Can dialysis patients still receive anesthesia and surgery?

We all know that the basic functions of the kidney include regulating water, electrolytes and acid-base balance, secreting several neurotransmitters and hormones, and removing metabolic waste from the body. So can dialysis patients still receive anesthesia and surgery?

First of all, we need to understand the classification and causes of kidney injury. Only by knowing ourselves and the enemy can our anesthesia and surgery be safer. Kidney injury is divided into acute kidney injury and chronic kidney disease according to the duration of injury.

Acute kidney injury (AKI) refers to the deterioration of renal function within hours or days, resulting in impaired renal excretion of nitrogenous substances and maintenance of water and electrolyte balance. Patients may experience oliguria (400 ml/day) or no oliguria (urine volume > 400 ml/day).

Despite the significant developments in dialysis therapy and intensive care in recent years, the mortality rate of patients with acute kidney injury is still high when multiple organ dysfunction occurs. Acute kidney injury is divided into prerenal, renal, and postrenal. An abnormal increase in the concentration of nitrogenous compounds (urea nitrogen and creatinine, etc.) caused by any reason is called azotemia, which is a hallmark of acute kidney injury.

Causes of acute kidney injury include: bleeding, trauma, drug toxicity, sepsis, urinary stones, etc. Especially in elderly patients, urinary stones lead to kidney damage and infection, and the disease progresses rapidly. The diagnosis of AKI mainly depends on our laboratory tests. Its main complications affect the nervous system (anxiety, nasal tremor, drowsiness, epilepsy, multiple neuropathies), cardiovascular system (hypertension, heart failure, pulmonary edema, arrhythmia), blood system (anemia, coagulation dysfunction), metabolic disorders (hyperkalemia, metabolic acidosis), gastrointestinal symptoms (anorexia, nausea, vomiting, intestinal obstruction), infection, etc.

Chronic kidney damage (CKD) is a persistent, irreversible renal decline caused by a variety of diseases. Common causes include diabetes, hypertension, kidney disease, etc. Eventually, patients need dialysis or kidney transplantation. Most patients are discovered during routine examinations. Common clinical manifestations include electrolyte imbalance, metabolic acidosis, coagulation disorders, changes in the nervous system, cardiovascular changes, renal osteodystrophy, pruritus, etc.

The anesthesia options include local anesthesia, nerve block, spinal anesthesia and general anesthesia. Spinal anesthesia should be chosen with caution because many dialysis patients have coagulation abnormalities and the effects of residual heparin in the body. The specific anesthesia method needs to vary depending on the patient's surgical procedure.

Patients should be evaluated before surgery, including physical examination, medical history, laboratory tests, etc., especially cardiopulmonary function, renal function, electrolytes, anemia, coagulation abnormalities, etc. Evaluation of the changing trend of plasma creatinine concentration can effectively determine whether the patient's renal function is stable. The evaluation of the patient's blood volume status can be achieved by comparing the changes in the patient's weight before and after dialysis, monitoring the patient's vital signs, and measuring atrial filling pressure. Dialysis patients with hypertension should stop taking ACEI or ARBS drugs on the day of surgery to prevent intraoperative hypotension. Blood sugar in diabetic patients should be controlled within the normal range before surgery. The blood potassium concentration should be controlled below 5.5mmol/L. Those with coagulation disorders can consider the use of desmopressin and other treatments.

The choice of anesthetic drugs includes opioids, sedatives, muscle relaxants (especially cisatracurium), inhaled anesthetics, local anesthetics, etc., which can be safely used in dialysis patients, and some dosages need to be adjusted. Some nephrotoxic anti-inflammatory drugs should be avoided. We pay attention to fluid management. Impairment of renal function narrows the safe range between fluid deficiency and fluid excess. In terms of intraoperative monitoring, invasive arterial pressure monitoring, central venous pressure monitoring, and blood gas analysis can be selected as needed.

After the operation, the patient should be given adequate analgesia, anti-infection and anti-thrombosis treatment, and strive to get out of bed and move around as soon as possible and give dialysis treatment.

In summary, whether dialysis patients can undergo anesthesia and surgery depends on the patient's benefits and risks, and should be evaluated by a professional doctor.

Zhang Xiuyue, Huanghua People's Hospital, Hebei Province

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