What is the optimal anesthesia management for a patient with stage‑3 acute kidney injury and left‑ventricular ejection fraction of 45 % undergoing laparoscopic cholecystectomy?

Anesthesia Management for Laparoscopic Cholecystectomy in AKI Stage 3 with EF 45%

This patient requires general anesthesia with controlled ventilation, meticulous hemodynamic monitoring, and nephroprotective strategies, but the surgery should proceed without delay as early laparoscopic cholecystectomy is the definitive treatment even in high-risk patients. 1, 2

Pre-operative Optimization

Fluid Status and Hemodynamics:

• Ensure adequate hydration with normal saline to prevent further AKI progression, as hydration is the cornerstone of AKI prevention 1
• Target euvolemia using clinical assessment and consider invasive monitoring given the reduced ejection fraction 1
• Avoid loop diuretics, as they are not recommended for prevention or treatment of AKI despite theoretical benefits 1

Cardiac Assessment:

• The EF of 45% represents mild-to-moderate systolic dysfunction but is not a contraindication to laparoscopic surgery 3
• A patient with EF <15% successfully underwent laparoscopic cholecystectomy with appropriate monitoring, demonstrating feasibility even in severe cardiac disease 3
• Consider invasive hemodynamic monitoring (arterial line, possibly central venous pressure monitoring) given the combination of AKI stage 3 and reduced EF 1, 3

Renal Protection:

• Calculate baseline eGFR and document urine output, as AKI stage 3 is defined by creatinine rise ≥3 times baseline or ≥354 μmol/L, or urine output <0.3 mL/kg/h for 24 hours 1
• The development of AKI reduces long-term survival even in patients with normal baseline function, making prevention critical 1

Anesthetic Technique

Choice of Anesthetic:

• General anesthesia with endotracheal intubation and controlled ventilation is mandatory for laparoscopic cholecystectomy to avoid hypercarbia from CO2 pneumoperitoneum 4
• Use propofol, sevoflurane, or dexmedetomidine as these agents have demonstrated protective effects against perioperative AKI through anti-inflammatory, anti-necrotic, and anti-apoptotic mechanisms 5
• Avoid or minimize nephrotoxic agents including NSAIDs, which should be used cautiously despite their role in multimodal analgesia 6

Ventilation Strategy:

• Controlled mechanical ventilation prevents hypercarbia, which is critical as pneumoperitoneum increases PaCO2 4
• Adjust ventilation parameters to maintain normocapnia and adequate oxygenation, as both hypoxia and hypercarbia can worsen renal perfusion 4

Intraoperative Management

Hemodynamic Monitoring and Goals:

• Establish invasive arterial blood pressure monitoring given the dual insults of AKI stage 3 and reduced EF 3
• Expect hemodynamic changes with pneumoperitoneum: increased mean arterial pressure, increased systemic vascular resistance, slightly increased heart rate and pulmonary artery wedge pressure, and minimally decreased cardiac output 3
• Reverse Trendelenburg positioning (used in laparoscopic cholecystectomy) further exaggerates these hemodynamic changes 3
• Maintain mean arterial pressure to preserve renal perfusion pressure, as hypotension is a major risk factor for AKI progression 1

Pneumoperitoneum Management:

• Minimize intra-abdominal pressure and keep surgical time as short as possible, as these are critical factors in high-risk patients 3
• Standard pneumoperitoneum pressures (10-15 mmHg) cause predictable hemodynamic changes that are generally well-tolerated even in severe cardiac disease if the patient is optimized 3

Fluid Management:

• Continue isotonic crystalloid (normal saline) administration to maintain euvolemia and renal perfusion 1
• Avoid excessive fluid administration that could precipitate pulmonary edema given the reduced EF, but prioritize renal perfusion 1
• Monitor urine output continuously as oliguria (<0.5 mL/kg/h) indicates ongoing or worsening AKI 1

Analgesia Strategy:

• Implement multimodal analgesia incorporating antiemetics and considering gabapentin/pregabalin, NMDA receptor antagonists, and low-dose opioids 6
• The use of nitrous oxide and high-dose narcotics remains controversial in laparoscopic cholecystectomy 4
• NSAIDs/COX-2 inhibitors should be avoided or used with extreme caution given AKI stage 3 6

Critical Intraoperative Pitfalls

Conversion Threshold:

• Be prepared for conversion to open surgery if hemodynamic instability, oxygenation difficulties, or ventilation problems occur 4
• Conversion is not a failure and should be performed promptly if severe inflammation, adhesions, or bleeding in Calot's triangle occurs 1
• Risk factors for conversion include age >65 years, male gender, diabetes, previous upper abdominal surgery, and thickened gallbladder wall >5mm 2

Avoid Delays:

• Do not postpone surgery for "optimization" beyond ensuring adequate volume status, as early surgery (within 7 days of admission, within 10 days of symptom onset) correlates with shorter hospital stays and fewer complications 2
• Even in high-risk patients, immediate laparoscopic cholecystectomy is superior to percutaneous drainage, with major complications of 5% versus 53% 2

Post-operative Considerations

Renal Monitoring:

• Continue close monitoring of creatinine, urine output, and fluid balance as postoperative AKI can develop or worsen 7
• AKI is associated with increased in-hospital mortality and decreased survival for up to 10 years after surgery 7

Antimicrobial Therapy:

• If source control is complete in uncomplicated cholecystitis, no postoperative antimicrobial therapy is necessary 2

Pain Management:

• Continue multimodal analgesia while avoiding nephrotoxic agents 6
• Incorporate antiemetics as postoperative nausea and vomiting are common complications 4