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Anesthesia for dialysis patients

Anesthesia for dialysis patients
Authors:
Jeremy P Campbell, MB, ChB (Hons.), MRCS, FRCA
Jonathan M Cousins, BSc, MBBS, FRCA, FFICM
Section Editors:
Stephanie B Jones, MD
Jeffrey S Berns, MD
Michael F O'Connor, MD, FCCM
Deputy Editors:
Nancy A Nussmeier, MD, FAHA
Eric N Taylor, MD, MSc, FASN
Literature review current through: Nov 2022. | This topic last updated: Sep 16, 2022.

INTRODUCTION — End-stage kidney disease (ESKD) requiring dialysis is a growing problem worldwide (see "Epidemiology of chronic kidney disease"). Patients on dialysis commonly require surgery and invasive procedures for reasons related to ESKD, including vascular access, parathyroidectomy, and kidney transplantation. Patients may also require elective or emergency surgical procedures for reasons unrelated to their ESKD.

This topic reviews anesthetic management of patients on dialysis. Preoperative and postoperative medical management of these patients is discussed separately. (See "Medical management of the dialysis patient undergoing surgery".)

PREANESTHETIC MANAGEMENT

Elective surgery: Assessment and medication management

Assessment of comorbidities – Patients with end-stage kidney disease (ESKD) on dialysis are assessed for comorbidities that may impact anesthetic and surgical care, including cardiovascular disease, hypertension, diabetes, anemia, bleeding diathesis, and nutritional status. These are discussed in a separate topic. (See "Medical management of the dialysis patient undergoing surgery", section on 'Assessment of comorbidities'.)

Dialysis considerations – The type and location of dialysis access are noted. Preoperative hemodialysis or peritoneal dialysis considerations for patients with ESKD are discussed separately. (See "Medical management of the dialysis patient undergoing surgery", section on 'Routine dialysis prior to surgery' and "Risk factors and prevention of peritonitis in peritoneal dialysis", section on 'All procedures'.)

Preoperative medication management

Chronically administered medications – Management of chronically administered medications for patients on dialysis is similar to that for patients without ESKD, as discussed in other topics. (See "Medical management of the dialysis patient undergoing surgery", section on 'Medication management' and "Perioperative medication management".)

Premedication

-Aspiration prophylaxis – Gastroparesis associated with diabetes may increase the risk of pulmonary aspiration during induction of general anesthesia [1,2]. (See "Unique aspects of gastrointestinal disease in dialysis patients".)

-Anxiolytics – Use of intravenous (IV) midazolam to treat anxiety in the immediate preoperative period is avoided or administered in reduced titrated doses (typically 0.5 mg increments). Protein binding of midazolam is decreased in ESKD, resulting in increased plasma levels of free midazolam [3,4]. Furthermore, elimination of midazolam and its main metabolite, a1-hydroxymidazolam, is reduced in patients with ESKD [5,6]. (See "General anesthesia: Intravenous induction agents", section on 'Midazolam'.)

-Opioids – If an IV opioid is necessary to treat pain in the immediate preoperative period, doses are reduced and titrated (eg, fentanyl administered in 25 mcg increments). (See "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Preinduction'.)

Emergency surgery considerations — For emergency surgical procedures, the nephrology service should be consulted when urgent preoperative dialysis (if feasible) may be desirable to treat severe hyperkalemia, metabolic acidosis, or intravascular volume overload. Institution of alternative therapies may be necessary if dialysis is not feasible. (See "Medical management of the dialysis patient undergoing surgery", section on 'Indications for urgent preoperative dialysis'.)

Management of hyperkalemia — Hyperkalemia is a potential indication for consultation with the nephrologist to assess the need for preoperative dialysis, although there are no guidelines that specify a maximum safe level of potassium prior to induction of anesthesia. Furthermore, there is neither an orderly progression of electrocardiographic (ECG) abnormalities in individual patients as potassium rises, nor does the absence of ECG changes preclude the possibility of hyperkalemia-associated cardiac arrest [7-10]. However, we avoid succinylcholine (SCh) if the potassium level is ≥5.5 mEq/L or if any ECG changes are evident. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Succinylcholine'.)

