamethonium should be avoided in
AKI patients with documented raised potassium levels as
it increases potassium efflux from muscle cells and its
administration can lead to life-threatening
hyperkalaemia.

29. Anesthetic techniques( General)
The administration of general anesthesia may induce a reduction in renal
blood flow in up to 50% of patients, resulting in the impaired excretion
of nephrotoxic drugs. In addition, the function of cholinesterase, an
enzyme responsible for breaking down certain anesthetic agents, may be
impaired, resulting in prolonged respiratory muscle paralysis if
neuromuscular blocking agents are used.
N -acetyl-procainamide, a metabolite of procainamide, accumulates in
persons with CKD . The dose of procainamide should be adjusted, or a
substitute should be used.
Fluorinated compounds, such as methoxyflurane and enflurane, are
nephrotoxic and should be avoided in patients with CKD.
Succinylcholine, a depolarizing blocker, causes hyperkalemia.

30. SURGICAL RISK ( A-B disorders)
Chronic metabolic acidosis in patients with ESRD has
not been associated with increased perioperative risk.
However, acidosis in patients with CKD or ESRD may
decrease the effectiveness of some local
anesthetics.

31. SURGICAL RISK( Bleeding)
Uremia can cause platelet dysfunction, that increase perioperative bleeding. To
minimize uremic complications, patients with ESRD should undergo dialysis on
the day before surgery.
Bleeding time is the most sensitive indicator of the extent of platelet dysfunction.
Higher bleeding times > 10 to 15 minutes are associated with a higher risk of
hemorrhage.
Antiplatelet agents, including aspirin and dipyridamole (Persantine), should not
be given within 72 hours before surgery in patients with ESRD or uremic CKD.
In addition, some agents that have only minor platelet effects in patients without
uremia can have exaggerated effects in patients with ESRD and may theoretically
increase the risk of intraoperative bleeding. These drugs include diphenhydramine
(Benadryl), NSAIDs, chlordiazepoxide (Librium), and cimetidine.

32. SURGICAL RISK( Bleeding Correction)
*A small amount of heparin is used during HD, with a residual
anticoagulant effect lasting as long as two and one-half hours. Therefore,
unless heparin-free dialysis is used, it is prudent to wait at least 12 hours
after the last HD with heparin before an invasive surgical procedure.
** Options for Correcting Elevated Bleeding
Times in Patients with Renal Failure: *Intensive
dialysis
* Desmopressin (DDAVP), 0.3 mcg per kg IV 1 hour before surgery
* Cryoprecipitate, 10 units over 30 minutes IV; effects should be
apparent in 1 hour.
*Transfusion of packed RBCs to raise the hematocrit to at least 30
percent, which increases platelet interaction with vessel walls.

33. SURGICAL RISK ( ANEMIA& HCT Level)
*As renal function declines, patients are likely to develop
anemia because of decreased renal production of erythropoietin.
* While there is no published standard for safe preoperative
HCT levels in patients with impaired RF, one study demonstrated
increased intraoperative complications in patients with ESRD and
preoperative HCT levels ranging from 20 to 26 %.
Correcting severe or hemodynamically significant anemia
may help to avoid complications from perioperative blood loss,
as well as hemodilutional effects
Given these concerns, transfusion is necessary in some
circumstances.

34. SURGICAL RISK( Anaemia Treatment)
A possible downside to blood product transfusion is
antibody formation, which may decrease a patient's
future chances of successful renal transplantation.
 In addition, intraoperative infusion of blood may
cause hyperkalemia as a result of cellular lysis.
If the surgery is elective, Epo. may be administered to
raise the HCT to the upper acceptable value (36 percent).
Treatment should be initiated several weeks before
surgery.
Iron stores should be checked in all patients receiving
erythropoietin. For maximum effectiveness of
erythropoietin, iron deficiency should be treated.

35. SURGICAL RISK( Prophylactic antibiotic)
* Many patients with CKD or ESRF receive prophylactic
antibiotics for surgical procedures, particularly dialysis graft
procedures. Although vancomycin (Vancocin) has been
routinely used for this purpose, bacteria are becoming
resistant to this drug. Hence, a first-generation
cephalosporin in a dosage appropriate for renal function
would be a better choice for empiric therapy.
* Even with minor procedures (e.g., dental care), antibiotic
prophylaxis using standard endocarditis regimens is
recommended for the first several months after the
placement of synthetic vascular access grafts.
* The purpose is to avoid bacterial seeding of the grafts
before epithelialization occurs.

