Anestesi pada pasien Gangguan Ginjal

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Anestesi pada pasien Gangguan Ginjal dan ureterolithiasis

Transcript of Anestesi pada pasien Gangguan Ginjal

  • URETEROLITHIASISDefinition:stone (due to deposition of uric salts, oxalate, or calcium) obstruction ureteric duct

    Stones can form in kidneys or pielum

    Stones cant pass the bladder ureter clog colic

  • Etiology- Kidney stones- Congenital abnormalities- Diverticula

    1. Supersaturasi existence of stone-forming substances 2. The factors that led to the crystallization of the substance 3. There is a substance that causes crystals gathered into one.

  • Clinical ManifestationsStrong contraction and pain colicSpread front of the abdomen, lower abdomen, groin area, and up to the genetaliaPain during urination or frequent urination stones of distal ureter
  • Diagnostic Tools- BNO radio-opaque stones only- IVP selected examination- USG - MRI- Laboratory:urine sediment examination, urine culture examination, renal physiology, electrolyte levels

  • Therapy1. Conservatives

    2. Extracorporeal Shock Wave Lithotripsy (ESWL)

    3. Ureteroskopi (URS)

    4. Open surgery


    Retention Na >> extracellular fluid easily got CHF and pulmonary edema

    Autonomic neuropathy slowing gastric emptying in CRF patients occurrence of aspiration in perioperative

    Renal function lab

  • Renal impairment Dysfunction of glomerular, tubular function or urinary tract obstruction

    BUN50mg/dl renal impairment

    Serum creatininea product of muscle metabolism without enzyme converted kekreatinin.20-25 mg / kg in men and 15-20 mg / kg in females.

  • BUN: creatinine ratioBUN: creatinine ratio > 15:1 in lower volume and edema with disorders related to reduced tubular flow (such as heart failure, cirrhosis, nephrotic syndrome) , obstruction uropathy, increased protein catabolism

    Creatinin Clearancethe most acurate method to assess renal function. Mild: 40-60 mL / min, Moderate : 25-40 mL/min, kidney failure :

  • URINALYSISthe most common test performed for the evaluation of renal function.pH, specific gravity (BJ), and glucose quantity detection, protein, bilirubin, and microscopic examination of the urine sediment

  • Changed of Renal Function and Effect to Anesthetics Agents Propofol and Etomidateno signifficant effect. Decrease in protein binding of etomidate (patient with hipoalbuminemia) accelerate the effects of pharmacological effects

    2. Barbituratesincreased sensitivity to barbiturates ,its caused by increased circulating free because decrease of bonding with protein

  • 3. KetamineChanged slightly due to kidney disease.Hypertension secondary to the effects of ketamine could not desirable in patients with renal hypertension

    4. BenzodiazepinesPotential accumulation of the active metabolite

  • 5. Opioids-Accumulation of morphine (morphine-6-glucuronide) and meperidine metabolites prolong respiratory depression have been reported in some patients with renal failure.- Increased levels of normeperidine, metabolitmeperidine, associated with seizures. -frequently used opioid agonist-antagonists (nalbuphine butorphanol and buprenorphine) not affected by renal failure.

  • Anticholinergic AgentsIn a premedication dose atropine and glycopyrolate usually safe in renal impairment patient.

  • Inhalation AgentsVolatile agentsVolatile anesthetic agents is almost ideal for patients with dysfunction renal not dependent on renal elimination

    NOMany clinicians do not use or limit the use of NO2 by 50% in patients with renal failure in the goal to increase the use of O2artery on the state of anemia.

  • Muscle ParalyticSuccinyl cholineSC can be used safely in renal failure

    Cisatracurium, atracurium & MivacuriumMivacurium dependent on renal elimination is minimal. Cisatracurium & atracurium elimination degraded in plasma by enzymatic hydrolysis of esters and nonenzymatik Hofman. These agents may be the drug of choice for muscle paralysis in patients with renal failure.

  • Vecuronium & RucoroniumElimination of vecuronium primarily in the liver, but >20% elimination in urine. The effects of large doses is extension work on severe kidney disease.