Management of hyperkalemia for surgical emergencies depends on the individual's chronic and current potassium levels, and urgency of the procedure (ie, whether it is safe to delay surgery to perform dialysis). Other factors include the likely degree of tissue damage that may occur during the procedure to cause release of potassium, anticipated blood loss and fluid shifts, and whether the patient has acid-base disturbances (eg, metabolic acidosis) that may affect the intraoperative rate of rise of serum potassium concentration. For patients with potassium ≥5.5 mEq/L before or during emergency surgery:

We generally proceed with surgery with particular attention to continuous intraoperative ECG monitoring and intraoperative point-of-care measurements of potassium [7,11]. We avoid use of SCh due to the potential for increasing the potassium level further and inducing life-threatening arrhythmias preceded by rapidly changing ECG findings [10]. (See 'Induction' below.)

Ideally, discussions among the surgeon, anesthesiologist, and nephrologist weigh risks of proceeding against risks of delaying surgery for dialysis, particularly if any ECG features of hyperkalemia are present (figure 1). Even one to two hours of hemodialysis typically reduces total body and serum potassium concentrations to a safer level.

In a life-threatening surgical situation when dialysis is not feasible (eg, significant hemorrhage), the operation is performed regardless of potassium level and ECG changes. If potassium is >6.5 mEq/L, the anesthesiologist must temporize with medical management of hyperkalemia. Specific treatments for such a hyperkalemic emergency include (algorithm 1 and table 1) [10] (see "Treatment and prevention of hyperkalemia in adults"):

IV calcium (eg, calcium chloride 500 to 1000 mg) to directly antagonize the cell membrane actions of hyperkalemia. Since hypocalcemia exacerbates potassium-induced cardiotoxicity, ionized calcium levels are monitored to avoid hypocalcemia. (See "Treatment and prevention of hyperkalemia in adults", section on 'Calcium'.)

IV insulin (typically given with IV glucose) to drive extracellular potassium into cells. (See "Treatment and prevention of hyperkalemia in adults", section on 'Insulin with glucose'.)

If severe acute metabolic acidosis is present (ie, pH <7.1 to 7.2), bicarbonate therapy 1 to 2 mEq/kg may be administered to raise pH and drive extracellular potassium into cells. The bicarbonate dose may be repeated if pH remains <7.1 after 30 minutes. Details regarding management of this circumstance are discussed in other topics:

-(See "Potassium balance in acid-base disorders", section on 'Metabolic acidosis'.)

-(See "Approach to the adult with metabolic acidosis", section on 'Overview of therapy'.)

-(See "Bicarbonate therapy in lactic acidosis".)

Though rarely necessary, continuous kidney replacement therapy or hemodialysis can be performed in the operating room if equipment and personnel are available (eg, during cardiopulmonary bypass in a cardiac surgical procedure) [12,13].

Management of intravascular volume overload — For patients with hypervolemia, if time allows, discussions among the surgeon, anesthesiologist, and nephrologist weigh risks of moderate or severe preoperative volume overload against risks of delaying surgery for dialysis. Intravascular volume overload and pulmonary edema in the preoperative period may be exacerbated by infusion of fluid or transfusion during surgery, which may necessitate urgent postoperative dialysis and/or a period of noninvasive positive pressure ventilation or controlled mechanical ventilation. Patients who are on dialysis but nevertheless have some degree of residual kidney function and urine output may respond to high doses of loop diuretics.

Management of bleeding — Patients with ESKD may have an increased tendency to bleed during and/or after surgery. (See "Medical management of the dialysis patient undergoing surgery", section on 'Uremic bleeding'.)

In a patient with likely uremia-induced platelet dysfunction, we administer IV desmopressin (dDAVP) 0.3 mcg/kg. (See "Uremic platelet dysfunction".)

If a uremic patient is actively bleeding, we also administer platelets (one apheresis unit or six units of pooled platelets) even in the absence of thrombocytopenia. Notably, platelet therapy will only be transiently effective for uremic platelet dysfunction because transfused platelets are rendered dysfunctional by the uremic milieu with variable rapidity. (See "Platelet transfusion: Indications, ordering, and associated risks", section on 'Platelet function disorders'.)

Furthermore, during the intraoperative period, point-of-care tests of coagulation (eg, thromboelastography, rotational thromboelastometry) are obtained if available, as well as standard laboratory coagulation tests including prothrombin time, activated partial thromboplastin time, international normalized ratio, and platelet count. We also obtain tests of platelet function if available (eg, platelet aggregometry, PFA-100), although these may not be reliable for diagnosing uremic platelet dysfunction. (See "Intraoperative transfusion of blood products in adults", section on 'Point-of-care tests' and "Intraoperative transfusion of blood products in adults", section on 'Standard tests' and "Platelet function testing".)

VASCULAR ACCESS — Obtaining intravascular access may be challenging in a patient on dialysis. Those receiving chronic hemodialysis typically have an arteriovenous fistula or graft or a hemodialysis catheter; access at these sites is avoided.

