quick sheet

CKD & the dialysis patient

Check the potassium, protect the fistula, and pick drugs that don't need kidneys.

Top concerns

1.Timing: ideally dialyzed within ~24h before elective surgery — and check the post-dialysis K⁺ today, not yesterday's
2.Hyperkalemia thresholds: elective cases generally deferred above ~5.5 mEq/L (context-dependent) — and succinylcholine's ~0.5 mEq/L bump lands on top of baseline
3.Fistula protection: no BP cuff, IV, or pressure on that limb; pad it visibly
4.Drug selection: cisatracurium (organ-independent Hofmann elimination) preferred; avoid morphine (M6G accumulation) and meperidine (normeperidine seizures)
5.Uremic platelet dysfunction: expect oozing despite normal counts; desmopressin is an option
6.Volume status is a moving target: post-dialysis hypovolemia vs missed-dialysis overload — examine, don't assume

AVOIDSuccinylcholine with elevated baseline K⁺— Additive ~0.5 mEq/L rise on an already-high baseline.
AVOIDMorphine / meperidine— Active metabolites accumulate (M6G narcosis; normeperidine seizures). Fentanyl/hydromorphone preferred.
PREFERCisatracurium— Hofmann elimination — kidney-independent offset.
CAUTIONLarge-volume 0.9% saline— Hyperchloremic acidosis shifts K⁺ up; balanced crystalloids in modest volumes are reasonable despite their potassium content.

The fistula is the patient's lifeline — treat it like an airway.
Ask when they last dialyzed and what they weigh today vs their dry weight; that's your volume exam starting point.

Check the potassium, protect the fistula, and pick drugs that don't need kidneys.

1.Timing: ideally dialyzed within ~24h before elective surgery — and check the post-dialysis K⁺ today, not yesterday's
2.Hyperkalemia thresholds: elective cases generally deferred above ~5.5 mEq/L (context-dependent) — and succinylcholine's ~0.5 mEq/L bump lands on top of baseline
3.Fistula protection: no BP cuff, IV, or pressure on that limb; pad it visibly
4.Drug selection: cisatracurium (organ-independent Hofmann elimination) preferred; avoid morphine (M6G accumulation) and meperidine (normeperidine seizures)
5.Uremic platelet dysfunction: expect oozing despite normal counts; desmopressin is an option
6.Volume status is a moving target: post-dialysis hypovolemia vs missed-dialysis overload — examine, don't assume

AVOIDSuccinylcholine with elevated baseline K⁺— Additive ~0.5 mEq/L rise on an already-high baseline.
AVOIDMorphine / meperidine— Active metabolites accumulate (M6G narcosis; normeperidine seizures). Fentanyl/hydromorphone preferred.
PREFERCisatracurium— Hofmann elimination — kidney-independent offset.
CAUTIONLarge-volume 0.9% saline— Hyperchloremic acidosis shifts K⁺ up; balanced crystalloids in modest volumes are reasonable despite their potassium content.

The fistula is the patient's lifeline — treat it like an airway.
Ask when they last dialyzed and what they weigh today vs their dry weight; that's your volume exam starting point.