From the Guidelines
Patients with end-stage renal disease (ESRD) undergoing plastic surgery are at high risk of fluid shifts, and their management should prioritize a mildly positive fluid balance of 1-2 L by the end of the case to protect kidney function, as recommended by the most recent and highest quality study 1.
Preoperative Evaluation
These patients should have a thorough preoperative evaluation including assessment of their dry weight, electrolyte status, and cardiovascular stability. Dialysis should be scheduled 24 hours before surgery to optimize fluid and electrolyte balance without causing hypovolemia.
Intraoperative Management
During surgery, fluid administration should be conservative, typically limiting crystalloids to 1-2 mL/kg/hr and using balanced solutions like Lactated Ringer's rather than normal saline to avoid hyperchloremic acidosis. Continuous monitoring of vital signs, urine output (if present), and central venous pressure may be necessary for major procedures.
Postoperative Care
Postoperatively, daily weights should be recorded, and fluid intake should be restricted according to the patient's established limits. Electrolytes, particularly potassium, calcium, and phosphate, should be monitored closely. Medications requiring renal clearance should be dose-adjusted or avoided. These precautions are necessary because ESRD patients lack the kidney's ability to regulate fluid volume and electrolyte composition, making them vulnerable to both fluid overload (leading to pulmonary edema and heart failure) and hypovolemia (causing hypotension and poor tissue perfusion).
Key Considerations
- Avoid routine use of albumin or synthetic colloid for intraoperative fluid administration, as recommended by 1.
- Use of advanced haemodynamic monitoring, such as arterial lines and multi-lumen central venous catheters, may be beneficial in high-risk patients, as suggested by 1.
- A zero-balance fluid strategy may not be suitable for all patients, as it may increase the risk of acute kidney injury, as noted in 1.
- The goal of fluid management should be to achieve a mildly positive fluid balance, rather than a zero-balance or excessive fluid administration, to minimize the risk of complications, as recommended by 1 and supported by 1.
From the Research
Risk of Fluid Shifts in ESRD Patients Undergoing Plastic Surgery
- Patients with End-Stage Renal Disease (ESRD) are at increased risk for fluid shifts and bleeding complications following surgery 2, 3.
- The risk of fluid shifts is higher in ESRD patients due to their altered cardiovascular function, homeostasis of body fluid, electrolytes, and acid-base equilibrium 2.
- In patients undergoing major elective plastic surgery, a brisk diuresis can occur, and excessive fluid administration can lead to cardiac failure 4.
- ESRD patients are more likely to experience fluid overload and derangements in electrolytes, which can be challenging to manage 5.
Management of Fluid Shifts in ESRD Patients
- A careful multidisciplinary approach is necessary for the perioperative management of ESRD patients undergoing surgery 2.
- Fluid management should be guided by a protocol that maintains adequate tissue perfusion, with minimal fluid administration and dynamic adjustment of fluid rates 4.
- ESRD patients may require more cautious fluid resuscitation due to the risk of volume overload, but aggressive fluid resuscitation may be safe in certain situations 6.
- Derangements in preoperative laboratories and baseline patient characteristics can be useful in assessing bleeding risk and guiding fluid management in ESRD patients 3.