Division Corner
Case Presentation
Riccardo Pinciroli, MD, Kaavya Mahajan, MD,
50 y/o M (BMI 27) with PMHx HTN, ESRD 2/2 NSAID Toxicity and Primary HTN (Last Dialysis: 1 day prior to surgery), anemia, s/p L Brachial-Basilic AV fistula creation presenting for second stage of procedure to superficialize the fistula.
Infrarenal aortic aneurysm, maximum outer diameter 6.5mm with US, * indicate intramural thrombus.
PSHx: L Brachial-Basilic AV fistula Creation (3/9/24 – MAC anesthesia & supraclavicular & intercostal brachial nerve block, nasal cannula, pre-op midazolam, propofol infusion, intermittent fentanyl boluses, procedure time – 2 hours)
Home Medications: amlodipine, carvedilol, epoetin alfa, calcium carbonate, B complex-folic acid
Allergies: NSAIDs and peanuts
Labs: Access to pre-procedure labs limited, as patient reports receiving dialysis at the prison
Preoperative Evaluation:
- Medical history, allergies and NPO status confirmed
- Cardiopulmonary history was unremarkable, with a functional capacity >4 METS
- Patient denies overt symptoms of delayed gastric emptying at baseline
- No complications with anesthesia in the past
- Consented for MAC with regional anesthesia, GA as a back-up plan
- Supraclavicular Nerve block placed by APS
- Pre-op TTE, Gastric Ultrasound performed by primary anesthesia team
Despite adequate fasting intervals, patients with a history of CKD are at high risk for aspiration due to delayed gastric emptying. In CKD, there is a clear underreporting of digestive pathologies due to the lack of knowledge of the mechanisms that lead to a wide range of symptoms 1 Presence of peripheral neuropathy should alert providers about the possible risk of co-existent autonomic neuropathy and delayed gastric emptying. Pain, trauma or stress can precipitate transient gastroparesis in patients undergoing surgery. Risk of aspiration is increased with induction and emergence of anesthesia. Aspiration of gastric acid content and bacteria from oropharyngeal areas can lead to chemical pneumonitis, aspiration pneumonia, airway obstruction and ARDS.
Anesthetic Considerations for Patients with Renal Failure to Minimize Aspiration Risk:
1. All patients with chronic renal failure should be treated as if they have an increased risk for aspiration(2), irrespective of pre-operative gastric ultrasound findings.
2. Gastric aspiration prophylaxis can be achieved using preoperative sodium citrate, metoclopramide, H2 blockers, rapid induction of GA.
3. Sedative and anesthetic doses should be reduced 30 to 50% to minimize intra-operative respiratory depression and loss of protective airway reflexes (2)
4. If patient undergoing GETA, maximize pre-oxygenation time, avoid bag mask ventilation, perform rapid sequence intubation with cricoid pressure
5. Access to functional suction irrespective of anesthetic modality used
6. Consider immediate intubation after vomiting event given risk of repeat emesis
7. Low threshold to perform bronchoscopy to suction aspirated contents
8. Consider the use of nasogastric or orogastric tube to decompress the stomach prior to wake-up
9. Plan for awake extubation after restoration of airway reflexes in right lateral positioning 10. Continue to monitor for aspiration in the postoperative period
References:
1. Shivraj S, Venugopal K. Gastrointestinal manifestations in patients with chronic kidney disease. Academia J Med. 2019;2:54-59. 2. Sladen RN. Anesthetic considerations for the patient with renal failure. Anesthesiol Clin North Am. 2000 Dec;18(4):863-82, x. doi: 10.1016/s0889-8537(05)70199-1. PMID: 11094695.