AnaesLhesla for 8enal

1ransplanLaLlon
ur Souvlk MalLra
C1 ueparLmenL of AnaesLheslology
lCML8 kolkaLa
W 1be fltst Jesctlptloo of ooestbeslo fot
klJoey ttoosploototloo oppeoteJ lo tbe
eotly 1960s betweeo lJeotlcol twlos
W 1be ooly mooltots oseJ tbeo wete o blooJ
ptessote coff ooJ electtocotJloqtom
(cC) ooJ tbe teclpleot tecelveJ splool
ooestbeslo
W lJoey ttoosploototloos ote tbe most
commooly petfotmeJ ttoosploototloos lo eocb
of tbtee mojot teqloos of tbe wotlJtbe
uolteJ 5totes otope ooJ Aslo
All paLlenLs sufferlng from LS8u (Cku v)
should undergo renal LransplanLaLlon unless
absoluLely conLralndlcaLed
-epbtol ulol 1toosploot 2000 15 5oppl 7 JJ8
Lt|o|ogy of LSkD |n kena| 1ransp|ant
rec|p|ent
1oLal cases()
W ulabeLec glomerulonephropaLhy 436
W CLher glomerulonephrlLls 232
W olycysLlc kldney dlsease 38
W Chronlc pyelonephrlLls 34
W CbsLrucLlve uropaLhy 34
W AlporL's syndrome 21
W Lupus nephrlLls 16
W Mlscellaneous lncludlng unknown 149
ConLralndlcaLlons
W so|ute
W DnconLrolled mallgnancy
W AcLlve Plv lnfecLlon
W Llfe expecLancy2yrs due Lo oLher lllness
ConLralndlcaLlons 8elaLlve
W Are over Lhe age of 70 years
W Pave an acLlve lnfecLlous process
W Pave clrrhosls chronlc llver dlsease or acLlve
hepaLlLls
W Are acLlve subsLance abusers
W Pave acLlve Luberculosls
W CCu and whose rlsk for anesLhesla ouLwelghs Lhe
poLenLlal beneflLs of LransplanLaLlon
W Severe dlffuse aLheroscleroLlc or CAu noL amenable
Lo surglcal repalr CA8C or 1CA
W LvLl of 20
W Any psychosoclal or behavloral abnormallLles
W 1hose who are morbldly obese (8Ml 33)
utcome
W kldney LransplanLaLlon ls Lhe mosL lmporLanL
cosLeffecLlve meLhods of LreaLlng LS8u
W Confers a 40 Lo 60 decrease ln Lhe deaLh raLe
compared wlLh paLlenLs remalnlng on dlalysls
W 1he overall grafL survlval raLe among cadaver
kldney LransplanL reclplenLs aL 3 years ls greaLer
Lhan 88 and lL ls approxlmaLely 93 ln
reclplenLs who recelve a kldney from a llvlng
donor
1ypes of donor
W Cadaverlc kldney donor
W Llvlng donor
DILkI kIDNL DN1IN
W kldneys are Lhe lasL organs Lo be recovered ln
mulLlple organ recovery
W AfLer Lhe Lhoraclc organs and llver have been
reLrleved lL ls advlsable LhaL Lhe kldney and
pancreas are recovered en bloc and separaLed
on Lhe back Lable
IIING kIDNL DN1IN
W Plgher success raLes
W An assessmenL of Lhe donor's renal funcLlon by a
nephrologlsL ls mandaLory ln all cases
W sychlaLrlc evaluaLlon of Lhe donor's moLlvaLlon
flLness and hls ablllLy Lo undersLand Lhe rlsks of
Lhe operaLlon
W A8C blood group PLA maLchlng ls Lhe lnlLlal
crlLerla for donor selecLlon
Lxc|us|on cr|ter|a for ||v|ng donors
so|ute contra|nd|cat|ons
ge 18 years
- Uncontro||ed hypertens|on
- D|aetes me|||tus
- rote|nur|a ( 300 mg]24 h)
- norma| GIk compared to
norma| range for age
- M|croscop|c haematur|a
- n|gh r|sk of thromoemo||sm
- Med|ca||y s|gn|f|cant |||ness
(chron|c |ung d|sease recent
ma||gnant tumour heart
d|sease)
- n|story of ||atera| k|dney
stones
- nII pos|t|ve
ke|at|ve contra|nd|cat|ons
W ct|ve chron|c |nfect|on
(eg tuercu|os|s hepat|t|s
8] paras|t|c)
W es|ty
W sych|atr|c d|sorders
Surg|ca| techn|ques |n ||v|ngdonor
nephrectomy
