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Anaesthesia for renal transplant surgery

Anaesthesia for renal transplant surgery. Moderator - P rof Chandralekha Dr Jyotsna. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Causes of ESRD :. DM Hypertension Glomerulonephritis Pyelonephritis Polycystic kidney

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Anaesthesia for renal transplant surgery

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  1. Anaesthesia for renal transplant surgery Moderator - Prof Chandralekha Dr Jyotsna www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Causes of ESRD : • DM • Hypertension • Glomerulonephritis • Pyelonephritis • Polycystic kidney • Others

  3. Treatment options for ESRD : Hemodialysis Peritoneal dialysis Transplantation

  4. Dialysis • Diffusion of solutes across a semipermeable membrane down conc gradient • Hemodialysis - shunt / fistula • Peritoneal dialysis – IPD, CAPD,CCPD

  5. Indications : • Hyperkalemia unresponsive to conservative means • Refractory acidosis • Volume overload • Uremic pericarditis • Uremic neuropathy

  6. Hemodialysis • Predominant technique • Done three times a week • Duration 2.5 - 5 hrs

  7. Access for dialysis Hemodialysis : • Arteriovenous fistula - long term • Arteriovenous shunt - short term • Temporary venous catheters – short term

  8. Care of fistula : • Needs 4 weeks to mature Complications : • Thrombosis • Infection • Haemorrage • Steal Precautions- • Padding of fistula • Avoid BP cuff • No sampling • Avoid hypotension

  9. Peritonial dialysis : • Peritoneum as endogenous dialysis membrane • CAPD /CCPD • Access via silastic catheter

  10. Hemodialysisvsperitonial dialysis

  11. Complications : Acute : • Hypovolemia • Electrolyte imbalance • Disequilibrium syndrome Chronic : • Dialysis dementia • Hypoproteinemia • infections

  12. Transplant Vs dialysis • Better quality of life • Better 5 yr survival rates 70% vs 30% • Improves anaemia , peripheral neuropathy , autonomic neuropathy and cardiomyopathy • Dialysis negatively affects success of transplantation

  13. Criteria for transplant : • Patients with ESRD with expected 5 yr survival

  14. Contraindications for renal transplant Absolute contraindications : • Disseminated or untreated cancer • Severe psychiatric disease • Irresolvable psychosocial problems • Persistent substance abuse • Severe mental retardation • Un-reconstructable coronary artery disease or refractory congestive heart failure

  15. Relative contraindications : • Treated malignancy • Chronic liver disease • History of substance abuse • Structural genitourinary tract anomaly • Past psychosocial abnormality

  16. Donors for kidney transplant : LIVE or CADAVER Live -> related or unrelated Ideal donor Age = 18 - 60yrs Compatible blood group No DM or HTN Psychologically motivated Viral markers ( - )

  17. Pre op consent • Fully informed of risk and benefits • Aware of alternative methods • Willing to donate • Psychosocially capable Unrelated donors – • Need permission from authorization committee

  18. Investigations • Hemogram ,KFT , LFT • CT angiography and urography • Psychiatry , dental ,opthalmologic and cardiac evaluation • CMV antibodies • DTPA scan and global GFR • Immunological testing

  19. Anaesthetic concerns for living donors • Good physical health ASA 1or 2 • Open / laparoscopic • Flank position – risk of hypotension • Maintain good hydration and diuresis • Mannitol before cross clamping • Avoid direct acting vasopressors • Post op pain – iv opioids , no NSAIDS

  20. Anaesthetic concerns for cadaveric donors : Brain dead donors or non heart beating : Brain dead donors : • Need peri op hemodynamic stabilization • Metabolic and electrolyte disturbances Intra op goals ( rule of 100 ): • Systolic BP >100 mm hg • Pao2 > 100mm hg • Urine output > 100ml /hr • Hemoglobin > 10 gm/dl • CVP between 5 -10 mm Hg

  21. Muscle relaxation needed • Analgesia not required • Volatile and opioids needed for hemodynamic stability Non heart beating donors : Long warm ischemia time

  22. Pre – operative assessment and optimization • CVS : • Control hypertension • Accelerated CAD - dyslipidemia , hypertension , Calcium & phosphate metabolism • volume overload - dialysis

  23. Hematological assessment : • Chronic anemia • Maintain hematocrit close to 25% • Erythropoietin supplementation Uremic coagulopathy : • deficient factor VIII , VWf and abnormal platelet function • Dialysis ,conjugated estrogen, desmopressin, cryoprecipitate , FFP

  24. Fluid and electrolytes : • Hyperkalemia – K >5.5 need treatment • Dialysis or pharmacological intervention • Calcium phosphate product > 60 - calcification in vessel • Hypermagnesemia - enhance muscle relaxants

  25. Pulmonary status : • Hypoalbuminemia or volume overload– risk of pulmonary edema • Pleural effusion • Dialysis , albumin supplementation

  26. DM • Stiff joint syndrome • Autonomic neuropathy • Silent MI • Peripheral neuropathy • Electrolyte imbalance • Diffuse atherosclerosis • Ensure blood sugar control