Intravenous access

General considerations

Peripheral venous catheters – Ideally, the veins on the back of either hand are used. If these veins are inadequate and peripheral venous access is necessary more proximally in an upper limb, the dominant arm is preferred because the nondominant arm is typically used for arteriovenous access.

If the patient already has arteriovenous access in the upper limb, the other arm should be used for peripheral venous catheters. As a last resort, the veins distal to arteriovenous access may be used, provided there is no plan to use those veins for future arteriovenous access.

Peripherally inserted central catheters (PICC) should be avoided in patients on dialysis in order to preserve the superficial veins for future arteriovenous fistulae. If a PICC line is necessary, a tunneled PICC line is preferred.

Central venous catheters – Central venous catheter (CVC) placement may be difficult, particularly if hemodialysis catheters have previously been inserted into central veins. Any previous studies of the patient's vascular anatomy should be reviewed for relevant information (eg, occluded internal jugular, subclavian, or femoral veins or the presence of vascular stents).

A new CVC should not be placed on the same side as an existing hemodialysis catheter. Also, placement of a CVC in a subclavian vein is avoided because of the possibility of inducing subclavian stenosis that may preclude subsequent creation of an arteriovenous fistula in the ipsilateral arm. (See "Overview of thoracic central venous obstruction", section on 'Intravascular device related' and "Central vein obstruction associated with upper extremity hemodialysis access", section on 'Central venous catheters'.)

We use ultrasound guidance during insertion of a CVC, particularly in the internal jugular vein location and in sites where the patient has a history of prior vascular instrumentation or venous thrombosis. Compared with the anatomic landmark approach, ultrasound guidance has been shown to result in a higher overall successful cannulation rate and a decreased rate of arterial puncture or pneumothorax [14-16]. (See "Principles of ultrasound-guided venous access" and "Central venous access: General principles".)

Avoid dialysis access

Arteriovenous fistula or graft – Venipuncture and vascular access at current fistula or graft sites must be avoided. Exceptions occur in emergency situations or when alternative vascular access is impossible. If using an arteriovenous fistula or graft is essential, cannulation should ideally be performed by an experienced dialysis nurse or technician. (See "Medical management of the dialysis patient undergoing surgery", section on 'Intravenous access'.)

During surgery, meticulous care of an existing fistula is essential to avoid potential thrombosis. This includes avoiding blood pressure measurements or needle sticks in the extremity with the fistula. Also, direct pressure on the fistula should be avoided during patient positioning and throughout the perioperative period.

Potential future fistula sites should also be avoided because of the risk of damaging these blood vessels (eg, veins in the antecubital fossa and the cephalic vein at the wrist, especially in the nondominant arm).

Hemodialysis catheter – Generally, a hemodialysis catheter should not be used for purposes other than dialysis. Exceptions may occur in an emergency situation when alternative vascular access is challenging, or to avoid multiple attempts to obtain IV access or insertion of a new CVC [17]. If use is necessary, residual heparin in the catheter must be aspirated and discarded before use, and the catheter must be appropriately flushed and reheparinized after use.

Intra-arterial access and blood pressure monitoring — If intra-arterial blood pressure monitoring is planned, results of previously performed Doppler vascular studies or point-of-care ultrasound may be helpful for selection of potential sites for arterial catheter insertion. (See "Intra-arterial catheterization for invasive monitoring: Indications, insertion techniques, and interpretation", section on 'Use of ultrasound guidance'.)

The extremity with a currently functioning fistula or graft site is avoided.

INTRAOPERATIVE ANESTHETIC MANAGEMENT

Local anesthesia — Local anesthesia with monitored anesthesia care (MAC) is often selected for patients on dialysis if this choice is appropriate for the surgical procedure. (See "Monitored anesthesia care in adults", section on 'Appropriateness of monitored anesthesia care'.)

Advantages for patients with end-stage kidney disease (ESKD) include avoiding a potentially hazardous general anesthetic in a patient with significant comorbidities, and avoiding the need to administer multiple intravenous (IV) anesthetic agents that may have delayed metabolism and excretion.

During MAC, small titrated doses of IV sedative, anxiolytic, or analgesic agents may be administered as necessary (table 2). Agents with rapid onset and short duration of action are preferred to allow rapid titration of effects and quick recovery. Notably, these agents can cause respiratory depression and hypotension in a dose-dependent manner. Furthermore, metabolism may be delayed in patients with ESKD due to variability in volume of distribution, degree of plasma protein binding, and excretion. We preferentially employ propofol infusion in these patients, and we minimize use of opioids and avoid benzodiazepines. (See "Monitored anesthesia care in adults", section on 'Drugs used for sedation and analgesia for monitored anesthesia care'.)

