Anesthetic agents and impaired renal function.
read also: Acute Kidney Injury. Causes and Differential Diagnosis.
Some agents can be used safely (cyan color of the table cells)
Most anesthesia agents are at least partly dependent on renal excretion for elimination. (yelow cells). But there are agents, that should be avoided (red cells). See the table below.
Anesthetic agents and impaired renal function
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Propofol
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The pharmacokinetics of Propofol do not appear to be different in people with chronic renal impairment compared to adults with normal renal function.
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Etomidate
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Decreased protein binding of etomidate in patients with hypoalbuminemia may enhance its pharmacological effects.
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Barbiturates
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Patients often exhibit increased sensitivity to barbiturates during induction ( due to decreased protein binding)
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Ketamine
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Some active hepatic metabolites are dependent on renal excretion and can potentially accumulate,
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Benzodiazepines
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Diazepam and midazolam should be administered cautiously in the presence of renal impairment because of a potential for the accumulation of active metabolites.
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Opioids
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Fentanyl, sufentanil, and alfentanil should be used with caution because of the hepatic metabolism and renal excretion.The accumulation of morphine and meperidine metabolites has been reported to prolong respiratory depression in patients with kidney failure. Remifentanil pharmacokinetics are unaffected by renal function due to rapid ester hydrolysis in blood.
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Anticholinergic Agents
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Atropine and glycopyrrolate can generally be used safely. Scopolamine central nervous system effects can be enhanced by the physiological alterations of renal insufficiency.
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H 2 -receptor blockers
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Their doses must be reduced.
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Proton pump inhibitors
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Can generally be used safely.
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Volatile Agents
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Can generally be used safely. But in case of severe anemia accelerated induction and emergence may be seen. Some clinicians avoid sevoflurane
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Nitrous Oxide
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Some clinicians omit entirely or limit the use of nitrous oxide to 50% concentration in severely anemic patients
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Succinylcholine
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Succinylcholine can be safely used in the absence of hyperkalemia
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Cisatracurium & Atracurium
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Can be used safely.
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Vecuronium & Rocuronium
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Prolongation of muscle relaxation has been reported. Large doses should be avoided.
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Pancuronium
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Dependent on renal excretion (60–90%), thus large doses should be avoided.
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Reversal Agents (drophonium, neostigmine, and pyridostigmine.)
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Should be avoided due to renal excretion.
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