ANAESTHESIA FOR RENAL TRANSPLANTATION

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ANAESTHESIA FOR RENAL TRANSPLANTATION

• Dr.M.Kannan MD DA
• Professor and HOD of Anaesthesiology
• Tirunelveli Medical College

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Demand-supply imbalance
3000
300 per million
1800 per year in Tamilnadu
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Associated co-morbid conditions

• Coronary artery disease
• Congestive cardiac failure
• Systemic Hypertension
• Diabetes Mellitus

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Associated co-morbid conditions

• Coronary artery disease
• Incidence 17-34
• Coronary angiography re-vascularisation
• Irreversible LV dysfunction with very low cardiac
  output

contraindication
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Associated co-morbid conditions

• Congestive cardiac failure
• CCF is present before dialysis
• CCF Associated with CRF
• IHD Hypoalbuminemia
• Old age Uremic cardiomyopathy
• Diabetes
• Anaemia AV-fistula

Independent prognostic Motality
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Associated co-morbid conditions

• Systemic Hypertension
• 70 of ESRD patients
• ACE-inhibitors
• Calcium channel blockers
• Beta-blockers
• Diuretics

Discontinued before surgery serum.K level
monitored
Continued peri-operatively
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LaryngoscopyIntubation

• Exaggerated stress response
• Opioids
• beta-blockers
• IV Lignocaine

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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.

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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
Hyperkalemia Acidosis Treatment-Dialysis Delays
recovery -Anaesthesia
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Pre-operative dialysis

• Optimize fluid and electrolyte balance
• Correct hemostatic abnormalities
• Post dialysis weight loss of gt2 kg
• -Indicate intra-vascular volume depletion
• -Thromboplastin time is checked for
  residual heparin
• -Hepatitis can be endemic

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Pre-operative optimazisation

• Adequate BP control
• Adequate control of blood glucose
• Correction of se.K levels.
• Correction of anaemia
• Correction of coagulopathy

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Anaesthetic Agents

• Thiopental
• Propofol
• Isoflurane
• -peripheral vaso-dilatation
• -minimal cardio-depressive effects
  -preservation of RBF
• -low renal toxicity
• Desflurane

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Sevoflurane

• Fluoride
• CompoundA
• Fresh gas flow rates gt4 L/min

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Opioids

• Morphine
• Pethedine
• Fentanyl, sufentanil, alfentanil, remifentanyl

• Reduced clearance
• Accumulation of active metabolites
• Safer
• Metabolites are not potent,

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Muscle Relaxant

• -Succinyl choline ? -not contra-indicated in
• pts. with ESRD

0.6 m eq/l can be tolerated without significant
cardiac risk
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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
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Monitors

• 5-lead ECG.
• Arterial BP
• SpO2
• EtCo2
• Temperature .
• Urine output

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Special Monitors
Hypotension Hypovolemia or Myocardial
contractility.
Sonicated albumin Predict renal viability
Guide pharmacological interventions.

• gt20/15
• Poorly controlled hypertension
• 2. CAD with LV dysfunction
• 3 .Valvular heart disease
• 4.COPD when severe.

• 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
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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.

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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

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Management of the Brain dead Kidney donor

• Selection -Stable hemodynamics
• Adequate respiratory
  parameters
• Absolute contra-indications
• Prolonged hypotension Hypothermia
• Collagen vascular diseases
• Congenital or acquired metabolic disorders
• Malignancies, Generalized viral or
  bacterial infections
• DIC Hep B, HIV.

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Relative contra-indications

• Age above 70 years
• Diabetes mellitus
• High serum creatinine before organ harvesting
• Excessive pre-terminal use of vaso-pressors.

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Guidelines for intra-op management of the brain
dead

• A systolic BP gt100 mm Hg
• PaO2 gt100 mm Hg
• Urine output gt100 ml/hr
• Hemoglobin concentration gt100 g/l
• Central venous pressure between 5 and 10 mm Hg

The rule of 100 is followed
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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.

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Anaesthetic management of kidney recipients

• General Anaesthesia with controlled ventilation
• -Good hemodynamic stability
• -Better patient comfort.
• Regional Anaesthesia
• Dis-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

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Anaesthetic considerations in the recipient

• Positioning Care of the AV Fistula