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Anesthesia and Renal Failure
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In renal failure, the induction dose of
which of the following should be
decreased ?
•
Propofol• Ketamine
• Thiopental
• Etomidate
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Induction Anesthetics
• Propofol: undergoes hepatic
biotransformation into inactive metabolites; in
renal failure duration of action is not affected
• Ketamine: hepatic metabolism and
redistribution are responsible for termination
of the anesthetic effects and
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Induction Anesthetics
• Thiopental: 85% is protein bound and in the
setting of uremia the free fraction is almost
doubled, so the induction dose should be
decreased
• Etomidate: 75% is protein bound so the free
fraction increases in renal failure; however
this increase is not clinically significant
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In renal failure, the induction dose of
which of the following should be
decreased ?
•
Propofol• Ketamine
• Thiopental
• Etomidate
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Volatile Anesthetics
• Nitrous Oxide: elimination is through
exhalation, so it is not affected by renal failure
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Fluoride Induced Nephrotoxicity
• Metabolism of sevoflurane, isoflurane,
methoxyflurane, enflurane and halothane
results in production of fluoride ions
• Nephrotoxicity is a result of 2 factors: the peak
fluoride concentration (with above 50 uM
toxic threshold) and the area under the curve
of serum fluoride concentration versus time
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Fluoride Induced Nephrotoxicity
• Isoflurane: 20 MAC-hours of isoflurane could
lead to serum flouride levels above 50uM,
however no postoperative renal dysfunction
was detected
• Sevoflurane: regularly 7% of patients who
receive sevoflurane will have serum flouride
levels above 50uM. Yet, no clinically significant
renal dysfunction was detected
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Fluoride Induced Nephrotoxicity
• Methoxyfluane and enflurane might cause
renal dysfunction especially when associated
with hypovolemia, shock and renal
vasoconstriction
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Sevoflurane and compound A
• Sevoflurane is degraded in basic carbon
dioxide absorbents, such as Barium Hydroxide
and Soda lime, into a vinyl ether called
compound A
• Compound A was proven to be nephrotoxic
when it reaches certain thershold levels that
differ among different animal species
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Sevoflurane and compound A
• Human studies have not associated
sevoflurane with any detectable postop
impairment of renal function
• Some clinicians recommemd that fresh gas
flow rate be al least 2L/min to avoid release of
compound A
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following is not affected by renal
failure?
• Succinylcholine
•
Rocuronium• Vecuronium
• Doxacurium
• Cisatracurium
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Renal Failure and Succinylcholine
• Succinylcholine: its duration of action is notsignificantly prolonged, so its use is justified inrapid sequence induction
• Renal failure patients are more prone tohyperkalemia and succinylcholine results in anincrease in serum potassium levels in normalsubjects (0.5mEq/L). Therefore, serum potassium
levels should be checked and normalized.
• Use of a continuous infusion is not recommendedsince its major metabolite succinylmonocholine is
active and dependent on renal excretion
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Intermediate acting Muscle Relaxants
• Vecuronium: has an active metabolite (3-desmethyl vecuronium) that accumulates in renalfailure causing an intubating dose to last around50% longer
• Rocuronium: pharmacokinetic studies on patientswith renal failure had conflicting results withrespect to the duration of action
• Atracurium and cisatracurium metabolism isindependent of renal and hepatic function, sothey are recommended in renal failure
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Laundanosine
• It is a breakdown product of Hofmann
elimination (of atracurium and cisatracurium)
that was found to cause seizures in
experimental animals.
• However, intensive care patients with renal
failure receiving prolonged infusions of
atracurium did not have any seizures
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Long acting muscle relaxant
•
Doxacurium and pipecuronium have reducedplasma clearance and prolonged duration of
action in renal failure patients
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following is not affected by renal
failure?
• Succinylcholine
•
Rocuronium• Vecuronium
• Doxacurium
• Cisatracurium
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Which of the following opioids is safe
in renal failure
• Meperidine
•
Fentanil• Sufentanil
• Morphine
• Remifentanil
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Opioids and Renal Failure
• Morphine undergoes hepatic metabolism tomorphine-3-glucuronide and morphine-6-
glucuronide. These metabolites can
accumulate in renal failure and result innarcosis and respiratory depression
• Merperidine is metabolised to normeperidinewhich might accumulate in renal failure
patients and result in CNS toxicity (seizures).
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Opioids and Renal Failure
• Fentanyl and alfentanyl are good choices in
renal failure since their metabolites are
inactive and the change in their free fraction isnot clinically significant
• Sufentanil has an active metabolite that mightaccumulate in renal failure upon chronic use
and result in prolonged narcosis
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Opioids and Renal Failure
• Remifentanil clearance is not affected by renal
failure
• It is metabolized to remifentanyl acid, whichwould accumulate in renal failure, but is 4,600
times less potent
• Thus, the clinical implications are limited
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Which of the following opioids is safe
in renal failure
• Meperidine
•
Fentanil• Sufentanil
• Morphine
• Remifentanil
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TURP syndrome
• In around 1.5 % of TURPs excessive
absorption of the irrigating solution may lead
to several symptoms described as TURP
syndrome
• Several irrigation solutions are available for
use during TURP, such as glycine, sorbitol,
mannitol and distilled water
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TURP syndrome
• The signs and symptoms can be divided into
those common to all irrigating solutions and
those peculiar to certain solutions.
• Excessive absorption of any of the solutions
might lead to fluid overload and hyponatremia
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Common Signs and Symptoms
• Fluid overload might manifest as hypertension,
bradycardia and pulmonary edema especially in
congestive heart failure patients
• Hyponatremia (if Na
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Glycine Solutions
• Glycine is an inhibitory neurotransmitter in
the cortex and retina
• Excessive absorption might lead to seizures
and post-op blindness that resolves when
glycine blood levels decrease
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Other solutions
• Distilled water might lead to hemolysis and
hyponatremia.
• Glucose solutions might cause hyperglycemia
•
Sortibol solutions could lead to hyperglycemiaand lactic acidosis
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Prophylactic measures
• To decrease fluid absorption, it is
recommended to:
1) Limit resection time to < 1 hour
2) Suspend the irrigating bag
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TURP Syndrome Treatment
• When symptoms and signs of TURP syndrome
occur:
1. Stop using the irrigation solution
2. If pulmonary and cardiac symptoms are
present, place the patient in reverse
Trendelenberg position to alleviate
symptoms by pooling blood in the lower
extremities
3. Electrolyte analysis: Sent blood for
electrolytes, creatinine, glucose and ABGs
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HyponatremiaTreatment
• If patients are symptomatic and have serum
[Na] < 120mEq/L, they should be corrected
with hypertonic saline at a rate < 100ml/hr till
they are asymptomatic or serum [Na] >120mEq/L
• Then hyponatremia is managed with fluid
restriction and loop diuretic (furosemide)
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Thank You
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