36. SURGICAL RISK( Evaluation OF CARDIAC RISK)
* CVD is the greatest cause of mortality in patients with renal
disease of any stage.
* One half of all deaths before and after kidney TX. are due to
cardiac causes, with diabetes increasing the chance of
atherosclerotic disease.
* Because of the high prevalence and rapid progression of
coronary artery disease in patients with kidney disease, cardiac
evaluation must be current to be useful.
* Targeting cardiac testing to patients with risk factors increases
the positive predictive value of an abnormal test that suggests
the presence of underlying heart disease.
* Cardiac risk factors include: age > 50 years; history of
angina, DM, or congestive HF & an abnormal ECG.

37. SURGICAL RISK( Evaluation OF CARDIAC RISK)
Stress testing (using exercise or pharmacologic agents), radionuclide
scanning, and stress ECHO have all been used to screen for coronary
artery disease in patients with ESRD.
Minor procedures, such as access manipulation, do not require an
extensive cardiac evaluation unless the preoperative ECG is abnormal.
Cardiac revascularization may decrease intraoperative cardiac risk and
enhance survival in patients with kidney disease, as in other patients.
However, cardiac revascularization is typically reserved for use in patients
whose cardiac risk is high enough to merit intervention independent of
preoperative management considerations.
Several guidelines on preoperative cardiac risk assessment are available.

38. Surgical risk( Cardiac Risk)
** Surgical procedures are classified in 3 groups according to
the combined risk of cardiac death and nonfatal MI:
High surgical risk, cardiac risk more than 5%
Aortic and other vascular surgery
Prolonged procedures with large fluid shift/blood loss
Intermediate, cardiac risk less than 5% but more than 1%
Carotid endarterectomy Head and neck
Intraperitoneal and intrathoracic
Orthopedic Prostate
Low, cardiac risk less than 1%
Endoscopy Superficial
Cataract Breast

39. Assessment Of Patient Risk Factors
Patient risk is assessed with the modified Revised
Cardiac Risk Index (RCRI):
4C+D is a mnemonic to remember the risk factors in
RCRI:CAD,CHF,CVA,CKD,DM
Ischemic( coronary) heart disease
History of congestive heart failure
History of cerebrovascular disease
Preoperative serum creatinine > 2.0 mg/dL
Insulin therapy for diabetes
Circulation, 1999;100:1043-1049)

40. Preoperative Renal Risk Stratification
The likelihood of developing AKI after cardiac surgery depends
on factors associated with poor cardiac performance and
advanced atherosclerotic vascular disease.
These factors, in combination with reduced baseline renal
function, can be used to stratify patients before surgery and to
identify several subgroups of patients at substantially increased
risk (≥5%).
We do not intend for these data to be used to withhold or advise
against required cardiac surgery. Rather, we hope that these data
will be used to promote quality enhancement in perioperative
care and to target high-risk subgroups for interventions aimed
ultimately at reducing the risk and ameliorating the
consequences of this devastating complication.

41. Perioperative AKI( Prevention)
** Measures to prevent AKI are simple and an essential
part of good peri-operative care.
* It is more likely that we will reduce perioperative AKI
through better optimization and management of the many
comorbidites and hemodynamic derangements that have
been shown to impact renal function.
* In the anaesthetic room adequate IV access should be
obtained.
* If necessary an arterial line inserted and other invasive
monitoring techniques considered
* The patient s‟ intravascular volume should be adequately
restored .

42. Intraoperative Renal Protection
The aim of intra-operative management in those at risk of AKI
is to maintain adequate renal perfusion pressure.
The following may allow optimal intra-operative care:
Appropriate intravascular volume replacement
 Avoidance of nephrotoxic drugs
 Urinary catheter aiming for a urine output >0.5ml/kg/hr
 Maintenance of a suitable Mean Arterial Pressure (MAP)
for the patient and operation
 Monitoring of central venous pressure (CVP)
 Monitoring of cardiac output

43. Intraoperative Renal Protection
Vasopressors (there is no evidence supporting the use of
“renal dose” dopamine)
 Anticipation of anaesthetic and surgically induced
haemodynamic perturbations both intra and post
operatively.
 Intra-operatively the neurohumoral response to
surgery causes a sympathetic response, releasing
vasopressin, aldosterone and cortisol in the „fight or
flight response. One of the aims of this is to aid salt and‟
water retention protecting the renal vasculature.
** N.B. Anaesthetic agents, ACE inhibitors and NSAIDs
will alter this protective response

44. POST Operative Care
Post operatively, patients may remain at risk of AKI due to relative
hypotension caused by ongoing 3rd space fluid loss, pharmacological
causes (NSAIDs and ACEIs/ARBs) and residual effects of anaesthesia.
Epidural anaesthesia has been cited as being a particular culprit by
causing hypotension secondary to sympathetic blockade. The risk of
AKI will be exacerbated if there is inadequate intra-operative fluid
replacement.
Postoperative fluid therapy is of utmost importance. This is guided
by clinical examination, monitoring of urine output and monitoring
renal function and electrolytes.
It has been shown that 80% of patients with post op AKI respond to
fluid therapy alone - ‘Optimise fluid and defend pressure’.

