Dialysis Timing & Optimisation
🗓️ Dialyse the day before — not on the morning of surgery
- Aim to dialyse within ~24 h before surgery — this corrects potassium, volume & acidosis.
- Not immediately before — the patient may be left with residual heparin, acute fluid shifts, hypovolaemia and relative hypokalaemia.
- Check K⁺, acid–base, Hb, coagulation and volume status ("dry weight") before theatre; correct hyperkalaemia if present.
- Continue essential cardiac medication; document the planned access arm.
Altered Drug Handling in Renal Failure
| Drug class | Renal-failure approach |
|---|---|
| Muscle relaxants | Prefer atracurium / cisatracurium (organ-independent Hofmann elimination); vecuronium & rocuronium have prolonged/variable duration; monitor with TOF |
| Suxamethonium | Raises K⁺ by ~0.5 mmol/L — avoid if the patient is already hyperkalaemic |
| Opioids | Avoid morphine (active metabolite morphine-6-glucuronide accumulates) and pethidine (normeperidine → seizures); fentanyl is reasonable; titrate carefully |
| Reversal | Neostigmine + glycopyrrolate; the sugammadex–rocuronium complex is renally cleared (use with awareness) |
| Others | Reduce/avoid renally-excreted drugs & active metabolites; acidosis/hypoalbuminaemia raise free drug fractions → titrate to effect |