{"id":203,"date":"2018-04-23T12:06:09","date_gmt":"2018-04-23T12:06:09","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=203"},"modified":"2021-08-04T11:25:43","modified_gmt":"2021-08-04T11:25:43","slug":"surgery-in-esrd","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/unithdbk\/procedures-radiology-surgery\/surgery-in-esrd\/","title":{"rendered":"Surgery in ESKD"},"content":{"rendered":"<p>Jump to perioperative <a href=\"#Perioperative_Management\">management of potassium<\/a><\/p>\n<p><strong><span style=\"color: #993300;\">Edinburgh:<\/span><\/strong> some of these protocols are specific to Edinburgh, but most are general.<\/p>\n<h5><strong><span style=\"color: #993300;\">Admission\u00a0\u00a0\u00a0<\/span><\/strong><\/h5>\n<p>In order to preven problems arising please consider the following:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Patients being admitted for surgery should usually be admitted on the morning of the day prior to surgery.\u00a0 This will enable adequate time for the SHOs to admit the patient, and identify any problems which require to be addressed prior to surgery.\u00a0 This will also mean that the anaesthetist will be able to see the patient and be aware of any potential anaesthetic problems.\u00a0 Patients should not be advised to come for surgery on the afternoon or evening of the day prior to surgery<\/li>\n<li>If we think there is a case for day-case surgery, then this should be discussed with the anaesthetist and a clear protocol arranged<\/li>\n<li>If on dialysis, then some reorganisation of the dialysis schedule may well be required. For haemodialysis, arrangements should be made for the patient to have dialysis on the day before surgery.\u00a0 The plan should be put in writing with copies to the Dialysis Unit and Ward doctors (if\u00a0 to be an in-patient)<\/li>\n<li>Urea and electrolytes, creatinine, and a full blood count should be done on the morning of admission so that results are available for the anaesthetist when they assess the patient.\u00a0 In addition, for HD patients (or APD or CAPD if dialysis has been interrupted) urea and electrolytes should be done urgently, as early as possible, on the morning of surgery and these results should be sent with the patient to theatre<\/li>\n<li>If hyperkalaemia\u00a0is anticipated, and since patients may be fasted overnight, there is a reasonable case for giving a slow dextrose infusion overnight and for some patients a single dose of calcium resonium on the evening prior to surgery.\u00a0 If hyperkalaemia is anticipated, proper planning avoids a crisis on the morning of surgery:\u00a0 <a href=\"#Perioperative_Management\">see below<\/a><\/li>\n<li>In patients with ESRF, veins are precious and we should avoid siting i.v. cannulae in veins which may be used for future vascular access &#8211; this applies particularly to the cephalic vein in the forearm, see \u2018Veins and vascular access.\u00a0 Clearly if a patient is going for vascular access procedure, then cannulae should not be placed in the arms being used for access<\/li>\n<li>Postoperatively, remember problems with prescribing of analgesics, especially NSAIDs and opiates, in different patient groups.\u00a0 There is a specific protocol for management of epidurals\u00a0and patient-controlled analgesia (PCA, using fentanyl) in renal failure<\/li>\n<\/ul>\n<h5><strong><span style=\"color: #993300;\"><a id=\"Perioperative_Management\"><\/a>Perioperative Management of Potassium<\/span><\/strong><\/h5>\n<p><strong><span style=\"color: #993300;\">Pre-operatively\u00a0<\/span><\/strong><\/p>\n<p>The objective is to ensure that [K+] is below 5mmol\/l.\u00a0 Post-dialysis [K+] should be checked at least 5 minutes after the end of dialysis.\u00a0 It should be well below 5.0 if possible (but in the normal range).\u00a0 This may necessitate arranging dialysis two days running, in patients who are frequently hyperkalaemic.<\/p>\n<p><strong><span style=\"color: #993300;\">If 5.0-5.5:<\/span><\/strong><\/p>\n<p>This may be too high for some types of surgery &#8211; eg prolonged, or likely to involve too much blood loss.\u00a0 If acceptable (discuss with anaesthetist), use the following maintenance regimen to prevent a further rise:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>infuse 10% dextrose at 40ml\/h (without insulin\u00a0in non-diabetic patients)<\/li>\n<li>give nebulised Salbutamol 5mg 6-hourly<\/li>\n<\/ul>\n<p>If there is much delay, recheck\u00a0 [K<sup>+<\/sup>]\n<p><strong><span style=\"color: #993300;\">If it is 5.5-6.5:<\/span><\/strong><\/p>\n<p>This is likely to indicate a need for further dialysis pre-operatively &#8211; and should have been avoided.\u00a0 If surgery is to go ahead.<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>give 50mls 50% dextrose with 5u Actrapid over 15 minutes<\/li>\n<li>follow with maintenance regimen above<\/li>\n<\/ul>\n<p>Such decisions will normally be made at a senior level.<\/p>\n<p><strong><span style=\"color: #993300;\">If it is over 6.5:<\/span><\/strong><\/p>\n<p>Dialysis is indicated except in an emergency.\u00a0 The relative risks then have to be judged.<\/p>\n<h5><strong><span style=\"color: #993300;\">Post-operatively<\/span><\/strong><\/h5>\n<p>Potassium should be checked after the patient returns. This may bot be necessary if potassium was under 5.0 pre-operatively, and the patient has had superficial surgery carried out under local anaesthesia, with insignificant blood loss.<\/p>\n<p>&nbsp;<\/p>\n<h5><strong><span style=\"font-family: georgia, palatino, serif;\">Parathyroidectomy<\/span><\/strong><\/h5>\n<p>Our protocol for the perioperative care of CKD patients undergoing parathyroidectomy is provided on our\u00a0<a href=\"https:\/\/edren.org\/ren\/handbook\/unithdbk\/ckd-for-nephrologists\/ckdmbd\/\">CKD-MBD (Mineral Bone Disease)<\/a> page.<\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt; color: #808080;\"><strong>Acknowledgements:\u00a0\u00a0<\/strong> Liam Plant was the original main author for this page. It was last updated by Caroline Whitworth and Neil Turner November 2006. The last modified date is shown in the footer.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Jump to perioperative management of potassium Edinburgh: some of these protocols are specific to Edinburgh, but most are general. Admission\u00a0\u00a0\u00a0 In order to preven problems arising please consider the following: Patients being admitted for surgery should usually be admitted on the morning of the day prior to surgery.\u00a0 This will\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/unithdbk\/procedures-radiology-surgery\/surgery-in-esrd\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":5515,"menu_order":46,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-203","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/203","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=203"}],"version-history":[{"count":6,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/203\/revisions"}],"predecessor-version":[{"id":5485,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/203\/revisions\/5485"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/5515"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=203"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}