anaesthesia for renal transplantation dr.m.kannan md da professor and hod of anaesthesiology...
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ANAESTHESIA FOR RENAL TRANSPLANTATION
Dr.M.Kannan MD DAProfessor and HOD of
AnaesthesiologyTirunelveli Medical College
Demand-supply imbalance
3000
300 per million
1800 per year in Tamilnadu
Associated co-morbid conditions
•Coronary artery disease
•Congestive cardiac failure
•Systemic Hypertension
•Diabetes Mellitus
Associated co-morbid conditions
Coronary artery disease
• Incidence 17%-34% • Coronary angiography & re-
vascularisation • Irreversible LV dysfunction with
very low cardiac output
contraindication
Associated co-morbid conditions
Congestive cardiac failure• CCF is present before dialysis
• CCF Associated with CRF IHD HypoalbuminemiaOld age Uremic cardiomyopathy DiabetesAnaemia AV-fistula
Independent prognosticMotality
Associated co-morbid conditions
Systemic Hypertension
• 70% of ESRD patients • ACE-inhibitors • Calcium channel blockers• Beta-blockers• Diuretics
Discontinued before surgeryserum.K+ level monitored
Continued peri-operatively
Laryngoscopy&Intubation
• Exaggerated stress response
• Opioids • beta-blockers• IV Lignocaine
Associated co-morbid conditions
Diabetes Mellitus Cardiac complications gets doubled Revised cardiac risk index • 1.High-risk surgical procedure.• 2.h/o IHD(excluding previous coronary re-
vascularization)• 3.Heart failure• 4.h/o stroke or transient ischemic attacks• 5.Pre-operative insulin therapy• 6.Pre-operative creatinine levels higher
than 2 mg/dl.
Patho-physiological consequences of ESRD
• Anaemia -Transfusion• Uremic Coagulopathy
• Uremic Cardiomyopathy • Se.K+& acid-base status
• Delayed gastric emptying
Erythropoietin Normocytic normochromic
anaemia Hypertension,
CVA,Thrombosis of fistulas
Sensitization of the recipient
Abnormal platelet function Factor 8
Pre-operative dialysis Toxins l- guanidinosuccinate,phenol
Phenolic acid
HyperkalemiaAcidosis
Treatment-DialysisDelays recovery -Anaesthesia
Pre-operative dialysis
• Optimize fluid and electrolyte balance• Correct hemostatic abnormalities• Post dialysis weight loss of >2 kg -Indicate intra-vascular volume
depletion -Thromboplastin time is checked for
residual heparin -Hepatitis can be endemic
Pre-operative optimazisation
• Adequate BP control
• Adequate control of blood glucose
• Correction of se.K+ levels.
• Correction of anaemia
• Correction of coagulopathy
Anaesthetic Agents
• Thiopental• Propofol• Isoflurane -peripheral vaso-dilatation -minimal cardio-depressive
effects -preservation of RBF
-low renal toxicity Desflurane
Sevoflurane
• Fluoride • CompoundA
• Fresh gas flow rates >4 L/min
Opioids
• Morphine • Pethedine
• Fentanyl, sufentanil, alfentanil, remifentanyl
• Reduced clearance
• Accumulation of active metabolites
• Safer • Metabolites are
not potent,
Muscle Relaxant
-Succinyl choline ? -not contra-indicated in
pts. with ESRD
0.6 m eq/l can be tolerated
without significant cardiac risk
Muscle Relaxant
• Pancuronium
• Vecuronium
• Atracurium
• Rocuronium
• Less desirable in uremia.
• Slight in duration
• Hoffmann elimination
• Clearance is unaffected in renal failure.
Elimination half lives of anti-cholinesterases are
prolonged
Monitors
• 5-lead ECG.• Arterial BP• SpO2• EtCo2• Temperature .• Urine output
Special Monitors
• CVP monitoring • Direct arterial
pressure monitoring
• Pulmonary artery occlusion pressure
• TEE • Contrast-
Enhanced Perfusion USG
Systolic BP variation
correlates well with LV end-diastolic volume
>20/15 1.Poorly controlled hypertension
2. CAD with LV dysfunction 3 .Valvular heart disease
4.COPD when severe.
Hypotension Hypovolemia
or Myocardial contractility.
Sonicated albumin:
Predict renal viability &
Guide pharmacological interventions.
Factors affecting kidney viability
• Management of the kidney donor(living or cadaveric).
• How well the harvested organ is preserved.
• Peri-operative management of the kidney recipient.
Anaesthetic considerations during donor nephrectomy
• Venous return due to the kidney -adequate hydration
• V/Q mismatching due to positioning
• Mannitol and IV heparin (3000-5000) units before cross-clamping the renal vessels.
• Administration of protamine to normalize coagulation
Management of the Brain dead Kidney donor
• Selection -Stable hemodynamics Adequate respiratory
parametersAbsolute contra-indicationsAbsolute contra-indications Prolonged hypotension Hypothermia Collagen vascular diseases Congenital or acquired metabolic disorders Malignancies, Generalized viral or
bacterial infections DIC’ Hep B, HIV.
Relative contra-indications
• Age above 70 years• Diabetes mellitus• High serum creatinine before
organ harvesting• Excessive pre-terminal use of
vaso-pressors.
Guidelines for intra-op management of the brain
dead• A systolic BP >100 mm Hg• PaO2 >100 mm Hg• Urine output >100 ml/hr• Hemoglobin concentration >100
g/l• Central venous pressure
between 5 and 10 mm Hg
Guidelines for intra-op management of the brain
dead• Vasodilators -Phentolamine• Hypotension- Fluid
administration Pharmacological support
• Bradycardia - Iso-prenaline (a direct acting chronotrope) and not
atropine.
Anaesthetic management of kidney recipients
General Anaesthesia with controlled ventilation
-Good hemodynamic stability -Better patient comfort.
Regional AnaesthesiaDis-advantages: Systemic blood pressure -viability of the kidney
donated. Large volumes of IVF precipitate acute LVF. Advantages It is cost-effective Complete abolition of stress response Less exposure to anaesthetic drugs
Anaesthetic considerations in the recipient
• Positioning – Care of the AV Fistula