Year : 2014 | Volume
: 4 | Issue : 2 | Page : 81--83
Anesthetic management for cesarean section in chronic renal failure
Hemlata Kapoor, Kuzhupully Parambhil Krishnan, Kutty Rajeev
Department of Anaesthesiology, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Four Bungalows, Andheri (West), Mumbai, Maharashtra, India
Department of Anaesthesiology, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Four Bungalows, Andheri (West), Mumbai - 400 053, Maharashtra
Pregnancy in chronic kidney disease is rare and is associated with high incidence of maternal and fetal morbidity. More women with chronic renal failure, due to better management and treatment modalities are able to conceive and carry on their pregnancy and delivery. The case report describes anesthesia for caesarean section in a parturient with chronic renal failure and reviews the literature.
|How to cite this article:|
Kapoor H, Krishnan KP, Rajeev K. Anesthetic management for cesarean section in chronic renal failure
.J Obstet Anaesth Crit Care 2014;4:81-83
|How to cite this URL:|
Kapoor H, Krishnan KP, Rajeev K. Anesthetic management for cesarean section in chronic renal failure
. J Obstet Anaesth Crit Care [serial online] 2014 [cited 2023 Mar 27 ];4:81-83
Available from: https://www.joacc.com/text.asp?2014/4/2/81/143878
Symptoms of chronic kidney disease (CKD) often appear when renal impairment is advanced; hence it is often diagnosed in later stages. CKD is graded into five stages based on the renal function.  Pregnancy in stages 3-5 of CKD is rare due to reduced fertility and increased incidence of early miscarriage.  In patients with CKD, hypertension and proteinuria are known to worsen in pregnancy.  The anesthesia technique used for caesarean section should preserve renal function and maintain fluid balance and hemodynamic stability. We describe the anesthetic management of a 30-year-old female patient with CKD stage V for a caesarean section at 32 weeks of pregnancy.
A 30-year-old woman was referred for caesarean section at 32 weeks of pregnancy. She was diagnosed to have CKD stage V on routine investigations in the second trimester of pregnancy. She was on regular follow up with an obstetrician and a nephrologist at our institute, throughout the antenatal period. She was managed medically in the antenatal period, and dialysis was not initiated. At 31 weeks and 5 days of pregnancy the hemoglobin was 7.9 g/dl and serum creatinine was 5.6 mg/dl. The serum creatinine at 20 weeks was 3.8 mg/dl. Though her serum potassium was within normal range it showed an upward trend in the 31 st week of pregnancy. There was no change in the amount of urine output. An elective caesarean section was planned when 32 weeks were completed.
The evening before surgery, the patient complained of discomfort whereas breathing and on auscultation of the chest, mild crepitations were noted. Her blood pressure was 124/78 mm of Hg and pulse rate was 100/min. Hematological investigations showed a serum creatinine of 5.89 mg/dl, potassium of 5 mmol/l, calcium of 9.4 mg/dl and International Normalized Ratio of 0.90. Urine routine investigation showed Specific gravity 1.010, pH 7.0, protein+, sugar++, ketones-, nitrite+, occult blood-trace, pus cells 4-5/hpf, red blood cells 2-3/hpf and epithelial cells 10-12/hpf. The electrocardiogram and the two-dimensional echocardiogram were normal.
The anesthesia plan included insertion of dialysis catheter in the right internal jugular vein under local anesthesia followed by spinal anesthesia. In the operation theatre electrocardiogram, noninvasive blood pressure, pulse oximetry, central venous pressure (CVP) were monitored. The hemodialysis catheter was inserted under ultrasound guidance. The patient was able to lie down flat on the operation table without any discomfort. On auscultation, the breath sounds were equal, and there were no crepitations. The hemodialysis catheter insertion was uneventful, and it was used intra-operatively to measure the CVP. After preloading with 200 ml of normal saline, spinal anesthesia was given with 8 mg hyperbaric bupivacaine at L3-L4 intervertebral space using a 25 gauge spinal needle, in left lateral position. The sensory block was assessed to be till T6 level. The caesarean section was uneventful and a 1500 g baby was delivered. The blood pressure remained stable around 120/70 mm of Hg and heart rate of 98 beats/min with an initial fall after spinal which did not require any intervention. The systolic blood pressure ranged between 90 and 120 mm of Hg and diastolic blood pressure between 60 and 70 mm of Hg. Intra-operatively 500 ml of normal saline was transfused. Intra-operative blood loss was estimated to be around 100 ml.
For postoperative management, the patient was shifted to Intensive Care Unit. She was initiated on heparin free dialysis for 3 h along with transfusion of one unit of packed red blood cells immediately after shifting. Her blood pressure was stable at 130/70 mm of Hg and heart rate around 88 beats/min. As the effect of spinal started wearing off she was given intravenous paracetamol and a continuous infusion of intravenous fentanyl at 20 μg/h while the dialysis continued. There was no adverse sequel of spinal anesthesia like postdural puncture headache. Patient required one more cycle of dialysis and one more unit of blood was transfused during her stay. In due course of time, the patient was discharged from the hospital.
Incidence of pregnancy in CKD patients has gradually increased over the years to 1-7% possibly due to better dialysis techniques leading to regular menstrual cycles and improved fertility.  Pregnancy in CKD patients is known to have poor outcomes both for the mother and the fetus and correlates strongly with the stage of CKD and the amount of proteinuria.  The renal function may deteriorate, and hypertension can worsen and progress into preeclampsia or eclampsia. Anemia, which worsens further in pregnancy, is another cause for concern.
