Kidney disease and risk of anesthesia

bebemau · Sep 2, 2013

Hello forum,

I am at a very difficult spot and was hoping to find information about cats with kidney disease and the risk of anesthesia.

Just a little background, my cat BJ is 13 years old, he was diagnosed with small cell lymphoma, and has metastasized, BJ also has kidney disease.

3 months ago we decided to move forward with chemotherapy. We chose CCNU because it doesnt require BJ to be put under. The concern was BJ is a bigger kitty (he is 13lbs) and the amount of anesthesia can crash his already weak kidney. So weighing the risks we decided to go with CCNU since anesthesia is not required.

3 monts later, based on latest ultrasound, oncologist believes BJ has stopped responding to CCNU, my oncologist has recommended stopping CCNU, and depending how I feel about risks, we can move forward and do the Wisconsin/madison protocol. With this protocol, BJ will need to be put under anesthesia, because BJ can be very hard to handle, once he stops cooperating, he attacks and he can cause blood. Again with BJ's kidney condition, the oncologist cant recommend either way. If we dont treat BJ with chemo, cancer will take over. If we do treat BJ with chemo, we can kill his kidney.

Had a discussion with a member on another board yesterday, she doesnt understand why I wouldnt move forward with chemo. She feels the risk of cancer killing BJ is way higher than the risk of anesthesia killing BJ and that the use of anesthesia is justifiable. That's why I want to ask the group, of your experience.

Thanks for listening, and thanks for any feedback.

Keren and BJ

denice · Sep 2, 2013

I guess I am not understanding the need for general anesthesia. My understanding is that the different protocols involve different forms of chemo drugs sometimes given by IV. Is it because of the need for an IV?

bebemau · Sep 2, 2013

The reason for anesthesia is so then BJ can be handled. BJ's tempermant is not the best he will growl, hiss and bite with all his power when I give him medicine. He has attacked my oncologist before during his CCNU treatment. My oncologist explained that these drugs(basically poison) must be handled carefully and knowing BJ, without him being sedated, it can be next to impossible to administer.

white shadow · Sep 2, 2013

Hi babema !

There are two things that can damage the kidneys when a cat's put "under":

the anesthetic agent itself......a risk that can be eliminated by using products that are not filtered through the kidneys but through the liver **
a drop in blood pressure.....a risk that can be reduced by having the cat on IV fluids.....careful monitoring while the cat is anesthetized and recovering can reduce the risk even further If the reason for anesthesia is surgery, I have seen recommendations for IV drip on the day before, and for several hours after. If it were my cat, I'd go for the full following day as well, I think.

** The Veterinary Anesthesia and Analgesia Support Group has a section on anesthesia protocols for dealing with renal patients - why don't you print it off and talk to the oncologist so that the appropriate anesthetics are used: Renal Disease Management - VASG.org

The 'Oracle' for all things CKD now has a section on anesthesia here: Anaesthesia - Tanya's Comprehensive Guide to Feline CKD

bebemau · Sep 3, 2013

Hello White Shadow,

Thank you so much for the response. That is very helpful, and I have searched high and low to find out exactly what is the concern.

And thanks for those links, I already have sent my oncologist a list of questions about how anesthesia will be administered and how will BJ be monitored etc etc. Still waiting for a response.....

Thanks again!!

Keren and BJ

white shadow · Sep 3, 2013

bebemau said:
I already have sent my oncologist a list of questions about how anesthesia will be administered and how will BJ be monitored etc etc.

Keren.......also ask which anesthetic(s)... + ......how it is excreted (kidney or liver).....accept only those cleared by the liver... + ....how will he maintain blood pressure.

THOSE are the essentials.

peaches08 · Sep 4, 2013

Are you saying that there are concerns with killing his kidneys with the chemo as well as anesthesia?

bebemau · Sep 4, 2013

White Shadow said:
Keren.......also ask which anesthetic(s)... + ......how it is excreted (kidney or liver).....accept only those cleared by the liver... + ....how will he maintain blood pressure.

THOSE are the essentials.

My oncologist has replied, this is what she says:

"We would only use gas anesthesia, with isofluorane. Propofol has to be administered in the vein and we cannot get a vein access on BJ without anesthesia. We have to induce him directly with gas by palcing him in a chamber where he is breathing the gas/air mixture to go to sleep. All the risks I described apply to gas anesthesia.

The treatments and anesthesia vary from 10 minutes to 45 minutes, depending on the drug he receives. We rotate 3 drugs that are given differently. There is nothing we can do to minimize his risk other than doing things as fast as we can, which we always do. He does get an IV catheter placed in for chemo. he is not placed on IV fluids during anesthesia because there isn't enough time for that, we get the treatment done right away to minimize his anesthesia time. IV fluids are done when the patient is expected to be under anesthesia for a longer procedure. Doing IV fluids afterward does not change his anesthesia risk or kidney risk during anesthesia."

She didnt mention anything about monitoring BP and I have asked that question, I will ask again. I was hoping BJ will be placed on IV the whole time, but I guess thats not happening since it is supposed to be a quick procedure.

bebemau · Sep 4, 2013

peaches08 said:
Are you saying that there are concerns with killing his kidneys with the chemo as well as anesthesia?

Hi peaches....

