Anesthesia for Kidney Transplant Surgery B 88401074 1
Anesthesia for Kidney Transplant Surgery 台大 B 88401074 戴逸承 中山醫學大學 陳信良 1
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 2
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 herbmedicine 3
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 4
Past History ¨ Allergy: NKA ¨ Smoking (-) ¨ Drinking (-) ¨ DM denied ¨ HTN denied ¨ Other systemic diseases denied 5
CKD Complications for Anesthesiology 6
CDK Complications I ¨ Anemia ¨ Platelet dysfunction ¨ Altered O 2 -carrying capacity ¨ Cardiovascular abnormalities ¨ Hypertension ¨ Peripheral neuropathy ¨ CNS dysfunction ¨ Electrolyte and fluid disturbances 7
CDK Complications II ¨ Acid-base abnormalities ¨ GI abnormalities ¨ Endocrine disturbances ¨ Dialysis-related problems 8
Pre-OP Evaluation ¨ BP ¨ CV diseases – CHF – CAD ¨ DM management ¨ Serum electrolytes – Especially potassium ¨ Degree of anemia ¨ Coagulation status 9
Lab data I ¨ BP 126/74 (mean) ¨ AC blood sugar 82; Hb. A 1 c ? ¨ CBC – HB 6. 2 g/d. L – HCT 20. 2 % – MCV 89. 4 f. L – 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 % 10
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/d. L – CRE 9. 1 mg/d. L – ALP 222 U/L – UA 7. 5 mg/d. L – Alb 4. 3 g/d. L 11
CXR ¨ Cardiomegaly ¨ No pleural effusion 12
ECG ¨ LVH by voltage 13
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 14
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 15
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 16
DM ¨ Stiff joint syndrome ¨ Autonomic neuropathy – Hypotension – Bradycardia – Labile blood pressure – gastroparesis ¨ Silent MI ¨ Peripheral neuropathy ¨ Electrolyte imbalance 17
DM ¨ Diffuse atherosclerosis ¨ Hyperglycemia – hyperkalemia ¨ Hypoglycemia ¨ ketoacidosis 18
Uremic Coagulopathy ¨ Abnormal platelet function – Ineffective production of • factor VIII • Von 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 19
Others ¨ Hyperkalemia ¨ Anemia – Right shift of oxyhemoglobin dissociation 20
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 21
Premedication II ¨ Preoperative dialysis causes volume depletion, large decrease of BP occurs after – Histamine releasing drugs • Morphine (alfentanil recommended) • Atracurium – Alpha-blockers • Droperidol • labetalol 22
Premedication III ¨ Preoperative opioid prolongs GI emptying – Cisapride – Antacid – Metoclopramide 23
Intra-OP Condition I Na K Cl CO 2 Ca Mg Glu Lac 141 4 10 33. 2 0. 9 9 105 6. 6 Hb Hct p. H p. O 2 HCO 3 BE 10. 6 32 7. 506 440 26. 4 Sa. O 2 +4. 1 100 24
Intra-OP Condition II 25
Operation Procedure 26
Pharmacokinetic& Pharmacodynamics 27
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 28
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 29
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 30
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. 5 m. Eq /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 31
Other Nondepolarizing muscle relaxant ¨ Atracurium and Cisatracurium are common used because their metabolism is by Hoffman elimination, an organindependent 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 32
Reversal agents ¨ Anticholinesterase drugs(eg neostigmine, prostigmine) ¨ The half-time is prolonged in p’t with uremia and hard to match the nondepolarizing muscle relaxants 33
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 b. Liberal use of albumin c. Loop diuretics d. Mannitol e. Ca channel blocker f. Dopamine and Dopexamine 34
Intravascular Volume ¨ The most important intraoperative measurement to ensure satisfactory perfusion of transplanted kidney ¨ To keep 1. CVP in 10 -15 mm. Hg 2. blood volume>70 m. L/kg plasma volume>45 m. L/kg 3. PAP>20/diastolic PAP>15 mm. Hg 35
Albumin Loop Diuretics ¨ Volume expansion ¨ Inhibition of the Na-K and presumably binding toxic agents ¨ Dosage : 0. 8 g/kg->improve outcome advocated the use of 1. 21. 6 g/kg ATPase pump and may result in resistance against ischemic injury 36
Mannitol 1. 2. 3. 4. 5. Protection against renal cortical and increasing tubular flow Diminishing potential for tubular obstruction Acting as a radical scavenger Risk for heart failure or pulmonary edema CCB 1. 2. Restore and maintain renal blood flow and minimized renal injury Ex: Verapamil Low dose: 0. 25 -0. 5 mg/kg 37
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. 38
Intraoperative complication ¨ Cardiovascular complications ¨ Intraoperative hemodynamics ¨ Potassium and Glucose levels 39
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 40
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 41
Potassium and Glucose levels ¨ ESRD can cause hyperkalemia by itself ¨ ACEI and ß-blocker also increase the risk of hyperkalemia ¨ Tx: 1. 50 m. L of 50% glucose +12 U insulin IV and 50 m. Eq of sodium bicarbonate 2. Hyperventilation: reduce serum K between 0. 3 -0. 6 m. Eq/L for every 10 mm. Hg reduction in Pa. O 2 3. Ca. Cl 2, direct antagonist of the effect of K on the heart 42
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 43
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