Anaesthesia for renal transplant surgery - PowerPoint Presentation

1. Anaesthesia for renal transplant surgery Dr M Sabra

2. ESRD is defined as irreversible decline in kidney function, which is severe enough to be fatal in the absence of dialysis or transplantation. ESRD is included under stage 5 of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative classification of chronic kidney disease (CKD), where it refers to individuals with an estimated glomerular filtration rate less than 15 mL per minute per 1.73 m2 body surface area, or those requiring dialysis irrespective of glomerular filtration rate End-stage renal disease (ESRD)

3. Stages of Chronic Renal Failure based on GFR STAGES GFR (ml/min/1.73m2 of a body surface area) STAGE-1 > 90 STAGE-2 60-89 STAGE-3 30-59 STAGE-4 15-29 STAGE-5 < 15 (ESRD)

4. DM HypertensionCoronary artery diseasesCongestive heart failure GlomerulonephritisPyelonephritisPolycystic kidneyOthers : tubulointerstitial diseases and -other familial and congenital diseases Causes of ESRD :

5. Dialysis Hemodialysis Peritoneal dialysis OR TransplantationTreatment options for ESRD :

6. Diffusion of solutes across a semipermeable membrane down conc gradientHemodialysis - shunt / fistulaPeritoneal dialysis Dialysis

7. Hyperkalemia unresponsive to conservative meansRefractory acidosisVolume overloadUremic pericarditisUremic neuropathyIndications :

8. Hemodialysis :Arteriovenous fistula - long termArteriovenous shunt - short termTemporary venous catheters – short termAccess for dialysis

9. Predominant technique Done three times a week Duration 2.5 - 5 hrsHemodialysis

10. Needs 4 weeks to mature Complications :Thrombosis InfectionHaemorrage StealPrecautions-Padding of fistulaAvoid BP cuffNo samplingAvoid hypotensionCare of fistula :

11. Peritoneum as endogenous dialysis membraneCAPD /CCPDAccess via silastic catheterPeritonial dialysis :

12. advantagesdisadvantagesHemodialysis – short time , better small solute removalNeed heparin ,vascular access , hypotension , poor BP controlPeritonial : steady state , higher hematocrit, better BP control , large solute removal , source of nutritionPeritonitis , hernia back pain , obesityHemodialysis vs peritonial dialysis

13. Acute :HypovolemiaElectrolyte imbalanceDisequilibrium syndromeChronic :Dialysis dementiaHypoproteinemiainfectionsComplications :

14. Better quality of life Better 5 yr survival rates 70% vs 30%Improves anaemia , peripheral neuropathy , autonomic neuropathy and cardiomyopathyDialysis negatively affects success of transplantationTransplant Vs dialysis

15. Patients with ESRD with expected 5 yr survivalCriteria for transplant :

16. 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 failureContraindications for renal transplant

17. Treated malignancyChronic liver diseaseHistory of substance abuseStructural genitourinary tract anomalyPast psychosocial abnormalityRelative contraindications :

18. LIVE or CADAVERLive -> related or unrelated Ideal donor Age = 18 - 60yrs Compatible blood groupNo DM or HTNPsychologically motivatedViral markers ( - )Donors for kidney transplant :

19. Fully informed of risk and benefitsAware of alternative methodsWilling to donatePsychosocially capableUnrelated donors –Need permission from authorization committee Pre op consent

20. Hemogram ,KFT , LFTCT angiography and urographyPsychiatry , dental ,opthalmologic and cardiac evaluationCMV antibodiesTumors scan and global GFRImmunological testingInvestigations

21. Good physical health ASA 1or 2Open / laparoscopicFlank position – risk of hypotension Maintain good hydration and diuresisMannitol before cross clamping Avoid direct acting vasopressorsPost op pain – iv opioids , no NSAIDS Anaesthetic concerns for living donors

22. Brain dead donors or non heart beating :Brain dead donors :Need peri op hemodynamic stabilizationMetabolic and electrolyte disturbances Intra op goals ( rule of 100 ):Systolic BP >100 mm hgPao2 > 100mm hgUrine output > 100ml /hr Hemoglobin > 10 gm/dlCVP between 5 -10 mm HgAnaesthetic concerns for cadaveric donors :

23. Muscle relaxation neededAnalgesia ????? requiredVolatile and opioids needed for hemodynamic stability

24. Important pre-operative considerations prior to renal transplant.Cardiovascular disease Ischaemic heart disease Congestive cardiac failure HypertensionDiabetes mellitusAnaemiaHyperparathyroidism and elevated calcium and phosphateDyslipidaemiasInfections Hepatitis B Hepatitis CNewer cardiovascular risk factors C-reactive protein HomocysteineDuration of end-stage renal diseaseCentre effect

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

26. Chronic anemia : Maintain hematocrit close to 25% Erythropoietin supplementationUremic coagulopathy : deficient factor VIII , VWf and abnormal platelet function Dialysis , desmopressin, cryoprecipitate , FFPHematological assessment :

27. Hyperkalemia – K >5.5 need treatment Dialysis or pharmacological interventionCalcium phosphate product - calcification in vessel Hypermagnesemia - enhance muscle relaxantsFluid and electrolytes :

28. Hypoalbuminemia or volume overload– risk of pulmonary edemaPleural effusionDialysis , albumin supplementation Pulmonary status :

29. 29DMStiff joint syndromeAutonomic neuropathySilent MIPeripheral neuropathyElectrolyte imbalanceDiffuse atherosclerosisEnsure blood sugar control

