ABSTRACT
Several neurological and psychological considerations are common to patients with CRF. These patients are chronically fatigued, may be depressed and lethargic, have a decreased seizure threshold, and may have muscular irritability and autonomic and peripheral neuropathies. The possibilities of drug interactions regarding any antidepressants and the effects of perioperative medications upon seizure threshold must be considered. For example, etomidate lowers the seizure threshold, may promote hypertension, and should be avoided unless the patient is hemodynamically unstable, in which case etomidate becomes the induction drug of choice. Enflurane should be avoided in renal failure patients for seizure threshold issues (as well as fluoride-induced
Table 1 Risk Factors for Perioperative Acute Renal Failure
Category Disorder/drug/procedure/comments
Preexisting Renal Insufficiency ↓ ’d GFR, ↓ ’d renal reserve Systemic diseases with renal effects Congestive heart failure
Diabetes Liver failure, jaundice Peripheral vascular disease Polycystic kidney disease Renovascular hypertension Rheumatoid arthritis Scleroderma SLE Wegener’s granulomatosis
Nephrotoxic drug exposure Acetominophen (usually with hepatotoxicity) Allopurinol Aminoglycosides (proximal tubule necrosis) Amphotericin B (GN and ATN) Asparaginase Cephalosporins (especially with aminoglycosides) Cisplatin (ATN) Cyclosporin-A I.V. contrast (oliguria within 24 h) Methotrexate NSAIDs (especially phenacetin, indomethacin, ibuprofen, naproxen) Nitrosoureas Penicillins (interstitial nephritis)
Procedures associated with ARF Biliary surgery Burns Cardiac surgery Genitourinary/Obstetric Transplant Trauma Vascular surgery (especially suprarenal x-clamp)
Intra-op hypovolemia Intra-op hypotension Prolonged hypotension or hypovolemia can cause ARF in normal patients and exacerbates the renal effects of all the above conditions.