In these patients mean period of pregnancy has been reported to be 32 weeks.  During preanesthetic workup, other co-morbidities associated with renal failure should be assessed thoroughly. On clinical examination, features of fluid overload and uremia should be assessed. Blood investigations for hemoglobin and hematocrit, platelet count, coagulation profile, serum creatinine, urea, electrolytes and acid base status should be carried out. Serum electrolytes are monitored routinely in such patients and serum potassium value before a caesarean section is essential. An electrocardiogram often reflects the electrolyte disturbances. A two-dimensional echocardiogram is useful in evaluating possible adverse effect of CKD on cardiac function. Dialysis might be required before caesarean section in order to optimize fluid volume and electrolyte status. Presently there are no guidelines regarding initiation of dialysis in a pregnant CKD patient. Intensification of dialysis is known to improve the maternal outcome but the extent of beneficial effect on the fetus is yet to be clearly ascertained. Fetal distress due to dialysis related hypotension has been reported.  Hence initiation of dialysis in a pregnant female is the attending nephrologists' prerogative. Our patient was not dialyzed in the antenatal period but was dialyzed immediately after surgery along with simultaneous infusion of blood. The blood urea nitrogen in our patient was 43.9 mg/dl which is much below the target level of 70 mg/dl set for initiating hemodialysis in such a patient. 
For hypertension, methyl-dopa and calcium channel blockers, beta-blockers, labetalol and hydralazine are usually used, while angiotensin converting enzyme inhibitors and angiotensin receptor blockers are avoided. Since diuretics can lead to hypovolemia, they are used with caution. Our patient was not on any antihypertensives. Anemia is a known complication of CKD and is associated with cardiovascular morbidity.  Hemoglobin and hematocrit are usually gradually corrected in the antenatal period. Our patient was given erythropoietin 4000 units twice weekly. Platelet dysfunction is another feature of renal failure which is known to improve with hemoglobin correction.  Hence a recent coagulation profile should always be done before caesarean section.
The anesthesia plan varies as per the patient profile. Factors predisposing to hyperkalemia should be avoided. These include administration of drugs like suxamethonium, acidosis, hypercarbia, hypoxia, hypothermia, blood transfusion and inadequate dialysis.
In general anesthesia, there is a possibility of altered drug clearance leading to accumulation of active metabolites which could be nephrotoxic. Delayed gastric emptying and altered gastric pH increase the chances of aspiration pneumonitis. The risk of anesthetic agents affecting the fetus leading to an altered APGAR score should be considered. These neonates often have intrauterine growth retardation, low birth weight and are premature hence are prone to the adverse effects of anesthetic agents.
Regional anesthesia can also be considered for these patients if the coagulation profile is normal. Peripheral neuropathy due to CKD should be looked for and documented. Both epidural and spinal anesthesia have been reported to be safe in these patients. Though sudden hypotension following spinal anesthesia leading to decreased uterine blood flow is a possibility, however, Modi et al. did not report any significant fall in blood pressure in their case series.  Epidural anesthesia with titration of doses to maintain stable hemodynamic has also been described.  We preferred spinal anesthesia to minimize the risk to the fetus. The patient had been hemodynamically stable throughout the antenatal period and her urine output was adequate. Hence, we postulated that in case there was hypotension due to spinal anesthesia, fluid could be given without precipitating pulmonary edema. In addition, we felt that general anesthesia could aggravate the preexisting renal disease due to delayed excretion of various metabolites.
Hemodynamic monitoring can be invasive or noninvasive depending on the patients' condition. We used the hemodialysis catheter port for intra-operative CVP monitoring. Since the blood pressure remained stable, arterial cannulation was not performed at any stage of the surgery. If possible, arteries in the upper limb should be preserved for future formation of arteriovenous fistula. Postoperative dialysis with simultaneous transfusion of blood was carried out to remove excess fluid and to correct any rise in potassium.
To conclude, the anesthesia should be planned to preserve the renal function of the mother and prevent any adverse effect on the fetus.
|1||National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-266.|
|2||Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038-47.|
|3||Williams D, Davison J. Chronic kidney disease in pregnancy. BMJ 2008;336:211-5.|
|4||Bili E, Tsolakidis D, Stangou S, Tarlatzis B. Pregnancy management and outcome in women with chronic kidney disease. Hippokratia 2013;17:163-8.|
|5||Piccoli GB, Attini R, Vasario E, Conijn A, Biolcati M, D'Amico F, et al. Pregnancy and chronic kidney disease: A challenge in all CKD stages. Clin J Am Soc Nephrol 2010;5:844-55.|
|6||Unzelman RF, Alderfer GR, Chojnacki RE. Pregnancy and chronic hemodialysis. Trans Am Soc Artif Intern Organs 1973;19:144-9.|
|7||Shemin D. Dialysis in pregnant women with chronic kidney disease. Semin Dial 2003;16:379-83.|
|8||SarinKapoor H, Kaur R, Kaur H. Anaesthesia for renal transplant surgery. Acta Anaesthesiol Scand 2007;51:1354-67.|
|9||Gotti E, Mecca G, Valentino C, Cortinovis E, Bertani T, Remuzzi G. Renal biopsy in patients with acute renal failure and prolonged bleeding time: A preliminary report. Am J Kidney Dis 1985;6:397-9.|
|10||Modi MP, Vora KS, Parikh GP, Shah VR, Misra VV, Jasani AF. Anesthetic management in parturients with chronic kidney disease undergoing elective Caesarean delivery: Our experience of nine cases. Indian J Nephrol 2014;24:20-3.|
|11||Ankichetty SP, Murphy C, Angle P, Halpern S. Elective cesarean delivery in non-dialyzed parturient with chronic renal failure. J Anaesthesiol Clin Pharmacol 2013;29:102-4.|