Classlc LransperlLoneal approach elLher Lhrough
a mldllne or Lhrough a lefL or rlghL subcosLal
lnclslon
- Sub/supracosLal exLraperlLoneal approach (lefL
or rlghL)
- uorsal lumbar approach ln whlch Lhe lnclslon
can be performed elLher underneaLh Lhe 12Lh
rlb resecLlng Lhe 12Lh rlb or above Lhe 12Lh rlb
(exLraperlLoneal exLra pleural)
- Laparoscoplc approach whlch can be elLher
LransperlLoneal or reLroperlLoneoscoplc
NLS1nLSI Ik IIING DNk
NLnkL1M
uonor ls noL golng Lo be beneflLed from
organ donaLlon so SIL1 ls Lhe prlme
concern Lo Lhe anaesLheslologlsL
reanaesthet|c Lva|uat|on
W lstoty
W lbyslcol exomlootloo
W lobotototy lovestlqotloos
omp|ete haemogram
I8S]8S
Urea]reat|n|ne
Serum e|ectro|ytes
I1
oagu|at|on prof||e
Ok
12|ead LG
2D Ln
Goa|s of naesthes|a
W SLable hemodynamlc
W Avoldance of hypoLenslon hypovolemla
W LllmlnaLlon of surglcal sLress response
W MalnLaln 88l
W MalnLaln urlne ouLpuL 2ml/kg/hr
W LxcellenL posLoperaLlve analgesla
W 8apld and compleLe recovery
Mon|tor|ng
W 8ouLlne ASA sLandard monlLors (nl8 3lead
LCC L1CC2 SpC2 1emperaLure)
W Cv monlLorlng (Dsed ln some cenLer)
W loley caLheLer for urlne ouL puL
remed|cat|on
W P2 blocker (ln[ 8anlLldlne 30 mg lv)
W ln[ Clonldlne (1mcg/kg) ln case of laparoscoplc
asslsLed nephrecLomy
W ln[ lenLanyl (2mcg/kg) ALLenuaLe
laryngscopy surge
W ln[ ClycopyrrolaLe
W lteopetotlve byJtotloo by 855 ovetolqbt
befote sotqety (Dsed ln some cenLer)
Induct|on
W Avoldance of hypoLenslon and laryngoscopy
sLress ellmlnaLlon ls uLmosL goal
W lv lnducLlon by LlLraLed dose of ropofol (2
3mg/kg) 1hlopenLone (43 mg/kg) LLomldaLe
(0203 mg/kg) can be used
W Muscle relaxaLlon achleved by elLher
Succlnylchollne (113mg/kg) or 8ocuronlum
(0912 mg/kg)
Ma|ntenance of naesthes|a
W LndoLracheal lnLubaLlon wlLh a cuffed L1 Lube
and conLrolled venLllaLlon Lo achleve a L1CC2 30
40mmPg ls Lechnlque of cholce
W AnaesLhesla ls malnLalned by C2Alr wlLh
lnhalaLlon anaesLhesLlc (lsoflurane) or ropofol
lnfuslon 100300 mcg/kg/mln
W Analgesla ls malnLalned by lncremenLal dose of
fenLanyl (03mcg/kg)
W Llberal fluld admlnlsLraLlon (1020ml/kg/hr)
W epotlo 100D/kg 3mln before renal arLery
clamplng
os|t|on
W Classlc kldney poslLlon le laLeral poslLlon wlLh
Lhe slde Lo be operaLed up and a bolsLer
below Lhe flank
Methods to augment k8I
W Avold hypoLenslon hypovolemla
W ALLenuaLe surglcal sLress response (8eglonal
supplemenLaLlon may be consldered)
W ln[ MannlLol 113gm/kg lnfuslon durlng hllum
dlssecLlon
W ln[ lurosemlde 2040 mg lv (10 mln before
renal arLery clamplng)
W uopamlne (033mcg/kg/mln) lnfuslon
W Llberal fluld admlnlsLraLlon by lsoLonlc 8SS
keversa|
W 8eversal of resldual nM8 done by
neosLlgmlne+ ClycopyrrolaLe
W LxLubaLlon done on C1 Lable when paLlenL
awake warm and calm and free from resldual
nM8
ostoperat|ve na|ges|a
W 1horaclc araverLebral block
W 1horaclc Lpldual Analgela
W lv CA by oplold
W nSAlus (keLorolca dlclofenac)
W lv CM (1gm 1uS)
kLSLkI1IN I nkILS1LD
kIDNL
W kldney from llvlng donor flushed wlLh
preservaLlve soluLlon or lced 8lngers lacLaLe
soluLlon conLalnlng heparln and mannlLol
W 1he co/d ishoemio time ln a llvlng donor
should be resLrlcLed Lo 2030 mlnuLes whlle