30. Risk of haemodynamic fluctuation Risk of gastric aspirationReduced heart rate variability >15 / min is normalAutonomic neuropathy:

31. Site of AV fistula Previous cannulationAscitesExamination :

32. ABO compatibilityHLA matchingCrossmatching negative PRA( panel reactive antibody) levels ideally less than10%Immunological assessment :

33. Hemoglobin , platelets ,KFT ,LFT, CXR ,ECG, echo , viral markers ,immunological testingPre op dialysis - a day prior to surgeryPatients native urine outputPost dialysis inv : serum electrolytes ,urea, ECG , CXR , pt weight (<2kg difference) Preoperative investigation

34. Aspiration prophylaxis – delayed gastric emptyingDose reduction of H2 antagonistsContinue antihypertensivesAnxiolysis - midazolam (water solubility )Premedication :

35. Standard ASA monitoring -> 5 lead ECG Pulse oximetereTCO2TempNIBP ( non fistula arm )CVP ( PAC – sig LV dysfunction )NMTMonitoring :

36. Safety profile of drugs for anaesthesia

37. Thiopentone - ↑free fraction needs reduced dosing, slow rate of administrationEtomidate – minimal cardiodepressant effectKetamine - hypertensive effect ; avoidPropofol - titrated dosesIV inducing agent :

38. Enflurane , methoxyflurane – flouride toxicityDesflurane , sevoflurane – safeHalothane – reduces RBF , cardiac depressant effectIsoflurane – preserves RBF , mild cardiodepressive effect , low renal toxicity Anesthetic agent of choiceInhalational agents :

39. Morphine , meperidine – metabolites renally excretedFentanylSufentanilAlfentanilRemifentanilDoses reduced by 30-50% opioids

40. Atracurium and cisatracurium - organ independent eliminationRapid sequence induction – Succinylcholine - K < 5.5 meq/LRocuronium – 1.5mg/kg , hepatobiliary eliminationVecuronium – metabolite accumulation Muscle relaxants :

41. Maintain asepsisSupine position , fistula carePreoxygenationRapid sequence intubation – diabeticsIV agents - thiopentone most popularInduction :

42. Adequate intravascular volume - improves graft functionMaintain CVP – 10 -15 mm hgMannitol - 0.5-1 g/kgIncreases renal cortical blood flow and intravascular volume , free radical scavenger , increases release of prostaglandinsIntraoperative management :

43. 43Dopamine and DopexamineLow dose Dopamine has been proved neither a reduction in acute renal failure nor an improvement in renal function in patient with renal failureIt also did not demonstrate improved renal protection when used in cadaveric renal transplantation.Dopexamine has been shown some renal protection during aortic surgery but its potential benefit during renal transplant has not been evaluated.

44. 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

45. Avoid potassium containing fluids in stage 5 CKDMedium / low molecular weight HES can be used Albumin can be used Fluids in renal transplant :

46. Adequate volume statusMaintain blood pressureAvoid renal vasoconstrictionPrevent tubular obstructiondiureticsFactors improving urine output

47. Extra caution :Intubation – avoid hypertension and tachycardiaAnastomosis - avoid hypotension, hypovolemia and hyperkalemia Extubation - NMB fully reversed , awake patient Intraoperative complications :

48. Monitor urine output Post op analgesia – intermittent boluses of fentanyl /morphine or PCAPotassium levels , urea and creatinine levels measure dailyMaintain adequate hydrationPostoperative period :

49. TIVA – propofol with fentanyl /alfentanyl/ remifentanil /atracuriumNeuraxial blocks – epidural / CSEAdvantages – avoids intubation , opioids and relaxants ,good post op analgesiaDisadvantages : uremic coagulopathy,peripheral neuropathy,hypotension ,duration of surgeryAnaesthetic techniques for renal transplant :

50. Local anaesthetics – Faster onset and offsetDose reduction by 25% to avoid CVS and CNS effects

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

52. Mediators of ischemic injury :ATP depletion ->loss of Na K ATPase pumpMovement of ions along conc gradient -> edema and cell swelling Ischemia -> anaerobic metabolism causing acidosis -> lysosomal disruptionFree radical productionKidney preservation :

53. Euro Collins solutionUniversity of Wisconsin solution Bretscheider HTK solution Compositon :Rich in potassium ,low Na ,free radical scavengers and other ionsStatic or perfused storage Preservative solutions :

54. University of wisconsin soltionCollins HTK custodialModified HESPotassium phosphateMagnesium sulphateAdenosineAllopurinolglutathionePotassium phosphatePotassium chlorideSodium bicarbonateGlucoseMagnesium sulphateHistidineTryptophanLow potassiumKetoglutrateCalciumMagnesiummannitol

55. Local anaesthetics – Faster onset and offsetDose reduction by 25% to avoid CVS and CNS effects

56. agenteffecttoxicitysteroids↓ interleukin productionHyperglycemia myopathy osteoporosis hypertensionazathioprineInhibits DNA synthesisAnaemia thrombocytopeniacyclosporineInhibits T cellsHyperkalemia hypertension nephrotoxicity hepatotocicityTacrolimus Inhibits IL 2 production Nephrotoxicity hyperkalemia hypertension,seizuresOKT 3Inactivates T cellCytokine release syndromneImmunosupressants

57. Induction therapy –iv tacrolimus ,MMF and methylprednisolone (2 days prior to surgery )Maintainance therapy – same drugs on post op day 0All three drugs continued through out lifeImmunosupressents in renal transplant

58. Criteria compliance with HARRT CD4 count > 200 undetectable viral load no systemic manifestation of disease/infectionHIV positive recepient

59. Thank you