Regional anesthesia — A regional anesthetic technique such as a peripheral nerve block or a neuraxial (spinal or epidural) anesthetic is often selected for patients on dialysis if this choice is appropriate for the surgical procedure. Considerations unique to patients with ESKD include the possibility of slow onset of action of the selected local anesthetic agent due to low serum bicarbonate level and possible shortened duration of local anesthetic action due to reduced protein binding [17]. (See "Overview of peripheral nerve blocks", section on 'Use of nerve blocks' and "Overview of neuraxial anesthesia", section on 'Use of neuraxial anesthesia'.)

Similar to local anesthetic techniques with MAC, an advantage of a regional technique is avoidance of a potentially hazardous general anesthetic and the need to administer multiple IV anesthetic agents. If necessary, supplemental IV sedative, anxiolytic, or analgesic agents may be administered in small titrated doses; however, benzodiazepines are avoided and opioids are minimized. (See 'Local anesthesia' above.)

Another advantage is the superior postoperative analgesia that neuraxial or peripheral blocks typically provide, with reduced requirements for systemic analgesic agents (particularly opioids). Furthermore, these techniques may improve patency and lower failure rates for vascular surgical procedures to provide dialysis access [18-20]. (See "Management of acute perioperative pain in adults", section on 'Regional analgesia' and "Overview of neuraxial anesthesia", section on 'General versus neuraxial anesthesia'.).

In selected patients with coagulopathy or significant bleeding diathesis or recent anticoagulation with heparin (eg, for hemodialysis), a disadvantage is the need to avoid regional techniques such as neuraxial anesthesia, paravertebral blocks, and deep plexus blocks (eg, lumbar plexus). A coagulation profile (eg, international normalized ratio, partial thromboplastin time, platelet count) is checked before beginning such regional techniques. Furthermore, if the patient has received heparin during postoperative dialysis, the coagulation profile should be checked prior to removal of a neuraxial catheter in the postoperative period [21-23]. (See 'Management of bleeding' above and "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)

General anesthesia — General anesthesia is necessary for many surgical procedures (see "Overview of anesthesia", section on 'Selection of anesthetic technique'). Metabolism and elimination of many IV anesthetic agents may be delayed in patients with ESKD due to impairment of glomerular filtration and renal tubular function, leading to accumulation of the drugs and their metabolites. Also, the volume of distribution and degree of plasma protein binding of anesthetic drugs may be altered, resulting in higher-than-expected plasma concentrations.

Induction

Sedative-hypnotic anesthetic induction and adjuvant agents – We typically induce general anesthesia with a reduced and carefully titrated dose of the sedative-hypnotic induction agent propofol (eg, 1 to 2 mg/kg) because the pharmacokinetic and pharmacodynamic responses to this agent are not markedly altered by ESKD [24,25]. Administration of higher bolus doses of propofol may result in profound hypotension due to venous and arterial dilation, as well as decreased myocardial contractility. (See "General anesthesia: Intravenous induction agents", section on 'Propofol'.)

A different sedative-hypnotic agent may be selected based on patient- or procedure-specific factors (table 3). (See "General anesthesia: Intravenous induction agents".)

Agents to facilitate endotracheal intubation

NMBAs for patients who require rapid sequence induction and intubation – Properties of neuromuscular blocking agents (NMBAs) are noted in the table (table 4).

-Succinylcholine for patients with potassium concentration <5.5 mEq/L – Succinylcholine (SCh) is typically selected to facilitate laryngoscopy for patients requiring rapid sequence induction and intubation (RSII) due to risk of aspiration (see "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Succinylcholine'). If the potassium concentration is <5.5 mEq/L and there are no electrocardiographic (ECG) changes, SCh can be safely used in patients on dialysis [26]. As in healthy patients, a transient potassium increase of approximately 0.5 to 1 mEq/L is observed after SCh administration, but this hyperkalemic response is not exaggerated in patients with ESKD. Notably, patients with ESKD have reduced levels of plasma cholinesterase, the enzyme that metabolizes SCh. Hence, the neuromuscular block caused by SCh may be prolonged [27]. However, we avoid SCh if the potassium level is ≥5.5 mEq/L or if any ECG changes are evident. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Succinylcholine'.)