No, my oncologist has confirmed that anesthesia is the only concern. The drugs this chemo uses doesnt cause issue to the kidney.

peaches08 · Sep 4, 2013

It looks like gas is their only choice. Propofol burns like the Dickens.

white shadow · Sep 4, 2013

peaches08 · Sep 5, 2013

White Shadow, do you work with anesthesia?

white shadow · Sep 5, 2013

OK, Keren, I may have something to take to your Vet.........who should then deal with this oncologist to ensure that safe sedation is provided.

This reference comes from the well-respected Veterinarian, Mark Peterson who 'discovered' feline hyperthyroidism in (I think) 1979.

If you read through yourself, you'll note the care that's given to the selection of the anesthetic agents.....and note that "sedatives" are given subcutaneously......a simple, painless injection in the scruff.....just like the sub-q fluid therapy given to kidney-cats.

Premedication (Preanesthetic Agents)

Even very friendly cats often object to physical restraint, sometimes making the anesthetic induction procedure extremely difficult to accomplish safely. Therefore, use of preanesthetic sedation is recommended in order to facilitate IV catheter placement and anesthetic induction in these hyperthyroid cats (3-5). This sedative also has an anesthetic-sparing effect during the maintenance anesthetic period.

In hyperthyroid cats, use of an opioid agent administered subcutaneously is suggested for its cardiovascular safety and analgesia (5-9). Such opioid drugs commonly used include hydromorphone (0.025-0.05 mg/kg), oxymorphone (0.025-0.05 mg/kg), or methadone (0.3-0.5 mg/kg). These opioid agents help create a sense of well-being or euphoria, but they do not typically sedate cats very well. Therefore, it is best to combine one of these opioid agents with another drug to produce the desired sedative effect.

Combining an opiate drug either with a mild tranquilizer or sedative is commonly done in veterinary practice. The benzadiazepine tranquilizers (diazepam or midazolam) cause only minimal cardiovascular depression and are therefore very useful preanesthetic agents for hyperthyroid cats (5,6,9,10). The dissociative agent ketamine, is a useful preanesthetic agent. However, this drug can produce an increased heart rate, cardiac output, and blood pressure and should never be used alone, especially if administered intravenously or at high doses (1,4).

A number of drug protocols are available for premedication prior to induction (3,4,5,7). Combinations of an opioid (e.g., hydromorphone, oxymorphone, or methadone) administered with a tranquilizer (e.g., midazolam [Versed]) is one commonly used protocol. Alternatively, use of a dissociative agent (e.g., ketamine [Ketaset]) given with a mild tranquilizer (midazolam) is also a popular choice among veterinarians.

As an alternative, a combination of 3 agents — a subcutaneous opioid (see doses above), midazolam (0.1-0.2 mg//kg, SC), and very low-dose ketamine (2 mg/kg, SC) — can be used to sedate fractious cats (5).

Such drug combinations also provide better restraint and analgesia than that achieved by single drug administration and have fewer side effects than the use of one class of preanesthetic alone. For example, when used alone, opioids can induce extreme excitement or “mania,” ketamine will produce increased severe muscle rigidity and excessive salivation, and midazolam may induce paradoxical excitement and dysphoria. When combined with other CNS depressants, these side effects will occur less frequency and are much milder.

http://animalendocrine.blogspot.ca/2012/11/sedation-and-anesthesia-for-cat-with.html

(about 1/3 down that page)

Hope this helps!

bebemau · Sep 5, 2013

White Shadow said:

Hey White Shadow,

I guess what she was saying is, they will do it as quick as possible to minimize the time he is under, it could vary from 15 to 45 minutes. I did talk to my vet and he might not do the same thing she does but he doesnt think she's necessarily wrong. I have an appointment with an internal med vet who does chemo next tuesday, he came highly recommended to me, will see how that goes. That also means chemo wont happen until late next week.

And regarding sedatives and general anesthesia, i thought they are different too, until someone told me its the same thing, i guess this is what happens when too much information. And thanks for the article about combining drugs for anesthesia, dont know if she can do it, but will bring it up.

peaches08 · Sep 6, 2013

Please let us know how things go with your kitty, and sending lots of warm vibes your way.

bebemau · Sep 6, 2013

Thank you peaches, will keep you guys posted.

bebemau · Sep 10, 2013

Hi Guys,

After many days of dilema, we finally went ahead and have BJ treated with the CHOP protocol.

We visited our new internal medicine vet over an hour away, longest drive for BJ so far. Chatted with him a bit, so far so good, he suspects his kidney issues might stem from the cancer. And since BJ was pretty calm today, he said we shouldnt need to put him under anesthesia and we can do it right now!! I was like, OKAY!!!

So anyways, BJ seems fine after the treatment. We will need to do a blood test next week to see if kidney values change, and then based on the result, decide what to do next.

Theres my update, thank you guys for your responses!

denice · Sep 10, 2013

I am so glad you found someone who did the treatment without anesthesia. I think some vets have a calm way of connecting with cats and that makes everything so much easier.

bebemau · Sep 10, 2013

Thanks Denise....

I do hope so but I think I also need to be realistic.

Today BJ was behaving, tomorrow he might not. Vet did say when it comes to that point then they will have no choice but put him under, also i guess depending on which drug, some pose more danger if patient is not still. Anyways, for now, it's good news, and I will take that

peaches08 · Sep 11, 2013

Hey, each time that kitty is not put under anesthesia reduces risks! Awesome!

I know what you mean about being realistic. Some cats are better patients than others. As Denice mentioned, some vets have a more calming presence about them. It sounds like you're doing the best that anyone can under these circumstances.

Kidney disease and risk of anesthesia

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