Case Summary

A 45-year-old female with a history of autosomal dominant polycystic kidney disease, status post bilateral nephrectomy, presented with an obstructed left lumbar incisional hernia and required emergency laparoscopic repair. She was dialysis-dependent with end-stage renal disease (ESRD), receiving thrice-weekly hemodialysis and had undergone emergency dialysis earlier on the day of surgery.

The surgery lasted one hour. Preoperative laboratory results following dialysis showed hemoglobin 9.6 g/dL, urea 2.9 mmol/L, creatinine 3.8 mg/dL, sodium 138 mmol/L, and potassium 3.3 mmol/L. Echocardiography revealed normal left ventricular function. She was on metoprolol XL 25 mg once daily.

Pathophysiological Considerations

Several key systemic issues influenced anesthetic management. From a renal perspective, ESRD caused impaired drug excretion, risks of fluid and electrolyte imbalance, and acid-base instability. The gastrointestinal risk was significant due to the obstructed hernia, necessitating a rapid sequence induction (RSI) to reduce aspiration risk. Cardiovascularly, chronic beta-blockade attenuated tachycardia and blunted the stress response to induction. Hematologically, anemia with hemoglobin 9.6 g/dL reduced oxygen-carrying capacity. Metabolically, uremia could blunt both sympathetic and respiratory responses to hypoventilation and acidosis.

Reference

Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s Clinical Anesthesiology. 6th ed. McGraw Hill; 2018.

Anesthesia TechniquePremedication

The patient received glycopyrrolate 0.2 mg IV to reduce secretions and prevent bradycardia, especially with succinylcholine; as a quaternary ammonium compound, it does not cross the blood-brain barrier. Midazolam 1 mg IV, a short-acting GABA-A agonist, provided anxiolysis and was safe in ESRD because of hepatic metabolism. Fentanyl 100 mcg IV, a μ-opioid receptor agonist with minimal renal clearance, was used for analgesia at a safe low dose. Dexamethasone 8 mg IV was given for its anti-inflammatory and antiemetic properties, metabolized hepatically and safe in ESRD.

Reference

Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 9th ed. Elsevier; 2020.

Physics and Pharmacology of RSI

RSI was indicated due to aspiration risk. The principle is to minimize time between induction and airway control, using rapid-onset hypnotics and neuromuscular blockade, without positive pressure ventilation before intubation.

Preoxygenation increased the functional residual capacity oxygen reservoir, extending safe apnea time to about 3–5 minutes. Induction was achieved with propofol 50 mg IV, a GABA-A agonist with rapid onset and short duration. While propofol undergoes hepatic metabolism and is safe in ESRD, caution is required due to hypotension from vasodilation and myocardial depression. Sevoflurane was used during induction and maintenance for hypnosis and bronchodilation; it is considered safe in renal failure because inorganic fluoride production is negligible in short cases.

Reference

Leslie K, et al. Rapid sequence induction: current controversies. Anaesth Intensive Care. 2018;46(5):420–426.

Precurarisation

To attenuate succinylcholine-induced fasciculations and potassium release, precurarisation was performed with atracurium at one-tenth the intubating dose (approximately 5 mg). This partially occupied acetylcholine receptors, reducing depolarization effects during succinylcholine administration. Onset occurred within 2–3 minutes.

Reference

Khandelwal M, et al. Precurarization: Facts and fallacies. Indian J Anaesth. 2017;61(4):336–338.

Succinylcholine

Succinylcholine, a depolarizing neuromuscular blocker, was used for RSI. It acts by opening acetylcholine receptor channels, causing depolarization, fasciculations, and subsequent paralysis. Onset is within 30–60 seconds and duration is 5–10 minutes. The major risk is hyperkalemia; however, the patient’s serum potassium was 3.3 mmol/L post-dialysis, making it safe in this context. Metabolism occurs via plasma pseudocholinesterase, independent of renal clearance.

Reference

Martyn JA, et al. Succinylcholine-induced hyperkalemia in acquired pathologic states. Anesthesiology. 2006;104(1):158–169.

Cricoid Pressure

Cricoid pressure was applied to reduce regurgitation risk by compressing the esophagus against the vertebral body. Despite ongoing debate about its effectiveness, it remains widely practiced during RSI.

Reference

Feldman SA. Pre-curarization—a reappraisal. Anaesthesia. 1986;41(7):691–695.

Maintenance and Analgesia

Atracurium 40 mg IV followed by infusion at 10 mg/hr was used for muscle relaxation. Its elimination via Hofmann degradation and ester hydrolysis makes it ideal in ESRD.

Sevoflurane was continued for hypnosis and bronchodilation, with minimal renal concerns.

Dexmedetomidine 30 mcg IV provided sedation, analgesia, and sympatholysis. Though hepatically metabolized, it is considered safe in ESRD with dose adjustment.

Paracetamol 1 g IV, metabolized hepatically, was used for analgesia and is safe in renal failure.

Morphine 5 mg IM was administered at closure for prolonged postoperative analgesia. However, its active metabolite morphine-6-glucuronide accumulates in ESRD, risking prolonged respiratory depression. Alternative opioids such as fentanyl or oxycodone are preferable.

Reference

Weinberg L, et al. Pharmacokinetics and pharmacodynamics of drugs in ESRD. Anesth Intensive Care. 2015;43(3):356–365.

IV Fluids

The patient received 500 mL normal saline intraoperatively, an appropriate choice for a dialysis-dependent patient at risk of volume overload.

Reversal

After more than 25 minutes following the last atracurium dose, neuromuscular blockade was reversed with neostigmine combined with glycopyrrolate. Neostigmine inhibits acetylcholinesterase, increasing acetylcholine at the neuromuscular junction, while glycopyrrolate prevented muscarinic side effects such as bradycardia and excessive secretions.

Reference

Miller RD, Cohen NH, Eriksson LI, et al. Miller’s Anesthesia. 9th ed. Elsevier; 2020.

Drug Elimination in ESRD: Key Considerations

In this patient, drug pharmacokinetics were central to safe anesthetic care. Propofol and fentanyl, both hepatically metabolized, were considered safe. Atracurium, eliminated by Hofmann degradation, was ideal as a neuromuscular blocker. Succinylcholine, metabolized by plasma cholinesterase, could be used with potassium monitoring. Morphine was relatively contraindicated due to accumulation of its active metabolite in renal failure, and thus should be avoided or minimized. Dexmedetomidine, hepatically cleared, can be used with caution and dose reduction. Paracetamol, primarily metabolized in the liver, required no adjustment.

Reference

Weinberg L, et al. Pharmacokinetics and pharmacodynamics of drugs in ESRD. Anesth Intensive Care. 2015;43(3):356–365.

Conclusion

This case highlights the complexity of providing anesthesia in ESRD patients undergoing emergency abdominal surgery. Rapid sequence induction was indicated because of high aspiration risk, with careful choice of agents to account for renal failure. Atracurium and sevoflurane were safe maintenance choices, and fluid therapy was judiciously restricted. The use of morphine illustrated a potential pitfall due to metabolite accumulation, underscoring the importance of tailoring analgesia in ESRD. Ultimately, understanding the pharmacology and elimination pathways of anesthetic agents ensures safe perioperative management in dialysis-dependent patients.