-Rocuronium for patients with potassium concentration ≥5.5 mEq/L – For patients with a potassium level ≥5.5 mEq/L who require RSII, we use a relatively large dose of rocuronium (1 mg/kg) if RSII is necessary. Although rocuronium is primarily eliminated by direct liver uptake and excretion in bile, some is excreted by the kidneys. Thus, neuromuscular blockade may be markedly prolonged after administration of a large dose suitable for RSII (see "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Sugammadex'). Although neuromuscular blockade due to rocuronium can be reversed with sugammadex, removal of the sugammadex/rocuronium complex by dialysis may be necessary due to concerns about the possibility of dissociation of the complex with recurrence of paralysis. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Sugammadex'.)

NMBAs for patients who do not require rapid sequence induction and intubation – Either the nondepolarizing NMBA atracurium, cisatracurium, or rocuronium is typically selected to facilitate laryngoscopy if RSII is not necessary. Elimination of atracurium or cisatracurium is independent of kidney function [28-30]. However, because of slow onset (three to four minutes for atracurium and five to seven minutes for cisatracurium), these agents are not ideal for RSII. As noted above, rocuronium is a suitable alternative, particularly for patients requiring RSII. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Atracurium' and "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Cisatracurium' and "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Rocuronium'.)

Remifentanil intubation technique – A remifentanil intubation technique can be used to facilitate laryngoscopy for patients who do not require RSII, thereby avoiding use of a NMBA. For this technique, propofol 1 to 2 mg/kg is administered followed by a relatively high dose of the ultrashort-acting opioid remifentanil (eg, 2 to 3 mcg/kg). This results in good intubating conditions in approximately two minutes. We administer ephedrine 10 mg together with the doses of propofol and remifentanil to minimize the profound bradycardia and hypotension that may otherwise result from combining large doses of both agents, particularly in a patient with ESKD. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Remifentanil intubation'.)

Sevoflurane during induction – Sevoflurane can be used instead of remifentanil, with administration of 3.5% for approximately three minutes, followed by administration of a reduced dose or propofol (0.5 to 1 mg/kg).

Maintenance

Inhalation or total intravenous anesthesia (TIVA) techniques – Either an inhalation-based technique or TIVA is a reasonable choice to maintain general anesthesia. Typically, a combination of inhalation and IV agents is employed. (See "Maintenance of general anesthesia: Overview".)

Inhalation anesthetic technique – Any one of the potent volatile agents (eg, isoflurane, sevoflurane, desflurane) may be administered with or without nitrous oxide (N2O). Sevoflurane has been used safely in patients with stable chronic kidney disease and those on dialysis [31-41]. This is despite concerns that have been expressed regarding the theoretical kidney toxicity of sevoflurane due to its inorganic fluoride ion metabolite [42] and formation of a substance known as "Compound A," particularly when low fresh gas flows are used or higher temperatures are present in the breathing circuit [43-45]. (See "Inhalation anesthetic agents: Clinical effects and uses", section on 'Sevoflurane'.)

TIVA technique – We typically use a continuous IV infusion of both a hypnotic agent (usually propofol at 50 to 150 mcg/kg/minute) and a short-acting opioid (usually remifentanil at 0.015 to 1 mcg/kg/minute). (See "Maintenance of general anesthesia: Overview", section on 'Total intravenous anesthesia'.)

Use of opioids during maintenance – Although opioids are routinely used as adjuvant agents during maintenance of general anesthesia, we carefully titrate any selected short-acting opioid according to individual patient needs in order to avoid postoperative respiratory depression. (See "Maintenance of general anesthesia: Overview", section on 'Analgesic component: Opioid agents' and "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Maintenance'.)

Short-acting opioids – Generally, the pharmacokinetic and pharmacodynamic responses to short-acting opioids (eg, fentanyl, remifentanil, and sufentanil) are not affected by ESKD, although interindividual variability exists [46-49]. Also, acute alkalinization induced by hemodialysis may increase the distribution of opioids across the blood-brain barrier into cerebrospinal fluid. Thus, it is particularly important to monitor for perioperative respiratory depression [49]. (See "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Prevention and management of adverse opioid effects'.)

-Fentanyl – We employ fentanyl in the majority of cases. It is predominantly metabolized in the liver to norfentanyl, an inactive metabolite. It has a short redistribution phase and its free fraction is not different in patients with ESKD compared with patients without ESKD. (See "Perioperative uses of intravenous opioids: Specific agents", section on 'Fentanyl'.)

