Preoperative Care of Patients with Kidney Disease
Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 73-year-old female with DM2 on insulin, CKD with creatinine of 2.5 mg/dL, HTN, CHF and PVD is here for preoperative evaluation for hysterectomy. She takes carvedilol (Coreg), clonidine, amlodipine (Norvasc), lisinopril and furosemide (Lasix).
She wants to know which medications to take on the morning of surgery.
The patient should take carvedilol (Coreg), clonidine and amlodipine (Norvasc) on the morning before the surgery.
Hypertension is common in patiens with CKD and ESRD, and it is often one of the major causes that lead to renal impairment in the first place. Optimal blood pressure control is often achieved by adjusting the doses of hypertensive medications which the patient is currently taking or by starting a beta-blocker, if indicated, for cardiovascular protection. In dialysis patients in particular, optimization of volume status via fluid removal is often helpful in controlling hypertension before surgery.
Angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB) and diuretics may lead to intraoperative hypotension which subsequently may worsen renal function. Patients should not take these medications in the morning of surgery.
Beta-blockers can decrease the risk for adverse cardiovascular events in the perioperative period in patients with a Revised Cardiac Risk Index (RCRI) equal or higher than 3. Therefore, if the patient is already on a beta-blocker or one was prescribed in the immediate preoperative period, the beta blocker should be taken in the morning of the surgery with a small amount of water. The recommendation data for calcium-channel blockers and clonidine is less certain but since the risk for harm is low, if the patient is already taking such medications, they should continue including taking them on the day of the surgery.
Table 1. Perioperative recommendations for common cardiovascular drugs.
Calcium channel blockers
Continue up to and including day of surgery, particularly clonidine and beta-blockers. If therapy cannot be interrupted and patient is on parenteral feeding, consider intravenous administration.
Angiotensin II receptor blockers (ARB)
Hold on morning of surgery, especially if the indication is congestive heart failure.
Table modified from source: Perioperative medication management: A case-based review of general principles. W. Saber. CCJM. Proceedings of the Perioperative Medicine, Supp. 1 to Vol. 73, March 2006.
Perioperative medication management: A case-based review of general principles. W. Saber. CCJM. Proceedings of the Perioperative Medicine, Supp. 1 to Vol. 73, March 2006.
Preoperative Care of Patients with Kidney Disease. Mahesh Krishnan, M.D., M.P.H. Am Fam Physician 2002;66:1471-6.
Perioperative Management of the Patient With Chronic Renal Failure. Kenneth E Otah, MD, MSc, Moro O Salifu, MD, MPH, Eseroghene Otah, MD. eMedicine.com, last accessed 3/7/06
Perioperative medication management. Visala Muluk, MD, David S Macpherson, MD, MPH
UpToDate, 2006 (subscription required).
Minimizing perioperative complications in patients with renal insufficiency (PDF). Martin J. Schreiber, Jr., MD, The Cleveland Clinic. Cleveland Clinic Journal of Medicine, Proceedings of the Perioperative Medicine Summit, Suppl. 1 to Vol. 73, March 2006.
Case 2: Does this patient need a beta-blocker? Clinical Cases and Images.
Which home medications should be continued perioperatively? The Hospitalist, 2009.