45. POST Operative Care
Those with significant metabolic disturbance e.g.
acidosis, hyperkalaemia, uraemia or fluid overload not
responsive to simple measures may need RRT in an
appropriate setting.
Anaesthetists are often responsible for prescribing
post-operative analgesia including NSAIDs. This
should be done with extreme caution if the patient
is at increased risk of developing AKI.
 Patients who do develop AKI post-operatively should
have this documented, and if possible highlighted on
the anaesthetic charts to inform future
anaesthetists.

46. What To Do If AKI Ruled In?
*AKI is common peri-operatively risk.
* With good initial assessment and simple measures including fluid
management and avoidance of nephrotoxic drugs, it is preventable.
* Delays in recognising and treating AKI lead to longer inpatient
stay, increased mortality and significantly increased healthcare costs.
* Patients who develop AKI and have complications such has
hyperkalaemia, electrolyte imbalance, acidosis or volume overload
are likely to die unless RRT is provided.
* Liaison with nephrology and critical care services is recommended
in such cases to allow optimal patient management.

47. What To Do If AKI Ruled In?
*If renal injury is confirmed and the patient is ruled in for AKI, then
multiple interventions can be initiated.
* An abbreviated list include:
Evaluate treatable causes of AKI: (a) Rhabdomyolysis, (b) obstruction,
(c) volume depletion, (d) glomerulonephritis, (e) sepsis, (f) acute
interstitial nephritis, (g) vascular events (e.g., arterial dissection,
atheroembolic disease, thrombotic thrombocytopenic purpura).
Optimize hemodynamics and consider objectively assessing cardiac
output (e.g., pulmonary artery catheter, echocardiography, noninvasive
cardiac output monitoring via arterial line).

48. What To Do If AKI Ruled In?
*Consider initiating goal-directed therapy with an emphasis on
conservative late fluid management after the initial resuscitation
.
* Minimize exposure (discontinue when possible) all
nephrotoxic drugs (e.g., NSAIDs, aminoglycosides,
amphotericin, radiocontrast material).
* If the patient is fluid overloaded and resistant to diuretics,
then consider ultrafiltration.

49. CONCLUSION
 Patients with CKD or AKI who present for surgery often have
complex medical problems.
Preoperative evaluation should strive to identify and correct any
modifiable risks.
Communication between the primary care team, nephrologist,
surgeon, and anesthesiologist should ensure timely and
appropriate investigation.
 Despite optimization, patients with CKD or AKI are at
significantly higher risk of morbidity and mortality during the
perioperative period.
These risks need to be communicated to the patient or
caregivers so that informed medical decisions can be made.

50. CONCLUSION
Perioperative goals for euvolemia, maintenance of renal
perfusion, and avoidance of nephrotoxins may require
modifications in the usual surgical or anesthetic care.
 Despite intense research into perioperative renal
protection, many successful therapies in animal models
have not achieved success in human populations.
Fenoldopam, as a prophylactic therapy in patients with
CKD undergoing high risk surgery or for those patients at
high risk of AKI, may be beneficial.
 Ultimately more research is required for a definitive
answer to this elusive goal.

51. THANK YOU

52. VIVA
EGYPT

53. Fenoldopam
Fenoldopam mesylate (Corlopam) is
a drug and synthetic benzazepine derivative which acts as
a selective D1 receptor partial agonist.[1]
 Fenoldopam is used as an antihypertensive agent.[2] It was
approved by the (FDA) in September 1997
Fenoldopam is used as an antihypertensive agent
postoperatively, and also intravenously (IV) to treat
a hypertensive crisis.[4] Since fenoldopam is the only
intravenous agent that improves renal perfusion, in theory
it could be beneficial in hypertensive patients with concomitant
renal insufficiency.

54. Fenoldopam
*Adverse effects
include headache, flushing, nausea, hypotension, reflextachycardia, and
increased intraocular pressure.[4][11]
*Contraindications, warnings and precautions[edit]
Fenoldopam mesylate contains sodium metabisulfite, a sulfite that may rarely
cause allergic-type reactions including anaphylactic symptoms and asthma in
susceptible people. Fenoldopam mesylate administration should be undertaken
with caution to patients with glaucoma or raised intraocular pressure as
fenoldopam raises intraocular pressure.[11]
Concomitant use of fenoldopam with a beta-blocker should be avoided if
possible, as unexpected hypotension can result from beta-blocker inhibition of
sympathetic-mediated reflex tachycardia in response to fenoldopam