  27. Autonomic neuropathy: • Risk of haemodynamic fluctuation • Risk of gastric aspiration • Reduced heart rate variability >15 / min is normal

  28. Examination : • Site of AV fistula • Previous cannulation • Ascites

  29. Immunological assessment : • ABO compatibility • HLA matching • Crossmatching negative • PRA( panel reactive antibody) levels ideally less than10%

  30. Preoperative investigation • Hemoglobin , platelets ,KFT ,LFT, CXR ,ECG, echo ,MCU, viral markers ,immunological testing • Pre op dialysis - a day prior to surgery • Patients native urine output • Post dialysis inv : serum electrolytes ,urea, ECG , CXR , pt weight (<2kg difference)

  31. Premedication : • Aspiration prophylaxis – delayed gastric emptying • Dose reduction of H2 antagonists • Continue antihypertensives • Anxiolysis - midazolam (water solubility )

  32. Monitoring : Standard ASA monitoring -> • 5 lead ECG • Pulse oximeter • eTCO2 • Temp • NIBP ( non fistula arm ) • CVP ( PAC – sig LV dysfunction ) • NMT

  33. IV inducing agent : • Thiopentone - ↑free fraction needs reduced dosing, slow rate of administration • Etomidate – minimal cardiodepressant effect • Ketamine - hypertensive effect ; avoid • Propofol - titrated doses

  34. Inhalational agents : • Enflurane , methoxyflurane – flouride toxicity • Desflurane , sevoflurane – safe • Halothane – reduces RBF , cardiac depressant effect • Isoflurane – preserves RBF , mild cardiodepressive effect , low renal toxicity Anesthetic agent of choice

  35. opioids • Morphine , meperidine – metabolites renally excreted • Fentanyl • Sufentanil • Alfentanil • Remifentanil • Doses reduced by 30-50%

  36. Muscle relaxants : • Atracurium and cisatracurium - organ independent elimination • Rapid sequence induction – • Succinylcholine - K < 5.5 meq/L • Rocuronium – 1.5mg/kg , hepatobiliary elimination • Vecuronium – metabolite accumulation

  37. Induction : • Maintain asepsis • Supine position , fistula care • Preoxygenation • Rapid sequence intubation – diabetics • IV agents - thiopentone most popular

  38. Intraoperative management : • Adequate intravascular volume - improves graft function • Maintain CVP – 10 -15 mm hg Mannitol - 0.5-1 g/kg • Increases renal cortical blood flow and intravascular volume , free radical scavenger , increases release of prostaglandins

  39. Dopamine and Dopexamine • Low dose Dopamine has been proved neither a reduction in acute renal failure nor an improvement in renal function in patient with renal failure • It also did not demonstrate improved renal protection when used in cadaveric renal transplantation. • Dopexaminehas been shown some renal protection during aortic surgery but its potential benefit during renal transplant has not been evaluated.

  40. Furosemide - counteracts action of stress induced ADH release , inhibits Na –K ATPase to decrease O2 consumption , converts oliguric to non oliguric • Calcium channel blockers – verapamil injection in renal artery .Preserves RBF , reduces effects of cold ischemia

  41. Fluids in renal transplant : • Avoid potassium containing fluids in stage 5 CKD • Medium / low molecular weight HES can be used • Albumin can be used

  42. Factors improving urine output • Adequate volume status • Maintain blood pressure • Avoid renal vasoconstriction • Prevent tubular obstruction • diuretics

  43. Intraoperative complications : Extra caution : • Intubation – avoid hypertension and tachycardia • Anastomosis - avoid hypotension, hypovolemia and hyperkalemia • Extubation - NMB fully reversed , awake patient

  44. Postoperative period : • Monitor urine output • Post op analgesia – intermittent boluses of fentanyl /morphine or PCA • Potassium levels , urea and creatinine levels measure daily • Maintain adequate hydration

  45. Anaesthetic techniques for renal transplant : TIVA – propofol with fentanyl /alfentanyl/ remifentanil /atracurium Neuraxial blocks – epidural / CSE • Advantages – avoids intubation , opioids and relaxants ,good post op analgesia • Disadvantages : uremic coagulopathy,peripheralneuropathy,hypotension ,duration of surgery

  46. Local anaesthetics – • Faster onset and offset • Dose reduction by 25% to avoid CVS and CNS effects

  47. Ischemia time • Warm ischemia time – from clamping of donor vessels to cold perfusion and placement to anastomosis in recipient • Duration affects acute tubular necrosis • < 30 min • Cold ischemia time : storage in preservation solution to implantation in recipient • Ideally < 24 hrs upto 72 hrs

  48. Kidney preservation : • Mediators of ischemic injury : • ATP depletion ->loss of Na K ATPase pump • Movement of ions along conc gradient -> edema and cell swelling • Ischemia -> anaerobic metabolism causing acidosis -> lysosomal disruption • Free radical production

  49. Preservative solutions : • Euro Collins solution • University of Wisconsin solution • Bretscheider HTK solution Compositon : • Rich in potassium ,low Na ,free radical scavengers and other ions • Static or perfused storage

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