Lhe worm ischemio time should noL exceed 3
3 mlnuLes
8kIN DLD kGN DN1IN
W Most potent|a| deceased donors are prev|ous|y
hea|thy |nd|v|dua|s who have exper|enced
roin deoth and do not have an extracran|a|
ma||gnancy or untreata|e |nfect|on
W ess than S of deaths sat|sfy these cr|ter|a
and on|y 10 to 20 of these e||g||e suects
actua||y ecome organ donors
tblcol coofllcts sottoooJloq tbe
Jefloltloo of btolo Jeotb lo Jlffeteot
soclol ooJ coltotol settloqs bove beeo oo
obstocle lo ttoosploototloo
Def|n|t|on
W 8tolo Jeotb ls JefloeJ os tbe lttevetslble
loss of fooctloo of tbe btolo locloJloq tbe
btolostem
D|agnost|c cr|ter|a
W rerequ|s|tes 8raln deaLh ls Lhe absence of cllnlcal
braln funcLlon when Lhe proxlmaLe cause ls known
and demonsLrably lrreverslble
W 1 Cllnlcal or neurolmaglng evldence of an acuLe
CnS caLasLrophe LhaL ls compaLlble wlLh Lhe cllnlcal
dlagnosls of braln deaLh
W 2 Lxcluslon of compllcaLlng medlcal condlLlons LhaL
may confound cllnlcal assessmenL (no severe
elecLrolyLe acldbase or endocrlne dlsLurbance)
W 3 no drug lnLoxlcaLlon or polsonlng
W 4 Core LemperaLure 32 C (90l)
1be tbtee cotJlool floJloqs lo btolo Jeotb ote como
ot ootespooslveoess obseoce of btolostem
teflexes ooJ opoeo
W 8ra|nstem kef|exes 1hat Shou|d 8e sent |n
8ra|n Death
W uplllary response Lo llghL
W Corneal reflex
W Cculocephallc reflex (dolls eye response)
W CculovesLlbular reflex (calorlc response)
W Cag and cough reflex
W laclal moLor response
W Coma or unresponslvenessno cerebral moLor response Lo paln ln all
exLremlLles (nallbed pressure and supraorblLal pressure)
W 2 Absence of bralnsLem reflexes
W a) uplls
l no response Lo brlghL llghL
ll Slze mldposlLlon (4 mm) Lo dllaLed (9 mm)
W b) Ccular movemenL
l no oculocephallc reflex (LesLlng only when no fracLure or lnsLablllLy of Lhe
cervlcal splne ls apparenL)
ll no devlaLlon of Lhe eyes Lo lrrlgaLlon ln each ear wlLh 30 ml of cold waLer
(allow 1 mlnuLe afLer ln[ecLlon and aL leasL 3 mlnuLes beLween LesLlng on each
slde)
W c) laclal sensaLlon and faclal moLor response
W l no corneal reflex Lo Louch wlLh a LhroaL swab
W ll no [aw reflex
W lll no grlmaclng Lo deep pressure on nall bed supraorblLal rldge or
Lemporomandlbular [olnL
W d) haryngeal and Lracheal reflexes
W l no response afLer sLlmulaLlon of Lhe posLerlor pharynx wlLh Longue blade
W ll no cough response Lo bronchlal sucLlonlng
Intraoperat|ve Management Goa|s
W SysLollc blood pressure greaLer Lhan 100 mm Pg
(mean 70 Lo 110 mm Pg)
W C
2
greaLer Lhan 100 mm Pg
W Drlne ouLpuL greaLer Lhan 100 mL/hr (1 Lo
13 mL/kg/hr)
W Pemoglobln concenLraLlon greaLer Lhan 100 g/L
W CenLral venous pressure (Cv) 3 Lo 10 mm Pg
W llC
2
less Lhan 40 (lf LoleraLed) for lung reLrleval
W Clucose concenLraLlons less Lhan 200 mg/dL (or
even 130 mg/dL)
W AnesLheslologlsL should use sLandard
monlLors measure urlne ouLpuL and use
lnvaslve measuremenLs of arLerlal pressure
and Cv (frequenLly wlLh a pulmonary arLery
caLheLer)
WLongacLlng nuM8 should be used for opLlmal
lnLraabdomlnal and lnLraLhoraclc exposure
W8radycardla ln bralndead paLlenLs does noL
respond Lo aLroplne so a dlrecLacLlng
chronoLrope such as lsoptoteteool musL be
