ANAESTHESIA FOR RENAL TRANSPLANTATION Dr.M.Kannan MD DA Professor and HOD of Anaesthesiology Tirunelveli Medical College
Dec 14, 2015
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