What are the recommendations for anesthetic management in a patient with End-Stage Renal Disease (ESRD) on dialysis?

Anesthetic Management for ESRD Patients on Dialysis

Timing of Dialysis

Perform hemodialysis within 24 hours before elective surgery to optimize fluid status, correct electrolyte abnormalities (especially hyperkalemia), and minimize uremic complications. 1, 2

• Schedule surgery for the morning following dialysis when the patient is in optimal metabolic balance 3
• Verify recent potassium, calcium, and acid-base status before proceeding 4
• Ensure adequate but not excessive ultrafiltration to avoid intravascular volume depletion 2

Preoperative Cardiovascular Assessment

ESRD patients have 6.4-7.8-fold higher all-cause mortality than the general population, primarily from cardiovascular disease, requiring aggressive cardiac risk stratification. 1

• Assess for ischemic heart disease, congestive heart failure, and hypertension—the leading causes of perioperative morbidity and mortality 2, 5
• Consider cardiopulmonary exercise testing for high-risk procedures to guide cardiovascular optimization 1
• Monitor blood pressure closely throughout the perioperative period, as hypertension is nearly universal 3, 5

Anesthetic Agent Selection

Local/Regional Anesthesia

Lidocaine, mepivacaine, and articaine require no dose adjustment in ESRD and are safe first-line local anesthetics. 3

• Maximum articaine dose: 7 mg/kg (same as general population) 3
• Reduce epinephrine concentration (use 1:100,000 or less) due to hypertension risk 3
• Lidocaine/prilocaine cream (EMLA) is safe for vascular access cannulation with negligible systemic absorption and hepatic metabolism 6
• Apply EMLA at least 1 hour before cannulation under occlusive dressing 6

Volatile Anesthetics

Sevoflurane is safe in ESRD despite elevated fluoride levels, as no nephrotoxicity has been reported even with prolonged exposure. 7

• Peak fluoride concentrations occur within 2 hours post-anesthesia and return to baseline within 48 hours in most patients 7
• Fluoride half-life is prolonged to approximately 33 hours (range 21-61 hours) in renal impairment versus 21 hours in normal patients 7
• Mean maximal fluoride concentration in renal patients is 26.1 µM, well below the 50 µM threshold historically associated with methoxyflurane nephrotoxicity 7
• Avoid fresh gas flow rates ≤1 L/min to minimize compound A formation with CO₂ absorbents 7

Sedatives

Diazepam and midazolam require no dose adjustment as they undergo hepatic metabolism, making them safe choices for anxiolysis. 3

• Diazepam: 0.1-0.8 mg/kg orally for conscious sedation 3
• Midazolam: 0.5-1 mg/kg (maximum 15 mg) for dental sedation 3
• Avoid midazolam in critical care settings due to delayed metabolism and elimination in renal impairment 4
• Avoid codeine and alprazolam entirely in dialysis patients 3

Opioids

Use shorter-acting opiates (fentanyl, remifentanil) rather than morphine or its derivatives, which accumulate dangerously in renal failure. 4

• Morphine and metabolites accumulate, causing prolonged sedation and respiratory depression 4
• Monitor closely for respiratory depression, which may be augmented by opioid premedication 7

Electrolyte Management

Hyperkalemia

Treat hyperkalemia emergently with IV insulin and nebulized salbutamol as temporizing measures until definitive RRT can be instituted. 4

• Verify serum potassium before surgery; ESRD patients are at constant risk 4, 5
• Be aware of perioperative hyperkalemia risk with volatile anesthetics, particularly in patients with neuromuscular disease 7
• Avoid succinylcholine due to hyperkalemia risk and association with cardiac arrhythmias and death 7

Hypocalcemia

Administer IV calcium replacement if hypocalcemia is associated with complications (prolonged QT, tetany, hemodynamic instability). 4

• ESRD patients are prone to hypocalcemia from secondary hyperparathyroidism 4
• Monitor for QT prolongation, as sevoflurane can further prolong QT interval and cause torsade de pointes 7

Fluid Management

Maintain euvolemia by coordinating with nephrology regarding target dry weight and avoiding excessive crystalloid administration. 1, 2

• ESRD patients cannot excrete excess fluid; diuretics are ineffective except in patients with residual urine output 4
• Preserve microvascular perfusion and capillary network integrity through careful fluid balance 1
• Monitor for circulatory collapse from rapid fluid shifts 5

Anticoagulation Considerations

Use unfractionated heparin for therapeutic anticoagulation as it is reversible and its clearance is independent of renal function. 4

• Avoid low-molecular-weight heparins due to renal clearance and accumulation 4
• ESRD patients have altered coagulation but also increased bleeding risk 2

Infection Prevention

Provide empiric antibiotic coverage for both Gram-positive and Gram-negative organisms, including MRSA coverage if a dialysis catheter is present. 4

Antibiotic Dosing Adjustments

• Amoxicillin: Prolong dosing interval to every 24 hours (from every 8 hours) 3
• Ampicillin/sulbactam: Prolong interval to every 12-24 hours 3
• Clindamycin, erythromycin, doxycycline, ketoconazole: No adjustment needed 3
• Avoid aminoglycosides and tetracyclines due to nephrotoxicity (except doxycycline) 3
• Administer prophylactic antibiotics 1 hour before incision with appropriate renal dosing 3

Monitoring Requirements

Continuously monitor ECG for arrhythmias, blood pressure for hypertensive crises, and respiratory status for depression throughout the perioperative period. 7, 2, 5

• Use troponin-I and CK-MB in combination (not troponin-T or BNP) for myocardial injury detection 4
• Check serum electrolytes if any symptoms develop postoperatively 8
• Maintain quiet environment and minimize interruptions to reduce anxiety and hypertensive responses 3

Special Considerations

Vascular Access Protection

Avoid blood pressure cuffs, IV lines, and arterial lines in the extremity with dialysis access (fistula or graft). 1, 2

• Preserve existing vascular access sites for future dialysis needs 1

Metabolic Acidosis

Expect baseline metabolic acidosis; correct severe acidosis (pH <7.2) preoperatively with dialysis rather than bicarbonate boluses. 5