readlly avallable
WaLlenLs declared bralndead do noL have paln
percepLlon so analgesla ls noL requlred
WvolaLlle anesLheLlcs or narcoLlcs may faclllLaLe
hemodynamlc sLablllLy
W1he changes ln P8 and 8 LhaL may occur wlLh
surglcal sLlmulaLlon are Lhe resulL of lnLacL
splnal reflexes
WPemodynamlc changes can be easlly
conLrolled wlLh vasoacLlve agenLs
NLS1nLSI Ik kLN
1kNSN1
reoperat|ve ons|derat|ons
W C8C plaLeleL counL elecLrolyLes serum
glucose 8Dn serum creaLlnlne 1 a11 ln8
llver funcLlon LesLs urlnanalysls LCC chesL
radlograph and 2u Lchocardlogram
W ulabeLlc paLlenLs wlLh LS8u are evaluaLed for
Lhe presence of coronary arLery dlsease
W uSL may be consldered ln hlgh rlsk cases
Mon|tor|ng
W SLandard ASA monlLors
W Cv measuremenL
W A8 measuremenL ln very hlgh rlsk cases
Iistu/oiresentmustetokencoreo
remed|cat|on
W AnLlsecreLory agenL (acLlon unalLered ln Cku)
W P2 blocker (acLlon unalLered ln Cku)
W Mldazolam (no pharamacoklneLlc alLeraLlon
lncreased senslLlvlLy due Lo pharmacodynamlc
alLeraLlon)
W MeLoclopromlde (slgnlflcanL reducLlon ln
clearance and prolongaLlon of Lhe Lermlnal half
llfe)
Induct|on
W Low albumln levels lncrease ln free fracLlon
W Dremla alLered 888 lncrease Lhe levels
of unbound drug crosslng Lhe 888 lnLo CnS
W uose of loJoctloo oqeots moy oeeJ to be
oJjosteJ occotJloq to tbe volome stotos
oclJlc p ooJ locteoseJ seosltlvlty of tbe
oetvoos system to tbese Jtoqs
W 1h|opentone no change ln dlsLrlbuLlon or
ellmlnaLlon lncreased free drug due Lo
decrease albumln
W ropofo| hlgher dose ls requlred (due Lo
lncrease plasma volume)
W ketam|ne no change ln dlsLrlbuLlon or
ellmlnaLlon
W Ltom|date no change ln dlsLrlbuLlon or
ellmlnaLlon
W 8apld sequence lnducLlon whlle malnLalnlng
crlcold pressure ls meLhod of cholce 8lsk of
hypoLenslon
W aLlenLs wlLh hyperLenslon and CAu are aL hlgh
rlsk of large flucLuaLlons ln P8 and 8
W ShorL acLlng beLa adrenerglc blocker esmolol and
shorL acLlng oplolds llke fenLanyl remlfenLanll
have been effecLlve for blunLlng Lhe
hemodynamlc response Lo lnLubaLlon
Musc|e ke|axant
W Succlnylchollne can be safely used (lf k+ 3
mmol/l)
W Jbeo cboosloq o ooo Jepolotlzloq oqeot fot
moloteoooce lt ls bettet to ose ooes tbot ote
loJepeoJeot of teool cleotooce mecboolsms
(clsottocotlom ottocotlom mlvocotlom)
W clsottocotlom ls tbe -,8 of cbolce
Ma|ntenance of naesthes|a
W C2+Alr+lnhalaLlon anesLheLlc or propofol
lnfuslon ls Lhe cholce
W soflotooe or Jesflotooe ls Lhe cholce
W 1ranslenL lmpalrmenL of renal concenLraLlng
ablllLy and renal Lubular ln[ury ln paLlenLs
recelvlng sevoflurane and enflurane
W lenLanyl sufenLanll alfenLanll and remlfenLanll
are sulLable for lnLraoperaLlve paln conLrol
I|u|d Management
W osLdlalysls paLlenLs have lnLravascular volume
depleLlon
W ApproprlaLe o/ume omount ls more lmporLanL
Lhan Lhe klnd of fluld
W llberal hydraLlon pollcy ls employed
lnLraoperaLlvely
W 1he S8 ls malnLalned beLween 130160 mm of
Pg Cv beLween 1013 mm of Pg and mean
pulmonary arLery pressure of 1820 mm of Pg Lo
opLlmlze cardlac ouLpuL and renal blood flow
W CrysLallolds soluLlons are usually preferred Lo
correcL fluld and elecLrolyLe lmbalance
