Management of Bursitis in ESRD Patients
For ESRD patients requiring surgical intervention for bursitis, schedule the procedure for the morning following dialysis to optimize metabolic balance, use appropriate anesthetic agents with renal dosing adjustments, and ensure meticulous perioperative monitoring of electrolytes and volume status. 1, 2
Preoperative Optimization
Timing of Surgery
- Schedule surgery for the morning immediately following dialysis when the patient is in optimal metabolic balance with normalized electrolytes, fluid status, and acid-base equilibrium 1
- Verify recent dialysis completion and current electrolyte panel before proceeding 2
Preoperative Assessment
- Check serum potassium, calcium, phosphate, and acid-base status within 24 hours of surgery 2
- Assess volume status carefully, as ESRD patients have altered cardiovascular function and fluid homeostasis 2
- Review all medications and adjust nephrotoxic agents or those requiring renal dosing 3
Anesthetic Management
Local Anesthetic Selection
- Use lidocaine, mepivacaine, or articaine as first-line agents—these require no dose adjustment in ESRD 1
- Articaine maximum dose: 7 mg/kg (same as general population) 1
- Reduce epinephrine concentration to 1:100,000 or less due to hypertension risk in ESRD patients 1
- EMLA cream (lidocaine/prilocaine) is safe for vascular access preservation with negligible systemic absorption 1
Sedation Options
- Diazepam (0.1-0.8 mg/kg orally) or midazolam (0.5-1 mg/kg, maximum 15 mg) require no dose adjustment as they undergo hepatic metabolism 1
- Avoid codeine and alprazolam entirely in dialysis patients 1
- Maintain a quiet environment to minimize anxiety and hypertensive responses 1
Infection Prevention
Antibiotic Prophylaxis
- Administer prophylactic antibiotics 1 hour before incision with appropriate renal dosing adjustments 1
- Amoxicillin: Prolong dosing interval to every 24 hours (from every 8 hours) 1
- Ampicillin/sulbactam: Prolong interval to every 12-24 hours 1
- Clindamycin, erythromycin, doxycycline: No adjustment needed 1
- Avoid aminoglycosides and tetracyclines (except doxycycline) due to nephrotoxicity 1
Intraoperative Considerations
Vascular Access Protection
- Preserve all peripheral veins meticulously—avoid IV placement in potential future dialysis access sites 3
- Protect existing arteriovenous fistulae or grafts from compression or blood pressure cuff placement 1
- Never use the arm with vascular access for blood pressure monitoring or venipuncture 2
Monitoring
- Monitor electrolytes closely during longer procedures 2
- Maintain careful fluid balance—ESRD patients cannot compensate for volume overload 2
Postoperative Management
Immediate Postoperative Care
- Check serum electrolytes if any symptoms develop postoperatively (arrhythmias, altered mental status, muscle weakness) 1
- Monitor for signs of volume overload or electrolyte disturbances 2
- Coordinate with nephrology regarding timing of next dialysis session 3
Pain Management
- Adjust opioid dosing for renal impairment—many require dose reduction or interval prolongation 2
- Avoid NSAIDs entirely due to cardiovascular and residual renal function risks 3
- Consider regional anesthesia techniques when feasible to minimize systemic medication exposure 2
Critical Pitfalls to Avoid
- Never schedule surgery on the day before dialysis—metabolic derangements will be at their worst 1
- Never use nephrotoxic agents (aminoglycosides, NSAIDs, contrast if avoidable) 1, 3
- Never compromise vascular access sites—these are lifelines for dialysis patients 3
- Do not assume standard drug dosing applies—most medications require adjustment 1, 2
- Avoid aggressive fluid resuscitation without considering dialysis-dependent volume management 2