-Remifentanil – We typically use remifentanil without dose adjustment as the analgesic component of a TIVA technique. Remifentanil is rapidly broken down by nonspecific plasma and tissue esterases; thus, accumulation does not occur regardless of duration of administration. Remifentanil has a predictable offset of action, with a context-sensitive half-time that is consistent in patients with or without ESKD [50]. (See "Perioperative uses of intravenous opioids: Specific agents", section on 'Remifentanil'.)

Use of NMBAs during maintenance – We monitor the degree of neuromuscular blockade if a nondepolarizing NMBA is administered to facilitate conduct of the surgical procedure since interindividual variability in pharmacokinetic and pharmacodynamic responses are likely due to preexisting acidosis or alterations in volume of distribution (table 4). We generally prefer cisatracurium since elimination is independent of kidney function [28-30]. Longer-acting NMBAs are avoided in patients with ESKD. (See "Clinical use of neuromuscular blocking agents in anesthesia".)

Cisatracurium – Cisatracurium is the cis-isomer of atracurium and is four times more potent than atracurium. In contrast with atracurium, it does not cause histamine release. Cisatracurium is also primarily metabolized through Hofmann elimination and has no active metabolites. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Cisatracurium'.)

Atracurium – Atracurium is metabolized through nonspecific plasma esterase-mediated hydrolysis and a nonenzymatic, pH- and temperature-dependent degradation called Hofmann elimination. Metabolism is essentially independent of hepatic and kidney function, and atracurium has no active metabolites. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Atracurium'.)

Mivacurium – Mivacurium may be used in patients with ESKD undergoing surgical procedures that are of moderate duration (one or more hours). Mivacurium is hydrolyzed by plasma cholinesterase, like SCh, and does not have active metabolites. Its usual duration of action is 15 to 20 minutes, but recovery may be slower in patients with ESKD due to reduced plasma cholinesterase activity [51]. Reversal (antagonism) of mivacurium with either neostigmine or edrophonium is faster than spontaneous recovery [52]. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Mivacurium'.)

Rocuronium – Rocuronium is increasingly used in patients with ESKD (eg, for patients who required RSII during induction of anesthesia) (see 'Induction' above). Rocuronium is excreted mostly through the biliary route, but some is excreted by the kidneys such that clearance is reduced by 33 to 39 percent in patients with ESKD. Furthermore, its metabolism results in 17-desacetyl-rocuronium, a compound that has 20 percent the activity of the parent compound. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Rocuronium'.)

Emergence — The following agents may be used to reverse the effects of NMBAs (see "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Reversal of neuromuscular block'):

Neostigmine – Pharmacokinetics of typical single-dose administration of the anticholinesterase agent neostigmine at the end of surgery do not differ from patients with normal kidney function [53]. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Anticholinesterases'.)

Sugammadex – Sugammadex is a chelating agent that encapsulates rocuronium or vecuronium in order to rapidly reverse neuromuscular blockade [54]. If high-dose rocuronium is used and reversed with sugammadex in a patient with ESKD (see 'Induction' above), the sugammadex-rocuronium complexes are retained in the body longer than in healthy patients before eventually being excreted by the kidneys. However, the clinical significance of this delay is not clear [55,56]. Also, the sugammadex-rocuronium complex can be removed by dialysis [57]. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Sugammadex'.)

Intraoperative concerns

Fluid management — Management of IV fluid administration may be challenging in a patient on dialysis. Hypervolemia may lead to pulmonary edema, while hypovolemia may cause hemodynamic instability [17]. (See "Intraoperative fluid management", section on 'Causes and consequences of intravascular volume derangements'.)

We administer fluids in 500 mL infusion bags with a micro-dripper to avoid fluid overload, unless large fluid shifts and/or a large volume of blood loss is likely. Fluid choices include the following:

Crystalloids – We typically select a balanced electrolyte solution unless the patient has hyperkalemia. In such cases, we select normal saline. However, administration of large volumes of normal saline may result in hyperchloremic metabolic acidosis compared with administration of balanced electrolyte solutions [58,59]. (See "Intraoperative fluid management", section on 'Crystalloid solutions'.)

Notably, patients with ESKD are at risk for development of hyperkalemia when nil per os (NPO; nothing by mouth) and receiving IV fluids without glucose. However, glucose-containing solutions are avoided in patients with hyperglycemia or if hypokalemia is present. If a glucose-containing solutions is administered, blood glucose levels should be monitored. (See 'Glucose control' below.)

Colloids – In rare circumstances when urgent and significant volume expansion is necessary in a patient with ESKD when transfusion of packed red blood cells (RBCs) is not available or is not indicated, 5% albumin is administered in the United States. Other colloid solutions (eg, Gelofusine) may be available for such situations in other nations. (See "Intraoperative fluid management", section on 'Colloid solutions'.)

