Methodist Journal


Lipids and Lipoproteins

Vol 15, Issue 1 (2019)



Lipids and Cardiovascular Disease: Putting it All Together

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Guest Editors Henry Pownall and Antonio Gotto Offer Insight and Expertise on the topic of Lipids and Cardiovascular Disease

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Cholesterol: Can’t Live With It, Can’t Live Without It

How Much Do Lipid Guidelines Help the Clinician? Reading Between the (Guide)lines

Statins: Then and Now

Poststatin Lipid Therapeutics: A Review

HDL and Reverse Cholesterol Transport Biomarkers

Revisiting Reverse Cholesterol Transport in the Context of High-Density Lipoprotein Free Cholesterol Bioavailability

High-Density Lipoprotein Subspecies in Health and Human Disease: Focus on Type 2 Diabetes

Gene Delivery in Lipid Research and Therapies


Device-Related Thrombus: A Reason for Concern?

Retained Coronary Balloon Requiring Emergent Open Surgical Retrieval: An Uncommon Complication Requiring Individualized Management Strategies

Loperamide Mimicking Brugada Pattern

Reversed Pulsus Paradoxus in Right Ventricular Failure


Transcatheter Embolization of a Persistent Vertical Vein: A Rare Cause of Left-to-Right Shunt and Right-Sided Heart Failure



Talking Statins with Antonio Gotto


Lipids and Renal Disease


Addressing the Feedback Loop Between Depression, Diabetes, and Cardiovascular Disease


The Kidney as an Endocrine Organ


Addressing the Underrepresentation of Women in Cardiology through Tangible Opportunities for Mentorship and Leadership

Vol 11, Issue 3 (2015)

Article Full Text


Administration of Anesthesia to Patients with Renal Failure

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Article Citation:

Juan Jose Olivero, Sr. Administration of Anesthesia to Patients with Renal Failure. Methodist DeBakey Cardiovascular Journal. September 2015, Vol. 11, No. 3, pp. 197.


The column in this issue is supplied by Dr. Juan Jose Olivero, M.D., a nephrologist at Houston Methodist Hospital and a member of the Nephrology Training Program. Dr. Olivero, Sr. obtained his medical degree from the University of San Carlos School of Medicine in Guatemala, Central America, and completed his residency and nephrology fellowship at Baylor College of Medicine in Houston, Texas.

  1. Never place a central line in the same extremity where the arteriovenous access (primary AV fistula or GORE-TEX® graft) is present.

  2. Do not administer large amounts of intravenous (IV) fluids to patients with end-stage renal disease (ESRD) or acute renal failure (ARF)-oliguric patients (i.e., no more than 1 mL/kg) for minor procedures and during stable clinical conditions.

  3. Choose the proper IV solution during anesthesia (0.9% or 0.45% NaCl) according to the following serum electrolyte levels:

    • normal saline (NS) if NA+ < 140 mEq/L

    • ½ NS if NA+ > 140 mEq/L or in patients receiving large amounts of exogenous NA+ in the form of fresh, frozen plasma. May alternate one liter of each during prolonged surgical procedures, particularly if large amounts of volume are needed. Add 5% dextrose in NS or ½ NS in nondiabetic patients or in diabetics who receive pre-op insulin.

  4. Severe intraoperative hyponatremia can frequently happen while receiving hypotonic solutions (< 0.9% NaCl). At highest risk are patients with:

    1. ESRD or ARF-oliguria,

    2. post-transurethral resection of the prostate using glycine with or without renal failure, or

    3. endometrial curettage/ablation with or without renal failure.

  5. Do not treat hyperkalemia unless levels of potassium are 6.0 mEq/L or above, in which case use:

    1. dextrose in water (D/W) 50% mL intravenous push (IVP) followed by 5 units (U) IVP regular insulin as the quickest way to reduce K+ levels by increasing cellular uptake. Do not use hypertonic glucose with blood sugar levels > 200 mg/dL. Use regular insulin alone; correction of hyperglycemia results in improvement of hyperkalemia. May use sliding scale for blood sugar as follows (using Accu-Chek® every 15 min):

      • 201–250 mg/dL 3 U regular insulin IV

      • 251–300 mg/dL 5 U regular insulin IV

      • 301–350 mg/dL 7 U regular insulin IV

      • 351–400 mg/dL 10 U regular insulin IV

      • 400 mg/dL 15 U regular insulin IV

      Conversely, if blood sugar < 100 mg/dL, hyperkalemia should improve with administration of hypertonic glucose alone (50 mL of 50% D/W IVP) without insulin.

    2. NaHCO350 mEq (1 amp) IVP unless pH is alkalemic (pH > 7.48), in which case do not administer.

    3. Calcium gluconate 1 gm IVP, particularly if EKG findings of hyperkalemia are present. Watch for hyperkalemia intra-op if:

      • radiographic contrast is used (particularly in ARF-oliguric patients, as a consequence of “solvent drag effect”),

      • large amounts of mannitol are given under the same circumstances as above, or

      • cardiovascular collapse develops with ensuing lactic acidosis (resulting in acidemia, “shifting,” and hyperkalemia).

  6. For intra-op hypertension in ESRD and ARF patients, avoid ACE inhibitors and beta-blockers as antihypertensive drugs since they can lead to hyperkalemia. Instead use calcium channel blockers, which may have a nephroprotective effect in ARF patients.

  7. In patients with acute ongoing metabolic acidosis and acidemia (pH < 7.30), D/5W 1 liter with 3 amps of NaHCO3 could be used as the solution of choice instead of 0.9% NaCl. Some of these patients could be hyperchloremic; moreover, “expansion acidosis” could further compound the situation. If the patient is hypernatremic (Na+ levels > 150 mEq/L), tris-hydroxymethyl aminomethane (THAM) is the preferred solution to provide buffer and prevent further worsening hypernatremia obligated by NaHCO3 infusion.

  8. Large amounts of citrate administered via multiple blood transfusions can lower Ca++ levels, for which calcium gluconate 1 gm IV should be administered for every 3 U of blood. Ca++ levels need to be followed closely to prevent high calcium-phosphorus double product and risk for calcium-phosphorus precipitation in vital organs.

  9. In the unusual event of severe hypophosphatemia (P < 2.0 mg%), replace NaHPO4 10 mmol IV over 1 hour or KHPO4 10 mmol over 1 hour according to the situation.

  10. Avoid drugs with potential nephrotoxicity in ARF patients; modify doses of medications according to reduced renal function (glomerular filtration rate (GFR) < 5 mL in ESRD). Formulas such as MDRD eGFR and Cockroft-Gault (140 – age in years) × (weight in kg)/SCr × 72 are of no use in ARF to calculate GFR since anuria is GFR 0 regardless of serum creatinine levels; this formula is only useful when renal function is at a steady state and not changing daily as with ARF.


Thumbnail image from Museum of Veterinary Anatomy FMVZ USP [CC BY-SA 4.0 (], via Wikimedia Commons


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