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1 Anesthesia for Kidney Transplant Surgery 台大 B88401074 戴逸承 中山醫學大學 陳信良.

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Presentation on theme: "1 Anesthesia for Kidney Transplant Surgery 台大 B88401074 戴逸承 中山醫學大學 陳信良."— Presentation transcript:

1 1 Anesthesia for Kidney Transplant Surgery 台大 B88401074 戴逸承 中山醫學大學 陳信良

2 2 History I  Name :張陳○○  Age : 49  Gender : Female  Height : 146.6 cm  Weight : 38.8 kg  Chart number : 2806138  Evaluation of living-related kidney transplantation

3 3 History II  Dyspnea and decreased urine output noted 4 years ago  No limb edema, skin dysaesthesia, or consciousness disturbance  Atrophic kidney revealed by abdomen ultrasound at 西園醫院 where she had been regularly follow-up for CKD  By when she started to take herb- medicine

4 4 History III  Progressing dyspnea and continuously BUN/Cre elevating since last month when she started dialysis  To 蔡孟昆 ’s OPD for opinion of kidney transplantation last month  Her son was the donor

5 5 Past History  Allergy:NKA  Smoking (-)  Drinking (-)  DM denied  HTN denied  Other systemic diseases denied

6 6 CKD Complications for Anesthesiology

7 7 CDK Complications I  Anemia  Platelet dysfunction  Altered O 2 -carrying capacity  Cardiovascular abnormalities  Hypertension  Peripheral neuropathy  CNS dysfunction  Electrolyte and fluid disturbances

8 8 CDK Complications II  Acid-base abnormalities  GI abnormalities  Endocrine disturbances  Dialysis-related problems

9 9 Pre-OP Evaluation  BP  CV diseases –CHF –CAD  DM management  Serum electrolytes –Especially potassium  Degree of anemia  Coagulation status

10 10 Lab data I  BP 126/74 (mean)  AC blood sugar 82; HbA1c ?  CBC –HB 6.2 g/dL –HCT 20.2 % –MCV 89.4 fL –PLT 222.0 K/μL –WBC 5.29 K/μL Seg 61.6 %, Eos. 3.0 %, Baso. 0.4 %, Mono. 8.9 %, Lym. 26.1 %Seg 61.6 %, Eos. 3.0 %, Baso. 0.4 %, Mono. 8.9 %, Lym. 26.1 %

11 11 Lab data II  Electrolytes –Na 138 mmol/L –K 4.5 mmol/L –Cl 99 mmol/L –Ca 2.27 mmol/L  Biochemstry –UN 53.0 mg/dL –CRE 9.1 mg/dL –ALP 222 U/L –UA 7.5 mg/dL –Alb 4.3 g/dL

12 12 CXR  Cardiomegaly  No pleural effusion

13 13 ECG  LVH by voltage

14 14 Coronary Artery Disease  Uremic cardiomyopathy is reversible –Unless ventricular dysfunction with low C.O.  Asymptomatic patient with DM may have a silent CAD  Thallium test sensitivity decreased –Increased adenosine enhances vasodilator effect of dipyridamole  Dobutamine stress ECG is recommended

15 15 Congestive Heart Failure  CHF in 50% of p’ts on chronic dialysis  Ultrasound best for screening  3 major causes –Uremic cardiomyopathy –Anemia –A-V fistula  Intraoperative hemodynamics not significantly different

16 16 Hypertension  Interruption of anti-HTN drugs will cause perioperative rebound hypertension, tachycardia, or MI. –CCB, beta blocker, diuretics, clonidine  Uninterruption of ACEI –Severe hypotension after induction –Life-threating hyperkalemia

17 17 DM  Stiff joint syndrome  Autonomic neuropathy –Hypotension –Bradycardia –Labile blood pressure –gastroparesis  Silent MI  Peripheral neuropathy  Electrolyte imbalance

18 18 DM  Diffuse atherosclerosis  Hyperglycemia –hyperkalemia  Hypoglycemia  ketoacidosis

19 19 Uremic Coagulopathy  Abnormal platelet function –Ineffective production of factor VIIIfactor VIII Von Willebrand factorVon Willebrand factor –Preoperative dialysis improve platelet function  Wound hematoma progress to infection  Conjugated estrogen –Effective then FFP, cryo  Desmopressin –Increases factor VIII and Von Willebrand factor

20 20 Others  Hyperkalemia  Anemia –Right shift of oxyhemoglobin dissociation

21 21 Premedication I  albumin↓ ↓, globulin ↓, protein-bound drugs need lower dose –Diazepam (albumin) –Non-depolarizing muscle relaxant (globulin)  ECF↑, water-soluble drug need larger dose –Midazolam

22 22 Premedication II  Preoperative dialysis causes volume depletion, large decrease of BP occurs after –Histamine releasing drugs Morphine (alfentanil recommended)Morphine (alfentanil recommended) AtracuriumAtracurium –Alpha-blockers DroperidolDroperidol labetalollabetalol

23 23 Premedication III  Preoperative opioid prolongs GI emptying –Cisapride –Antacid –Metoclopramide

24 24 Intra-OP Condition I NaKClCO2CaMgGluLac 14141033.20.991056.6 HbHctpHpO2HCO3BESaO210.6327.50644026.4+4.1100

