ANESTESIA E IRC
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ANESTESIA E IRC
Ancizar De La Peña Silva
Anestesiología y Reanimación
Residente II
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IRC
TFG <60ml/min/1.73m2 >3meses
Daño Renal > 3meses
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EVALUACION FUNCIÓN RENAL
Tasa de Filtración Glomerular Inulina IhotalamatoAclaramiento de Creatinina
Ecuaciones de Estimacion
MDRD = 186 x (Scr)-1.154 x (Age)-0.203 x (0.742 Mujer) x (1.212 Negro)
Cockroft-Gault = (140-edad) x (Peso Kg) x 0,82 (mujer)
(72 . Scr)
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Clasificación correcta comparada con 99mTc-DTPA GFR
Cistatina C: 76%
MDRD: 65%
Cockroft – Gault: 67%
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ESTADIOS
Estadio TFG (ml/min/1.73m2 Sc)
I >90
II 60 – 89
III 30 – 50
IV 15 – 29
V < 15
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UK2005: 604/1´000.000
USA2003: 434/1´000.000
PREVALENCIA
DM44.8%
HTA27.1%
ESTADIO III - IV8´000.000
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ESTADIO POBLACION
%
I 18.465.483
64.3
II 8.959.923 31.2
III 1.234.861 4.3
IV 57.435 0.2
V 17.443 0.2
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FR PERIOPERATORIO
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IMPACTO SISTEMICO
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CARDIOVASCULAR
Arterioesclerosis
Acelerada HVI
Anormalidades De La
conducción
Calcificación Vascular
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HEMATOLOGICO
Anemia
DisfunciónPlaquetaria
Estado Hipercoagulab
le
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EQUILIBRIO ACIDO BASEamonio
• Producción
H+
• Retención de hidrogeniones
PH• Acidosis Metabólica
HCO3
• Disminución de Bicarbonato
• Compensación Limitada
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EQUILIBRIO ACIDO BASE Anion Gap Normal
Acidosis Hipercloremica (110mEq/l)
Anion Gap ElevadoSulfatos y fosfatos
Base Buffer DepletadaHCO3: 15 – 18 mEq/l
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SNA Neuropatía autonómica
65% pacientes
Sensibilidad Baroreceptores
Hipertonicidad Simpática
Disfunción parasimpática variabilidad FC Respuesta AtropinaEKG
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LIQUIDOS Y ELECTROLITOS
Sobrecarga Hídrica SSN
Excresion de Sodio Acidosis Hipercloremica
Concentración y Dilución Urinaria Establecer el peso Seco
Hiperkalemia Estadio V Exógeno Intercambio Transcelular
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HIPERKALEMIA
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ACCESOS VASCULARES
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PERMANENTES TRANSITORIOS
FISTULA ARTERIOVENOSA NATIVA
CAT DE CORTA DURACION NO TUNELIZADO SIN MANGUITO
INJERTO ARTERIOVENOSO
CATETERES DE LARGA DURACION TUNELIZADOS CON MANGUITO
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OBJETIVOS PERIOPERATORIO Evitar Hipotensión
Mantener FSR
Evitar Desbalance Hidrolectrolitico
Asegurar Diálisis 24 h Posquirurgicas
Estratificar Adecuadamente el riesgo
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PARACLINICOS PREOPERATORIOS
GASES ARTERIALES
EKG
ELECTROLITOS
CREATININA Y BUN
HLG
TIEMPOS DE COAGULACION
RX DE TORAX
SEGÚN RIESGO QUIRURGICO
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MEDICACIÓN PERIOPERATORIA IECA´s o ARA II
Suspender 10 H previos
Dialisis Día previoNO EL DIA QUIRUGICO
Terapia Antiagregante plaquetaria
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CIRUGÍA Medios de Contraste no iónico
Cirugía laparoscopiaVentajas
Menor incisión quirúrgica Menor invasión Menor Dolor POP Asegurar PIA < 15mmHg
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MANTENIMIENTO EUVOLEMICO Peso Seco PAM
65 – 70mmHg PVC
10 – 15mmHg (Estático)Variaciones < 4mmHg (Dinámico)
PCAP10 – 15 mmHg
Ecocardiografia Transesofagica
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FARMACOLOGIA
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CONSIDRACIONES
ACLARAMIENTO
ACUMULACIONMETAB. ACTIVOS
MAYOR DAÑORENAL
TFG < 50ml/min/1.73m2 SC
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ABSORCION
PH Gástrico
Gastroparesia
Motilidad Intestinal
Edemaintestinal
GlicoproteinaP
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DISTRIBUCION
• Volumen de
Distribución
Diálisis
• Albumina• GAAC
Prot. Plasmática
s • Inización
PH
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ELIMINACION 18% de la act. C. p450 es Renal
40% de la act. Microsomal HepáticaFlujo SanguíneoFracción LibreCapacidad Metabólica Enzimática
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OPIOIDES
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RELAJANTES NM
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INDUCTORES
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PROPOFOL
Dosis inducción (0,2mg/Kg cada 15 seg)Dosis Mantenimiento (BIS 50)
1.42mg/kg FRT Vs 0.89/Kg (Normales) P<0.05 2.03 (0.4) mg/kg Vs 1.39 (0.43) P<0.05
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RELAJANTES NM Eliminación Renal
Metabolitos Activos
Mayor Latencia
Evite Relajante de Larga Accion
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ATRACURIO Y CISTRATACURIO
Metabolismo Hoffman
Laudanosina y acrilato
Farmacocinética Alterada
Farmacodinamia InalteradaLatencia 3.7 Vs 2.4 min
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VECURONIO Y ROCURONIO
33% Eliminación renal
RecuperacionT4/T1 25%: 40 vs 32 minT4/T1 70%: 88 vs 55 min
Sugammadex
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INHIBIDORES DE CALCINEURINA
Ciclosporina y TacrolimusPotencian efecto
Tiopental Fentanyl RMND
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ANTICOLINESTERASICOS
NEOSTIGMINE
Prologada vida media de eliminaciónEfectos Muscarinicos
Preferir asociación con glucopirrolato
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POSOPERATORIO Manejo del Dolor
Extubacion Postergar si Acidosis Metabolica Severa Bicarbonato si PH <7.15
Gases arteriales y Electrolitos
UCPA Casa
UCI
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