Anaesthetic management of patients requiring vascular access surgery for renal dialysis

Abstract

End-stage renal failure (ESRF) creates a considerable health burden in the UK. Despite the increasing number of kidney transplants and a plateau in the incidence of patients starting renal replacement therapy (RRT), the prevalence of patients undergoing dialysis has been steadily increasing, with over 56 000 individuals registered for RRT in 2013 (Fig. 1). 1 As the population ages and the survival of those on dialysis increases, it is likely that the requirement to provide anaesthesia for renal access will only increase.Chronic renal disease significantly increases mortality risk, 8 worsening as glomerular filtration rate (GFR) falls. For those aged 35-39 yr who require RRT, the relative risk of death is 16.2 times that of the general population. In addition to the independent risk of death conferred by RRT, many of the commonest causes of ESRF (see Table 1) are serious systemic diseases in their own right, affecting multiple other organ systems. Decision to offer dialysisChronic kidney disease (CKD) describes abnormal kidney function and/or structure, 2 and its classification has evolved, being most recently described by the updated 2015 NICE guidelines on CKD. 2 It had previously been defined as GFR <60 ml min À1 (1.73 m 2 ) À1 for 3 months or more, or abnormalities of kidney function or structure with implications for health, 3 but the NICE guidance now describes grades of CKD using both GFR and albumin:creatinine ratio (ACR) (Fig. 2).It is usual for patients with G5 CKD, or less severe but rapidly accelerative disease, to be offered dialysis. Types of RRT Peritoneal dialysisThe main advantage of peritoneal dialysis (PD) is that it can be done at home, and it therefore has less impact on daily living. Most patients are on continuous ambulatory PD where they do

Combined interscalene and supraclavicular brachial plexus block using ultrasound guidance versus general anaesthesia for brachioaxillary graft in patients with chronic renal failure

“…This finding was confirmed by Bradley et al who stated that regional anaesthesia for patients with CRF requiring vascular access surgery reduces the need of postoperative analgesia and hastens their discharge. 15 Interestingly, our study reported no phrenic nerve paralysis due to usage of a small volume ultrasound technique. 18 This compares with Riazi et al who compared two volumes of local anaesthetics (20 versus 5 ml) in ISB and concluded that ultrasound guided mixture injection was associated with lower respiratory complications than the large volumes.…”

“…13 General anaesthesia may decrease renal blood flow up to 50% leading to reduced nephrotoxic drugs excretion. 14 Despite BPB providing a promising alternative to other anaesthetic techniques due to less exposure to the various anaesthetic drugs, vasodilator effect, early mobility and excellent postoperative analgesia 15 , there is no evidence for the best approaches of BPB for brachioaxillary graft surgery.…”

The importance of anesthesiological methods in the creation of arteriovenous fistulas

“…The degree of drug ionization will also be affected by chronic metabolic acidosis, which in combination with hypoalbuminemia and low plasma proteins increases the concentration for those drugs that have a higher affinity for protein binding. 9 In patients with end-stage renal disease, the pharmacokinetics of the drug are altered, especially anesthetics (Table 1), therefore the doses of thiopental and benzodiazepines should be reduced by 30-50%. The pharmacokinetics of propafol do not change in renal failure, but there is some evidence to suggest that patients with established renal insufficiency require higher initial doses to achieve the same level of hypnosis.…”

“…Rocuronium relies in part on renal excretion and as such shows prolonged action in renal failure. 9 Local anesthetics are extremely useful drugs in surgical interventions in patients with chronic renal failure. In end-stage renal disease, metabolic acidosis reduces both the duration of anesthetic action and plasma protein binding, which increases the possibility of toxicity, so maximum doses must be reduced by 25%.…”

“…Performing neuroaxial blockade and possibly peripheral regional blocks may be contraindicated, which in turn may pose an increased risk for patients in need of general anesthesia. 9…”