Question 13

List and briefly discuss the considerations in managing a patient with dialysis dependent End Stage Renal Failure (ESRF) admitted to the ICU post-operatively from an uncomplicated Hartmann’s procedure.

[Click here to toggle visibility of the answers]

College answer

Not available.


B) Respiratory considerations:

  • Tendency towards pulmonary oedema

C) Cardiovascular considerations:

  • These chronically hypertensive patients may require higher MAP to perfuse their organs
  • They are prone to pericardial effusions
  • The myocardium may be hypertrophied
  • Atheromatous disease is amplified; coronary artery disease will likely be present; risk of MI is greater, even though the Hartmanns was uncomplicated, and the troponin will be harder to interpret

D) Pharmacokinetics are affected:

  • Renally cleared substances will persist until the next dialysis session
  • Renally cleared metabolites will also have a persisting effect
  • Volume of distribution is increased
  • Neurological function can be impaired by high urea

E) Electrolyte and acid-base balance will be disturbed:

  • High potassium
  • High phosphate
  • Accumulation of non-volatile acids (sulfate, urate, etc)

F) Fluid balance will be disturbed:

  • Inability to produce urine makes the patient more likely to develop fluid overload
  • Vascular access will also be an issue:

    • If the patient is on haemodialysis, they will have a fistula, which means a part of their upper limb circulation will be inaccessible for central line placement

    • If the patient was on peritoneal dialysis, this will no longer be possible after abdominal surgery, in which case they will need a vas cath

    • The fistula will not be a satisfactory access point for CRRT

G) Nutrition is affected:

  • Low-protein diets are usually required to decrease the rate of urea production.
  • Albumin may be low (eg. with nephrotic syndrome) which decreases its positive antioxidant and scavenging effect.
  • Thus, the patient may have impaired healing as the result of the protein deficiency

H) There may be anaemia due to decreased EPO synthesis.

I) There may be immune dysfunction and increased risk of infection.


Clermont, Gilles, et al. "Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes." Kidney international 62.3 (2002): 986-996.

Szamosfalvi, Balazs, and Jerry Yee. "Considerations in the critically ill ESRD patient." Advances in chronic kidney disease 20.1 (2013): 102-109.

Arulkumaran, N., N. M. P. Annear, and M. Singer. "Patients with end-stage renal disease admitted to the intensive care unit: systematic review." British journal of anaesthesia 110.1 (2013): 13-20.

Thompson, Stephanie, and Neesh Pannu. "Renal replacement therapy in the end-stage renal disease patient with critical illness." Blood purification 34.2 (2012): 132-137.