1)     RECOMMENDATIONS

a)      General Approach

i)        Focus on maintaining adequate hydration and normal blood pressures

ii)       Avoid drugs that dependent on renal clearance for recovery

iii)     More advanced renal patients usually benefit from IV fluid administration initiated the day prior to the planned anesthetic event.

b)      Pre-anesthetic Medications

i)        Good choices include mu agonists like morphine, hydromorphone, or oxymorphone alone or in combinations with Midazolam or Diazepam

c)      Induction

i)        Hydromorphone or oxymorphone and diazepam

(1)   See Anesthetic Induction section

ii)       Low dose propofol

(1)   Precede propofol with 0.2 to 0.4 mg/kg diazepam

(2)   Use lidocaine if needed to reduce propofol dose in dogs

iii)     Etomidate is another option due to its ability to maintain optimal blood pressures

(1)   With the standard US product, Amidate, the relatively high propylebe glycol content can cause hemolysis and subsequent renal pigment load which might adversely affect the kidneys

(a)    This is more of a concern with cats

(2)   The etomidate-lipuro product is prepared in a hyperlipid vehicle similar to propofol and is not associated with this concern

iv)     If ketamine/diazepam is being considered for induction, precede the ket/val with 0.2 mg/kg diazepam IV to reduce the overall ketamine need

d)      Maintenance

i)        Isoflurane or sevoflurane unless blood pressure management is a problem

(1)   Hydromorphone or oxymorphone alternated with diazepam is a consideration for maintenance in dogs that do not maintain adequate blood pressure on inhalant agents

(a)    See Anesthetic Maintenance section for details

e)      Support

i)        IV fluids are a must but, by themselves, are no guarantee of adequate patient blood pressure and tissue perfusion

(1)   Blood pressure monitoring is crucial to safe renal patient management

(a)    Doppler monitors are preferred for smaller patients

ii)       Appropriate supplemental heat is very important

2)     PRECAUTIONS

a)      Pre-anesthetic Medications

i)        Avoid acepromazine or use low-end doses

(1)   May reduce blood pressures

ii)       Avoid NSAIDs

b)      Induction

i)        Avoid ketamine or minimize doses especially in cats

(1)   Requires renal clearance

(a)    Although significant hepatic clearance occurs in dogs and people

c)      Maintenance

i)        Some patients do not have stable blood pressures when under isoflurane or sevoflurane

(1)   Consider switching dogs to hydromorphone or oxymorphone and diazepam

(2)   Morphine or fentanyl CRIs, with lidocaine for dogs, can help reduce inhalant agent needs

(3)   Local blocks should be considered when appropriate to help reduce overall inhalant need

d)      Support

i)        Remember, some renal patients are hypertensive

(1)   Blood pressure monitoring is a must