Wound healing is impaired in patients with chronic renal failure, and wound dehiscence and evisceration are potential problems. Wound healing is most appropriately aided by nutritional assessment preoperatively and maintenance of adequate caloric and protein intake in the perioperative setting. Antibiotic prophylaxis should be used in these patients, and uremia should be treated with dialysis as indicated. A running mass closure of the midline vertical incision with continuous monofilament sutures should be used to decrease the risk of wound dehiscence and evisceration (256).
Patients with chronic renal disease have an altered ability to excrete drugs and are prone to significant metabolic derangements secondary to the altered bioavailability of many commonly used medications. Because of this, and the effect of dialysis on drug pharmacokinetics, the gynecologic surgeon and nephrologist must be aware of the lowered metabolism and bioavailability of narcotics, barbiturates, muscle relaxants, antibiotics, and other drugs that require renal clearance. Of particular note is the inability of patients with renal insufficiency to clear the neuromuscular blockade caused by pancuronium (257). Care must be taken with D-tubocurarine, especially if repeated doses are given (258). Midazolam, propofol, vecuronium, and atracurium are used safely in patients with renal failure (254). Succinylcholine is reported to cause significant hyperkalemic responses in patients with renal failure (259). When succinylcholine is used in patients with chronic renal insufficiency, careful monitoring of the serum potassium level is necessary (260).
Perioperative acute renal failure in previously normal patients may be caused by decreased renal perfusion, nephrotoxins, or both. Patients with impaired cardiac function, intravascular volume depletion, sepsis, or hypotension fall under the first category. Nephrotoxic medications such as aminoglycosides, chemotherapeutic agents such as cisplatin, or iodinated contrast agents fall under the second category (261–263). The risk of renal impairment becomes cumulative if more than one of these factors exist at the same time, and especially if a variety of factors are associated with intervascular volume depletion (264). Several measurements should be used to avoid acute renal failure. All nephrotoxic drugs should be discontinued when possible. When it is not practical to withdraw medication, strict attention should be paid to the pharmacokinetic characteristics of each drug and to the regular measurements of serum creatinine levels. Patients with diabetes should be given reduced doses of radiocontrast agents and should be well hydrated because they are particularly susceptible to renal injury from these materials (265). Volume repletion is essential to lower the incidence of renal impairment (266).
Laboratory Testing The biochemical profile (alkaline phosphatase, calcium, lactate dehydrogenase, bilirubin, serum glutamic–oxaloacetic transaminase, cholesterol, uric acid, phosphorous, albumin, total protein, and glucose) is not useful for routine preoperative evaluation (267). Mild abnormalities can result in further extensive testing that requires consultation, delays in surgery, and increased cost without net benefit. A possible exception is selected use of biochemical testing when the history or physical examination reveals abnormalities. Patients with known liver disease should undergo albumin and bilirubin testing using the Child’s risk classification (Table 22.21). This system