Blood – Perioperative blood transfusion is avoided when possible. However, if hemoglobin is <7 g/dL, particularly with ongoing surgical bleeding, transfusion of RBCs is often necessary. Potassium should be checked regularly during transfusion since hyperkalemia may develop in an anuric patient.

Further discussion of transfusion and alternatives to transfusion in patients with ESKD is presented separately. (See "Medical management of the dialysis patient undergoing surgery", section on 'Anemia' and "Treatment of anemia in patients on dialysis".)

Glucose control — We maintain blood glucose <180 mg/dL (<10 mmol/L) throughout the perioperative period in both patients with and without diabetes. Either hyperglycemia or hypoglycemia may occur, particularly in patients on dialysis with type 1 diabetes. Even in those without diabetes, glucose intolerance is a feature of uremia. Hyperglycemia is a common consequence of the administration of high doses of steroids in patients with ESKD.

If insulin is administered, the serum glucose level is checked one hour later, or every 30 to 60 minutes when a perioperative insulin infusion is used [60]. It is particularly important to avoid hypoglycemic episodes. Although hyperglycemia is associated with an approximately two- to fourfold increased risk of a myocardial ischemic event in noncardiac surgery [61,62], attempts to tightly control glucose may cause harm due to inadvertent hypoglycemia [63]. (See "Glycemic control in critically ill adult and pediatric patients".)

POSTOPERATIVE ANALGESIA — Most patients with end-stage kidney disease (ESKD) can be admitted to a post-anesthesia care unit depending on other procedure-specific and patient-specific factors. Those with hemodynamic instability, bleeding, electrolyte abnormalities, or volume overload are admitted to an intensive care unit. We use a multimodal approach to postoperative pain in either setting. (See "Medical management of the dialysis patient undergoing surgery", section on 'Pain management'.)

Regional and local anesthetic techniques – For many types of surgical procedures, regional and local analgesic techniques such as neuraxial analgesia, peripheral nerve blocks, or wound infiltration with local anesthetic agents are encouraged as part of a multimodal pain management strategy to reduce or eliminate opioid requirements [64]. (See 'Regional anesthesia' above and "Management of acute perioperative pain in adults", section on 'Regional analgesia'.)

Pharmacologic agents

Nonopioid analgesics – Nonopioid pharmacologic agents such as acetaminophen and ketamine are often employed. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Acetaminophen' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Ketamine'.)

Opioid analgesics – For patients requiring short-term opioid administration to control pain in the immediate postoperative period, we use a patient-controlled analgesia regimen with fentanyl [17]. (See "Management of acute perioperative pain in adults", section on 'Patient-controlled analgesia' and "Management of acute perioperative pain in adults", section on 'Fentanyl' and "Management of acute perioperative pain in adults", section on 'Hydromorphone' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Glucocorticoids'.)

Agents to avoid

-Meperidine – Although commonly used to treat postoperative shivering (see "Perioperative temperature management", section on 'Shivering'), meperidine is avoided in patients with ESKD. The renally excreted active metabolite normeperidine accumulates and may cause respiratory depression as well as adverse neuroexcitatory effects (eg, myoclonic activity and/or seizures) in patients [65].

-Long-acting opioids – We generally avoid long-acting opioids due to potential accumulation of metabolites. However, selected longer-acting opioids may be used after some painful surgical procedures (eg, hydromorphone 0.1 to 0.2 mg IV every five minutes in the postanesthesia care unit [PACU], titrated to pain, consciousness, and respiratory status). (See "Management of acute perioperative pain in adults", section on 'Patient-controlled analgesia' and "Management of acute perioperative pain in adults", section on 'Fentanyl' and "Management of acute perioperative pain in adults", section on 'Hydromorphone' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Glucocorticoids'.)

-Gabapentinoids – Although used in some multimodal pain protocols, patients with ESKD are particularly vulnerable to adverse effects of gabapentinoids (eg, sedation, respiratory depression) [64,66]. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Gabapentinoids'.)

-Nonsteroidal antiinflammatory drugs (NSAIDs) – NSAIDs are avoided in patients who might have residual kidney function (eg, patients on chronic peritoneal dialysis who still have some daily urine output or those who have initiated hemodialysis within the last 6 to 12 months). (See "NSAIDs: Acute kidney injury".)

SUMMARY AND RECOMMENDATIONS

Preanesthetic management

Elective surgery – Prior to elective surgery, patients with end-stage kidney disease (ESKD) on dialysis are assessed for comorbidities that may impact anesthetic and surgical care. Management of chronically administered medications is similar to that for those without ESKD. (See 'Elective surgery: Assessment and medication management' above.)