    Pancuronium, Pipecuronium, Alcuronium, & DoxacuriumThese medications primarily dependent on renal excretion (60-90%). Should be closely monitored when these drugs are used in abnormal kidney function.

  • Metocurine, Gallamine & DecamethoniumThese drugs are almost entirely dependent on renal excretion for elimination and its use should be avoided in patients with impaired renal function.

    Reversal MedicationsRenal excretion is the primary route of elimination for Tensilon, neostigmine and pyridostigmine. The half-life of these drugs in patients with impaired renal function is extent.

  • ACUTE RENAL FAILURE rapid decline in kidney function resulting in the build up of waste nitrogen (azotemia).

    CHRONIC RENAL FAILURE characterized by a progressive decline in renal function and the irreversible within 3-6 months. GFR decreased < 25 mL / min.

  • Manifestations of Renal FailureMetabolicHematologicCardiovascularPulmonaryEndocrineGastrointestinalNeurology

  • Preoperative EvaluationEvaluation of azotemiaPhysicalLaboratorySigns of fluid overload or hypovolemiaBlood gas analysisThorax rontgenEKGEchhoAnemia transfusion

  • Muscle relaxantsMetocurine, Gallamine, Decamethonium, pancuronium, Pipecurium, Doxacurium, Alcuronium

    AnticholinergicsAtropine, Glycopyrrolate

    MetoclopramideH2reseptor antagonistsCimetidine, ranitidine


  • Calcium channel antagonistsNifedipine, Diltiazem

    Adrenergic beta blockersPropranolol, Nadolol, pindolol, Atenolol

    Anti HipertensivesClonidine, methyldopa, Captporil, Enalapril, lisinopril, hydralazine nitroprusside (thiocyanate)

    AntiarrhytmicsProcainamide, Disopyramide, Bretylium, Tocainide, Encainide (genetically determined)


  • PsychiatricLithium

    AntibioticsPenicillins, Cephalosporins, aminoglycosides, Tetracycline, Vancomycin

    AnticonvulsantsCarbamazepine, ethosuximide, primidone


    - Stable and conscious patirnts reduction of the dose opioid or benzodiazepines. Promethazin 12.5-25 mg intramuscular sedation and anti emetic. aspiration prophylaxis H2 blocker ( indicated in patients nausea, vomiting or gastrointestinal bleeding). Ex.Metoclopramide, 10 mg orally or slow IV dripshould be continued anti-hypertension

  • INTRAOPERATIVEMonitoring overall medical condition danger of the occlusion blood pressure indicated in patients with uncontrolled hypertension Aggressive invasive monitoring diabetic with severe renal disease who are undergoing major surgery(high morbidity 10 x more in diabetic patients without kidney disease)

  • Induction Patients with nausea, vomiting or gastrointestinal bleeding should undergo irapid induction with cricoid pressure. Thiopental 2-3 mg / kg or propofol 1-2 mg / kg ( often used). Etomidate ,0,2-0, 4 mg / kg in patients with no hemodynamic stabil. Opioid, beta-blockers (esmolol), or lidocaine reduce hypertension renponse from the intubation Succinylcholine, 1.5 mg / kg, can be used to intubasiendotrakeal if blood potassium levels less than 5 meq / L. Rocuronium (0.6 mg / kg), cisatracurium (0.15 mg / kg), atracurium (0.4 mg / kg) or mivacurium (0.15 mg / kg) can be used for intubated patients with hyperkalemia. Vecuronium, 0.1 mg / kg alternative, but its effects must be considered.

  • Maintenance Control hypertension with minimal effects on cardiac output, due to an increase in cardiac output is a mechanism of compensation principle in anemia. Volatile anesthetics, nitrous oxide, fentanyl, sufentanil, alfentanil, and morphine satisfactory maintenance agent. Isoflurane and desflurane are volatile substances choice because they have minimal effect on cardiac output. Nitrous oxide : cautiously Meperidine not a good choice Morphine may be used Ventilation controlled safest method in patients with renal failure.

  • - Fluid Therapy Superficial surgery require fluid replacement with 5% dextrose in water. RL should be avoided in patients with hyperkalemia who require a lot of fluids, because the content of potassium (4 meq / L)Blood loss :PRC