Professor Panditrao expresses his views about the day to day challenge, faced in clinical practice. Considered to be a simple surgery, but the anesthetic management is very challenging because of the primary pathology, co-morbidities and repeated surgeries involved.

2. RENAL PATIENTS
FOR VASCULAR ACCESS :
PERI-OPERATIVE MANAGEMENT
CHALLENGES, LESSONS LEARNT
&
RECOMMENDATIONS!

3. PROF. MRIDUL M. PANDITRAO
CONSULTANT
DEPARTMENT OF ANESTHESIOLOGY
PHA’S RAND MEMORIAL HOSPITAL
FREEPORT
GRAND BAHAMA
THE BAHAMAS

4. Challenge Oriented Approach
• Related to the Primary pathology
• Related to the Surgical procedure
• Related to Anesthesia
• Related to Logistical/Infrastructural facilities

5. Primary Pathology:
• CRF/CRD/CKD/ESRDS/Uremia
• Defined as
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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 %

12. Surgical Procedures
• Related to Primary pathology/Intervention
– Vascular access for hemodialysis*
– Procedures for peritoneal dialysis
– Renal transplantation
• Unrelated co-incidental pathology

13. Vascular Access:
• Temporary
• Permanent

14. 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)

15. Temporary Catheter

16. Permanent:
AV Fistula & Graft

17. AVF/AVG

18. Challenges
• Leading normal life is a stress
• Added stress of anesthesia and surgery
• Decompensate the patients
• Avoidable errors of judgment
• High Morbidity and Mortality

19. 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

20. 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

21. Anesthesia
Aims& 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

22. Anesthesia
• Two choices
– General Anesthesia
– Regional technique: Supra-clavicular brachial
Plexus Block

23. GA
• Anesthetic agents: IV or Inhalationals
– Cardio-depressants
– Arrythmogenic
– Peripheral vasodilatation
– Negative inotropism
– No chance of poly-pharmacy
– Fluid restriction
– Co-morbidities

24. 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

25. 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

26. 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

27. Limitations!
• Limited applicability
• Useful only if distal/Forearm vessels planned
• Relative contra-indications
– Patient acceptability
– More proximal vessels
– Coagulopathy
– Anticipated longer time required

28. Logistical/ Infrastructural
• Time constraints
• Human resources/ manpower
• Perception related
• Overall team approach

29. 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)

30. 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!

31. 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

32. 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

33. 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

34. 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!”

35. 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”

36. 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

37. 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

38. 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.

39. 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

40. 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 Nonintervention!
– Watch for surgical complications: hemorrhage/
oozing!

41. 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

42. 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

43. 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

44. Take Home Message!!!!
No Justification in having additional
Morbidity/ mortality, than inherent
to the primary pathology due to
inadequate/improper
planning, Overzealousness
&
Non-coordination!!