Chronic Renal Failure
Considerations
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Gastroparesis & risk of aspiration
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Dysregulation of volume status, acid-base (metabolic acidosis), & electrolytes (↑ K, ↓ Na, ↓ Ca, ↑ PO4, ↓ glucose, ↑ triglycerides)
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Coexisting diseases & end-organ complications:
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Autonomic dysfunction with hemodynamic instability
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Pulmonary: pulmonary edema from low albumin, ↓ forced vital capacity, atelectasis
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Cardiac: LV dysfunction, hypertension, coronary disease, heart failure, pericarditis, pericardial effusion, arrythmias
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Hematologic: anemia/thrombocytopenia
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Altered pharmacokinetics due to ↓ elimination, acidosis, hypoalbuminemia
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Potential difficult IV access
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Cr > 200 independent risk factor for cardiac complications & mortality
Conflicts
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Hyperkalemia vs. need for emergency surgery/RSI
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Hemodynamic instability vs. RSI
Goals
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Optimize electrolytes, volume status, comorbidities
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Avoid worsening renal failure (avoid nephrotoxins, maintain adequate volume status)
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Coordinate perioperative dialysis if on hemodialysis
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If on peritoneal dialysis: consider draining it to optimize respiratory function
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Avoid compromising dialysis access (AV fistulas, indwelling IV lines, PD ports)