25 25 Intra-OP Condition II

26 26 Operation Procedure

27 27 Pharmacokinetic& Pharmacodynamics

28 28 Intravenous Induction Agent  Thiopental-a reduced dose is indicated because of reduced protein binding  Etomidate- minimal CV effect and not affected significant by renal impairment  Ketamine-little affected by renal disease, but undesireable for its hypertensive effect  Propofol-transient hemodynamic change but is safely as a induction agent for uremia p’t

29 29 Inhalation agent  ESRD have no significant effect on clinical dosing  Isoflurance has been considered the choice of inhalation agent for renal transplantation (Desflurane)  The safety of Sevoflurance in p’t with impaired renal function is still controversial

30 30 Opoids  Older-generation opoids( such as morphine, oxycodone and meperidine ) should be avoided because of drceased clearance in ESRD p’t  Fentanyl, Sufentanil, Alfentanil and Remifentanil are safe alternatives

31 31 Muscle relaxants in rapid intubation  Succinylcholine is not contraindicated in p’t with ESRD and it can be used in p’t with serum potassium <5.5mEq /L  Two non-depolarizing muscle relaxant – Rocuronium and Rapacuronium are alternatives to SCC for their rapid onset and less metabolic influence by impaired renal function

32 32 Other Nondepolarizing muscle relaxant  Atracurium and Cisatracurium are common used because their metabolism is by Hoffman elimination, an organ- independent pathway.  Vecuronium has a rapid hepatic metabolism and can be also used in p’t with ESRD  The long-acting muscle relaxant- Pancuronium is predominant renal elimination and not suitable for ESRD p’t

33 33 Reversal agents  Anticholinesterase drugs(eg neostigmine, prostigmine)  The half-time is prolonged in p’t with uremia and hard to match the non- depolarizing muscle relaxants

34 34 Anesthetic management of kidney recipient  Early onset of urine output(90% of living donor kidney transplants ; 40-70% of cadaveric transplants) is most important and as a prognosis factor of renal transplantation  Several methods are used to stimulate urine production a. Intravascular volume expansion a. Intravascular volume expansion b. Liberal use of albumin b. Liberal use of albumin c. Loop diuretics c. Loop diuretics d. Mannitol d. Mannitol e. Ca channel blocker e. Ca channel blocker f. Dopamine and Dopexamine f. Dopamine and Dopexamine

35 35 Intravascular Volume  The most important intraoperative measurement to ensure satisfactory perfusion of transplanted kidney  To keep 1.CVP in10-15mmHg 2.blood volume>70mL/kg 2.blood volume>70mL/kg plasma volume>45mL/kg plasma volume>45mL/kg 3.PAP>20/diastolic 3.PAP>20/diastolic PAP>15 mmHg PAP>15 mmHg

36 36 Albumin Loop Diuretics  Volume expansion and presumably binding toxic agents  Dosage : 0.8g/kg->improve outcome 0.8g/kg->improve outcome advocated the use of 1.2- 1.6g/kg advocated the use of 1.2- 1.6g/kg Inhibition of the Na-K ATPase pump and may result in resistance against ischemic injury 

37 37 MannitolCCB 1. Protection against renal cortical and increasing tubular flow 2. Diminishing potential for tubular obstruction 3. Acting as a radical scavenger 4. Risk for heart failure or pulmonary edema 5. Low dose:0.25-0.5mg/kg 1. Restore and maintain renal blood flow and minimized renal injury 2. Ex:Verapamil

38 38 Dopamine and Doxamine  Low dose Dopamine has been proved neither a reduction in acute renal failure nor an improvement in renal function in p’t with renal failure  It also did not demonstrate improved renal protection when used in cadaveric renal transplantation.  Doxamine has been shown some renal protection during aortic surgery but its potential benefit during renal transplant has not been evaluated.

39 39 Intraoperative complication  Cardiovascular complications  Intraoperative hemodynamics  Potassium and Glucose levels

40 40 Cardiovascular complication  Many p’t undergoing renal transplant are in poor general health, especially with diabetes and CV complications  CAD, CHF, Dysrhythmia and HTN  AMI may occur when intraoperative fluid loading increase LVEDP excessively

41 41 Intraoperative hemodynamics  HTN 1.Because of hypervolemia and augmented sympathoadrenal discharge caused by ESRD 2.Tx:short-acting IV antihypertensive drug-the first drug choice is IV NTG  Hypotension 1.May predispose to delay or fail renal function, especially after revascularization of the graft 2.Tx:Maintaining adequate intravascular volume ; vasopressors should be used as a last resort

42 42 Potassium and Glucose levels  ESRD can cause hyperkalemia by itself  ACEI and ß-blocker also increase the risk of hyperkalemia  Tx: 1.50mL of 50% glucose +12U insulin IV 1.50mL of 50% glucose +12U insulin IV and 50mEq of sodium bicarbonate and 50mEq of sodium bicarbonate 2.Hyperventilation:reduce serum K between 2.Hyperventilation:reduce serum K between 0.3-0.6mEq/L for every 10mmHg reduction 0.3-0.6mEq/L for every 10mmHg reduction in PaO2 in PaO2 3.CaCl2, direct antagonist of the effect of K on 3.CaCl2, direct antagonist of the effect of K on the heart the heart

43 43 Postoperative Care  Closely monitor of the urine output  Re-exploration of wound should not be delayed, if kinking of vessel or obstruction of ureter are suspected

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