Emergency surgery – For emergency surgical procedures, the nephrology service is consulted when urgent preoperative dialysis may be desirable to treat severe hyperkalemia, metabolic acidosis, or intravascular volume overload. Institution of alternative therapies may be necessary if dialysis is not feasible.

-Hyperkalemia – If potassium is ≥5.5 mEq/L, we dialyze if time allows, since even one to two hours of hemodialysis reduces potassium concentration. If dialysis is not possible and potassium is >6.5 mEq/, intravenous (IV) calcium chloride, insulin, or bicarbonate may be administered, or intraoperative continuous kidney replacement therapy or hemodialysis may be initiated (algorithm 1 and table 1). (See 'Management of hyperkalemia' above.)

-Intravascular volume overload – Risks of moderate or severe preoperative volume overload are weighed against risks of delaying surgery for dialysis. (See 'Management of intravascular volume overload' above.)

-Bleeding – If uremia-induced platelet dysfunction is suspected, we suggest administration of IV desmopressin (dDAVP) (Grade 2C). For patients with active bleeding, platelets are administered even in the absence of thrombocytopenia. (See 'Management of bleeding' above.)

Vascular access – Veins on the back of the hand are used for peripheral venous catheters; the dominant arm is preferred. We avoid any arteriovenous fistula or graft, potential future fistula sites (eg, antecubital veins and cephalic vein at the wrist), and the hemodialysis catheter. Exceptions may occur in an emergency situation when alternative vascular access is challenging, or to avoid multiple attempts to obtain IV access or insertion of a new central venous catheter (CVC). We also avoid intra-arterial cannulation in the extremity with a fistula or graft. (See 'Vascular access' above.)

Intraoperative anesthetic management

Local anesthesia – Local anesthesia with monitored anesthesia care (MAC) is often selected if appropriate for the surgical procedure, thereby avoiding general anesthesia with multiple anesthetic agents that may have delayed metabolism and excretion. Short-acting IV sedative, anxiolytic, or analgesic agents may be administered in reduced carefully titrated doses (table 2). (See 'Local anesthesia' above.)

Regional anesthesia – A regional anesthetic technique (eg, peripheral nerve block, neuraxial anesthesia) is often selected if appropriate for the surgical procedure, thereby avoiding general anesthesia, as well as providing superior postoperative analgesia. (See 'Regional anesthesia' above.)

General anesthesia (See 'General anesthesia' above.)

-Induction – General anesthesia is typically induced with a reduced carefully titrated dose of propofol (eg, 1 to 2 mg/kg).

If rapid sequence induction and intubation (RSII) is necessary, succinylcholine (SCh) can be used as the neuromuscular blocking agent (NMBA) if potassium is <5.5 mEq/L. However, we avoid SCh if potassium is ≥5.5 mEq/L, and use the nondepolarizing NMBA rocuronium instead, with planned sugammadex reversal.

If RSII is unnecessary, an NMBA with slower onset (eg, cisatracurium, rocuronium) can be used. Alternative techniques without use of any NMBA include a remifentanil intubation technique, or use of sevoflurane 3.5% for three minutes plus a reduced dose of propofol (ie, 0.5 to 1 mg/kg). (See 'Induction' above.)

-Maintenance – Inhalation-based or total IV anesthesia (TIVA), or combinations of IV and inhalation agents may be used to maintain anesthesia. A short-acting opioid may be carefully titrated.

Fluid management – We typically select a balanced electrolyte solution unless the patient is hyperkalemic. In such cases, we select normal saline. In rare circumstances when urgent and significant volume expansion is necessary, 5% albumin may be administered. Transfusion is avoided when possible, but red blood cells (RBCs) are administered if hemoglobin is <7 g/dL, particularly with ongoing surgical bleeding. (See 'Fluid management' above.)

Glucose control – We maintain blood glucose at <180 mg/dL (<10 mmol/L). (See 'Glucose control' above.)

Postoperative analgesia – We use a multimodal approach to postoperative analgesia including nonpharmacologic techniques (eg, neuraxial analgesia, peripheral nerve blocks, wound infiltration with local anesthesia), nonopioid analgesics (eg, acetaminophen, ketamine), and opioid analgesics (typically, patient-controlled analgesia with fentanyl). We avoid gabapentinoids, meperidine, long-acting opioids, and nonsteroidal anti-inflammatory agents. (See 'Postoperative analgesia' above.)

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References