Chronic Renal Failure Flashcards
What are the two leading causes of end-stage renal
disease?
Diabetes mellitus and hypertension.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 341.
What percentage of the nephrons will be destroyed
before patients with ESRD become symptomatic?
90%
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 341.
What electrolyte imbalances does chronic renal
failure cause?
Hyponatremia, hyperkalemia, hyperphosphatemia,
hypocalcemia, and metabolic acidosis.
Yao FF. Anesthesiology: Problem-Oriented Patient
Management. 7th ed. Philadelphia: Lippincott, Williams, and
Wilkins; 2012: 651.
What are the clinical signs of chronic renal
insufficiency?
Initially, nonspecific signs such as malaise and fatigue may be
present. Volume overload, electrolyte and acid-base
alterations, and decreased urine output are late signs of chronic
renal insufficiency.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 342-344.
What are the first substances that begin to
accumulate in the plasma as renal failure
progresses?
Urea and creatinine are the first substances to accumulate in
the plasma in patients with ESRD. They begin to elevate when
renal function drops to 50%.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 342.
When during the progression of renal failure does
the serum potassium begin to rise? How does the
body try to compensate for this?
When the glomerular filtration reaches 10% of normal, serum
potassium begins to elevate. The kidneys compensate by
increasing blood flow through the remaining nephrons and by
excreting more potassium through the gastrointestinal tract.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 342.
What hematologic changes occur with ESRD?
Anemia is universal among patients with ESRD and is due to
chronic blood loss, hemolysis, uremic suppression of bone
marrow, iron and folate deficiency, and a decrease in the
production of erythropoetin.
Yao FF. Anesthesiology: Problem-Oriented Patient
Management. 7th ed. Philadelphia: Lippincott, Williams, and
Wilkins; 2012: 652.
How does chronic renal failure affect coagulation?
Patients with ESRD exhibit prolonged bleeding times due to
uremia despite normal platelet counts, prothrombin time, and
partial thromboplastin time. They may also exhibit a
predisposition to thromboembolism related to impaired
fibrinolysis, increased platelet aggregation, and altered protein
C and protein S activity.
Yao FF. Anesthesiology: Problem-Oriented Patient
Management. 6th ed. Philadelphia: Lippincott, Williams, and
Wilkins; 2008: 824.
What are the anesthesia considerations at induction
of anesthesia for patients with chronic renal failure?
Induction should proceed slowly using conventional agents
(thiopental, propofol, etomidate) to avoid excessive
hypotension. Regardless of the volume status of the patient
with ESRD, they respond as if they were hypovolemic. Uremia
can slow gastric emptying time, which can increase the risk for
gastric reflux.
What positioning concerns would you have for a
patient with chronic renal failure?
Poor nutritional status makes their skin extremely susceptible to
sloughing and bruising. Be sure to provide extra padding at
vulnerable areas such as the dialysis fistulas, elbows, knees,
and heels. Try to avoid tucking the arm with the fistula if the
patient undergoes dialysis so that it can be evaluated during the
procedure.
Stoelting RK, Dierdorf SF. Anesthesia & Co-Existing Diseases.
5th ed. New York, NY: Churchill-Livingston; 2008: 338.
What is of extreme importance when performing
neuraxial anesthesia or placing invasive lines in
patients with chronic renal failure?
Aseptic technique should be adhered to strictly because these
patients are extremely susceptible to infection.
Stoelting RK, Dierdorf SF. Anesthesia & Co-Existing Diseases.
5th ed. New York, NY: Churchill-Livingston; 2008: 339.
Would you expect awake patients with chronic renal
failure to exhibit hyperventilation or hypoventilation
at rest? Why or why not?
They tend to exhibit hyperventilation. This may be due to
chronic metabolic acidosis and the increased predisposition to
pulmonary edema.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1411.
A patient with chronic renal failure exhibits extreme
hyperkalemia. What are appropriate methods for
reducing the potassium level urgently?
Severe hyperkalemia can be life-threatening and must be
treated immediately. Administration of calcium chloride
stabilizes the heart against dangerous arrhythmias while other
methods of reducing the serum potassium are begun.
Administration of glucose and insulin, sodium bicarbonate
administration, hyperventilation, dialysis, and administration of
potassium-binding resins are all methods of reducing the serum
potassium level.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 1129-1130.
Should patients on dialysis undergo treatment during
the perioperative period?
Yes. Patients who are on hemodialysis should be dialyzed
within 24 hours of surgery to minimize the chances of volume
overload, hyperkalemia, and uremic bleeding.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 346.
What is the most common cause of death in patients
receiving hemodialysis?
Cardiovascular events and infection
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 345.
