7. RENAL CONCERNS
CHRONIC RENAL FAILURE
*Chronic renal failure is a risk factor for increased perioperative morbidity/mortality.
1) HEMODIALYSIS should be performed either the day of or the day before surgery. In general, the closer to surgery the better. Postoperatively hemodialysis can be resumed at the usual interval unless it is needed sooner for fluid, electrolyte, and/or bleeding problems related to surgery. (Peritoneal dialysis should be performed as close to the time of surgery as is feasible and then resumed soon thereafter.)
2) CHRONIC ANEMIA is generally well-tolerated, but preoperative transfusion should be considered if significant blood loss is anticipated, if hgb is under 8 grams, or if patient has known CAD and hgb is under 9-10 grams. Transfusion is best administered during hemodialysis.
3) FLUIDS should be given cautiously. In general, a lower IVF rate than usual is recommended.
4) ELECTROLYTES should be monitored routinely. HYPERKALEMIA can be managed acutely without hemodialysis by giving kayexalate 60 grams orally or as an enema (works in 1 to 2 hours) with repeat dose in 6 hours if needed. Additionally or alternatively, one amp of D50 slow IVP over 5 minutes immediately followed by regular insulin 10 units IVP works rapidly. Sodium bicarb one amp slow IVP over 2 minutes also can be administered to lower potassium rapidly, with repeat dose in 15 minutes. (Calcium gluconate one amp slow IVP over 2 minutes counteracts the effects of hyperkalemia acutely, but it does not serve to lower the potassium level.)
5) DDAVP can be given acutely to improve hemostasis if excessive bleeding is noted during or after surgery. Alternatively, it can be administered prophylactically at the start of the procedure if heavy bleeding is anticipated. *The dose is 0.3 mcg/kg-maximum 20 mcg-in 50cc NS over 30 minutes IV. (Repeat dose can be given in 12 to 24 hours.)
6) DRUG DOSING is of particular concern, and most medication doses need to be adjusted. Also, I generally recommend avoiding demerol due to seizure risk in renal failure patients, although as a single dose demerol can be given safely on a one-time basis only.