Anaesthesia in chronic dialysis patients: A narrative review

Table 2 Perioperative medical management of the chronic dialysis patient

Medical issue	Practice points
Glycaemic control	The perioperative blood glucose goal is usually between about 5-10mmol/L[55]. Guidelines recommend a glycaemic target of 7.8-10 mmol/L for critically ill adults[56]. Pre-existing insulin and oral anti-hyperglycaemic drugs are frequently withheld or reduced
Antihypertensives	Blood pressure targets are uncertain. Usually continued perioperatively and during acute illness unless hypotension is problematic
Antithrombotics	There should be an antithrombotic medication management plan where feasible. The intention is to balance the risk of surgical bleeding if the antithrombotic is continued with the risk of thromboembolism if withheld. Due to the complexity of decision-making, guidelines and local policies should be followed
Bleeding reversal and transfusions	Spontaneous and postoperative bleeding rates are significantly increased. Bleeding diathesis is predominantly explained by uraemic platelet dysfunction and the frequent use of anti-thrombotic medications. Haemodialysis reduces the bleeding time and prevents haemorrhagic complications[54]. Options to reverse acute haemorrhage include intravenous calcium, desmopressin, and tranexamic acid, and acute haemodialysis; however, clinical studies are scant. Consider empiric protamine where heparins are used for anticoagulation in dialysis. Transfusion protocols guided by bedside viscoelastic assays are advocated but have not been studied in this context. Erythropoietin-stimulating agents have no role in acute anaemia management. Where a blood transfusion is necessary in a potential candidate for kidney transplantation, leukocyte-depleted allogenic red blood cells are preferred
Neuraxial anaesthetic blocks	Renal impairment is associated with a slightly increased risk of epidural haematoma with neuraxial procedures[58], but objective data are scarce. The approach to regional anaesthesia relies on clinician judgement and standard anaesthesia and preoperative guidelines[38]. Experts recommend ensuring a low plasma urea and heparin-free dialysis near the time of the procedure