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Surgery - Operative procedures in renal and hepatic disorders
Renal dysfunction
Renal impairment encompasses a continuum, from individuals with subclinical dysfunction (normal serum creatinine and urea levels, although borderline creatinine clearance) to those with end-stage renal failure. It is beneficial to categorize these patients into two primary groups: those with chronic renal impairment and those who are dialysis-dependent.
Chronic kidney dysfunction
Surgery may induce acute renal failure in patients with chronic renal insufficiency. Avoid hypovolemia and hypotension. Ensure that these patients obtain sufficient intravenous hydration if they are to remain nil by mouth for an extended duration. Avoid nephrotoxic agents wherever feasible, including non-steroidal anti-inflammatory medications (NSAIDs), aminoglycosides, ACE inhibitors, and radiographic contrast media. Decrease dosages of medications eliminated by the kidneys, such as morphine, low-molecular-weight heparin (LMWH), and digoxin, and regularly seek relevant levels.
Patients with diagnosed renal insufficiency undergoing dialysis
For patients undergoing major surgery, consult with the anesthesiologist and ICU regarding their post-operative management at the earliest opportunity. Dialysis must be conducted the day before to surgery. Patients are required to undergo a complete blood count (FBC) and urea and electrolytes (U&Es) upon admission, as well as pre- and post-dialysis assessments. Additionally, U&Es should be conducted twice day following major surgery until the patient is stabilized on their standard dialysis regimen.
Decrease dosages of medications eliminated by the kidneys, such as morphine, low molecular weight heparin (LMWH), and digoxin, and regularly seek relevant serum values. If the patient is typically anuric, the insertion of a urine catheter is unwarranted, as it poses an unnecessary risk of infection.
Identify the locations of arteriovenous fistulae. Avoid utilizing them for phlebotomy or cannulation, and refrain from applying blood pressure cuffs on that side.
These patients are susceptible to several complications:
Hyperkalemia, acidosis, and pulmonary edema are potential life-threatening situations (% Renal complications, pp. 136–8). Infection. Anemia with coagulopathy. Disruptions in fluid and electrolyte balance.
Metabolic acidosis. Systemic hypertension, pericarditis.
Hepatic dysfunction
The risk associated with liver disease in patients undergoing general surgery was assessed by Child and Turcotte (refer to Box 2.3). Child grade C correlates with elevated perioperative mortality. Liver failure results in the subsequent complications: Hypoglycemia; hepatic encephalopathy; coagulopathy (international normalized ratio); ascites; and infection.
Multiple variables can precipitate abrupt decompensation of mild hepatic impairment and should be avoided or managed vigorously in this population: • Infection, particularly bacterial peritonitis; drowsiness; diuretics; constipation; electrolyte imbalance; dehydration; and hypotension.
• Preoperatively: assess hepatitis serology, order liver ultrasound for newly detected hepatic impairment; consult with haematology on additional blood product requests; confer with a specialist about normal drug dosages. Jaundice Patients with obstructive jaundice are susceptible to post-operative renal failure (hepatorenal syndrome). This is believed to result from the nephrotoxic impact of toxins typically excreted by the liver, along with alterations in circulation. • Maintain sufficient hydrated. For a patient who is NBM, administer IV normal saline 1L over a duration of 6 to 8 hours. • Insert a urine catheter and initiate an hourly fluid balance chart. • Conduct daily assessments of urea and electrolytes (U&E) and liver function tests (LFTs). Coagulopathy in chronic cholestatic jaundice may be ameliorated with 1 mg of intravenous vitamin K—consult with hematology. Avoid or minimize the dosages of hepatotoxic medications and those eliminated by the liver.
Renal dysfunction
Renal impairment encompasses a continuum, from individuals with subclinical dysfunction (normal serum creatinine and urea levels, although borderline creatinine clearance) to those with end-stage renal failure. It is beneficial to categorize these patients into two primary groups: those with chronic renal impairment and those who are dialysis-dependent.
Chronic kidney dysfunction
Surgery may induce acute renal failure in patients with chronic renal insufficiency. Avoid hypovolemia and hypotension. Ensure that these patients obtain sufficient intravenous hydration if they are to remain nil by mouth for an extended duration. Avoid nephrotoxic agents wherever feasible, including non-steroidal anti-inflammatory medications (NSAIDs), aminoglycosides, ACE inhibitors, and radiographic contrast media. Decrease dosages of medications eliminated by the kidneys, such as morphine, low-molecular-weight heparin (LMWH), and digoxin, and regularly seek relevant levels.
Patients with diagnosed renal insufficiency undergoing dialysis
For patients undergoing major surgery, consult with the anesthesiologist and ICU regarding their post-operative management at the earliest opportunity. Dialysis must be conducted the day before to surgery. Patients are required to undergo a complete blood count (FBC) and urea and electrolytes (U&Es) upon admission, as well as pre- and post-dialysis assessments. Additionally, U&Es should be conducted twice day following major surgery until the patient is stabilized on their standard dialysis regimen.
Decrease dosages of medications eliminated by the kidneys, such as morphine, low molecular weight heparin (LMWH), and digoxin, and regularly seek relevant serum values. If the patient is typically anuric, the insertion of a urine catheter is unwarranted, as it poses an unnecessary risk of infection.
Identify the locations of arteriovenous fistulae. Avoid utilizing them for phlebotomy or cannulation, and refrain from applying blood pressure cuffs on that side.
These patients are susceptible to several complications:
Hyperkalemia, acidosis, and pulmonary edema are potential life-threatening situations (% Renal complications, pp. 136–8). Infection. Anemia with coagulopathy. Disruptions in fluid and electrolyte balance.
Metabolic acidosis. Systemic hypertension, pericarditis.
Hepatic dysfunction
The risk associated with liver disease in patients undergoing general surgery was assessed by Child and Turcotte (refer to Box 2.3). Child grade C correlates with elevated perioperative mortality. Liver failure results in the subsequent complications: Hypoglycemia; hepatic encephalopathy; coagulopathy (international normalized ratio); ascites; and infection.
Multiple variables can precipitate abrupt decompensation of mild hepatic impairment and should be avoided or managed vigorously in this population: • Infection, particularly bacterial peritonitis; drowsiness; diuretics; constipation; electrolyte imbalance; dehydration; and hypotension.
• Preoperatively: assess hepatitis serology, order liver ultrasound for newly detected hepatic impairment; consult with haematology on additional blood product requests; confer with a specialist about normal drug dosages. Jaundice Patients with obstructive jaundice are susceptible to post-operative renal failure (hepatorenal syndrome). This is believed to result from the nephrotoxic impact of toxins typically excreted by the liver, along with alterations in circulation. • Maintain sufficient hydrated. For a patient who is NBM, administer IV normal saline 1L over a duration of 6 to 8 hours. • Insert a urine catheter and initiate an hourly fluid balance chart. • Conduct daily assessments of urea and electrolytes (U&E) and liver function tests (LFTs). Coagulopathy in chronic cholestatic jaundice may be ameliorated with 1 mg of intravenous vitamin K—consult with hematology. Avoid or minimize the dosages of hepatotoxic medications and those eliminated by the liver.
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