What anesthesia is suitable for patients with Impaired renal function (kidney failure)?

From the Guidelines

For patients with kidney failure, I strongly recommend using lidocaine or mepivacaine as local anesthetics, with careful dose adjustment and consideration of the patient's hypertension and renal function, as evidenced by a study published in the International Journal of Oral Science 1. When it comes to anesthesia for kidney failure patients, the choice of medication and dosing is crucial to prevent further renal injury.

• Local anesthetics such as lidocaine and mepivacaine can be safely used in renal failure patients, as they do not rely heavily on renal elimination for metabolism 1.
• It is essential to reduce the dose of epinephrine when using local anesthesia due to the potential for increasing blood pressure, which can be a complication of chronic kidney disease (CKD) 1.
• For anxious patients, topical anesthesia can be used to reduce the pain of the anesthesia injection, and anxiolytics such as diazepam, midazolam, and other benzodiazepines can be safely used, with careful consideration of the patient's renal function and consultation with a nephrologist 1.
• The recommended doses for diazepam vary from 0.1 to 0.8 mg per kg of body weight in a single oral dose for conscious sedation, while midazolam can be used at doses ranging from 0.5 to 1 mg·kg − 1 with a maximum of 15 mg 1.
• Nitrous oxide can be used as an anxiolytic gas, but its long-term exposure may result in health problems, including kidney disease, although there is limited evidence on its harmful effects in CKD patients 1.

From the FDA Drug Label

Sevoflurane was evaluated in renally impaired patients with baseline serum creatinine > 1. 5 mg/dL. Fourteen patients who received sevoflurane were compared with 12 patients who received isoflurane. In another study, 21 patients who received sevoflurane were compared with 20 patients who received enflurane. Creatinine levels increased in 7% of patients who received sevoflurane, 8% of patients who received isoflurane, and 10% of patients who received enflurane Because of the small number of patients with renal insufficiency (baseline serum creatinine greater than 1.5 mg/dL) studied, the safety of sevoflurane administration in this group has not yet been fully established. Therefore, sevoflurane should be used with caution in patients with renal insufficiency (see WARNINGS). Sevoflurane should be used with caution in patients with renal insufficiency 2. The safety of sevoflurane administration in this group has not yet been fully established due to the small number of patients studied. Key considerations for anesthesia in kidney failure patients include:

• Monitoring creatinine levels
• Using sevoflurane with caution in patients with renal insufficiency.

From the Research

Anesthesia for Kidney Failure Patients

• The choice of anesthesia for patients with kidney failure is crucial, as it can affect renal function and overall outcome 3, 4, 5.
• Studies have compared the effects of different anesthetics, such as halothane, isoflurane, sevoflurane, and propofol, on renal function in patients undergoing surgery 3, 4, 5.
• One study found that halothane, isoflurane, sevoflurane, and propofol infusion anesthesia did not affect early postoperative renal functions in patients undergoing coronary artery bypass surgery 3.
• Another study compared the effects of low-flow sevoflurane and isoflurane anesthesia on renal function and found no differences in blood urea nitrogen, creatinine, and creatinine clearance among the groups 4.
• However, low-flow sevoflurane anesthesia was associated with mild and transient proteinuria, which was not associated with any changes in renal function 4.
• A study comparing renal responses to low-flow desflurane, sevoflurane, and propofol found that alterations in postoperative renal function were common and unrelated to the choice of anesthetic 5.
• Fluid management is also crucial in patients with kidney failure, as hypovolemia can result in inadequate blood flow to meet metabolic requirements and must be treated urgently to avoid complications, including acute renal failure 6.

Factors Affecting Renal Function

• The choice of anesthetic can affect renal function, but other factors, such as fluid management and surgical procedures, may also play a role 6, 5.
• Hypovolemia is a major causal factor of morbidity during hemodialysis and may contribute to further renal insults 6.
• The use of neuromuscular blocking agents and other adjuvants may also affect intubating conditions and renal function 7.
• The duration and type of surgery may also impact renal function, with longer surgeries and those involving central regions being associated with greater alterations in renal function 5.