Anesthetic Management for ESRD Patients on Dialysis

Preoperative Planning

Schedule surgery for the morning following dialysis when the patient is in optimal metabolic balance 1
Lidocaine, mepivacaine, and articaine require no dose adjustment in ESRD and are safe first-line local anesthetics, according to the International journal of oral science 1

Maximum articaine dose: 7 mg/kg (same as general population) 1
Reduce epinephrine concentration (use 1:100,000 or less) due to hypertension risk 1
Lidocaine/prilocaine cream (EMLA) is safe for vascular access cannulation with negligible systemic absorption and hepatic metabolism 2
Apply EMLA at least 1 hour before cannulation under occlusive dressing 2
Diazepam and midazolam require no dose adjustment as they undergo hepatic metabolism, making them safe choices for anxiolysis 1
Diazepam: 0.1-0.8 mg/kg orally for conscious sedation 1
Midazolam: 0.5-1 mg/kg (maximum 15 mg) for dental sedation 1
Avoid codeine and alprazolam entirely in dialysis patients 1

Amoxicillin: Prolong dosing interval to every 24 hours (from every 8 hours) 1
Ampicillin/sulbactam: Prolong interval to every 12-24 hours 1
Clindamycin, erythromycin, doxycycline, ketoconazole: No adjustment needed 1
Avoid aminoglycosides and tetracyclines due to nephrotoxicity (except doxycycline) 1
Administer prophylactic antibiotics 1 hour before incision with appropriate renal dosing 1

Check serum electrolytes if any symptoms develop postoperatively 3
Maintain quiet environment and minimize interruptions to reduce anxiety and hypertensive responses 1