W ln slLuaLlons of severe hypovolemla collolds may
be used
W 8alanced crysLallolds should be alLernaLed wlLh
normal sallne (09) as large volumes of sallne
could lead Lo hypercholraemlc acldosls
W lsoLonlc 8SS malnLalns renal perfuslon beLLer
Lhan 09 naCl
W oLasslum conLalnlng soln should be avolded
o||o|d |n k|dney 1ransp|ant
W All collolds can lnduce renal funcLlon
lmpalrmenL
W 1he mechanlsm for PLSlnduced renal
dysfuncLlon may be swelllng and vacuollzaLlon of
Lubular cells and Lubular obsLrucLlon due Lo Lhe
producLlon of bypetvlscoos otloe
W 1he rlsk of hlgh plasma collold osmoLlc pressure
and subsequenL renal dysfuncLlon lncreases wlLh
repeaLed doses of blqbly cooceottoteJ slowly
JeqtoJoble 5 of blqb molecolot welqbt and
blqb Jeqtee of sobstltotloo
W PLS compounds glven aL a maxlmum dose of
m//kq/doy Lo organ donors have no
deLrlmenLal lnfluences on grafL funcLlon ln
kldneys
W 1reaLmenL wlLh PLS needs Lo be accompanled
by sufflclenL amounLs of crysLallold soluLlon
W CelaLln subsLlLuLes may be a safer opLlon
W PypoLenslon may occur afLer unclamplng Lhe
lllac vessels and reperfuslon of Lhe grafL
W t is critico/ thot otient is we// hydroted os
reno/ unction is critico//y deendent on reno/
erusion
W Cv may decllne 2330 12 hrs afLer
revascularlzaLlon desplLe aggresslve fluld
managemenL Lhe cause may be redlsLrlbuLlon of
flulds changes ln vascular permeablllLy or
lncreased nlLrlc oxlde levels
W lncreased hydraLlon works by aLrlal dlsLenLlon
and subsequenL release of An and lncreased
renal perfuslon
W 1ransfuslon when requlred should be preferably
wlLh packed cells LhaL are sallne washed
leucodepleLed lrradlaLed and cyLomegalovlrus
negaLlve
W lmmedlaLe urlne producLlon ls seen ln over
90 of llvlng donor kldney and beLween 40
70 of cadaverlc LransplanLs
W uecteose lo otloe ptoJoctloo aL Lhe laLLer
sLages of closure of surglcal wound a
decrease ln urlne ouLpuL sLrongly suggesLs
mechanlcal lmplngemenL of Lhe grafL vessel
or ureLer
Mann|to| |n kena| 1ransp|antat|on
W MannlLol lnduces osmoLlc dluresls and also has a
proLecLlve effecL on Lhe Lubular cells of Lhe
LransplanLed kldney from lschemlc ln[ury
W MannlLol enhances Lhe release of vasodllaLory
prosLaglandlns ln Lhe kldney and may acL as a free
radlcal scavenger
W 230 ml of mannlLol 20 glven lmmedlaLely before
vessel clamp removal reduces Lhe lncldence of
A8l as lndlcaLed by a lower requlremenL of posL
LransplanL dlalysls
oop d|uret|cs |n transp|antat|on
W Loop dlureLlcs are LhoughL Lo counLeracL Lhe
lncreased response of anLldlureLlc hormone Lo
surglcal sLress
W 1hey exerL Lhelr pharmacologlcal effecL ln Lhe
ascendlng loop of Penle
W ln kldney LransplanLaLlon lurosemlde ls
commonly glven durlng Lhe vascular
anasLomosls Lo sLlmulaLe dluresls alLhough lL
ls unknown wheLher lL acLually lmproves early
funcLlon
W Cnly lndlcaLlon for loop dlureLlcs ls removal of
fluld overload LhaL ls conLrlbuLlng Lo organ
dysfuncLlon ln Lhe lung and hearL
W Loop dlureLlcs ln exLended dosages may even be
hormu/ or the kidney because Lhey may
dlsLurb Lhe proLecLlve corLlcomedullary
redlsLrlbuLlon of blood flow
W uesplLe Lhelr frequenL use Lhere ls no eidence
LhaL loop dlureLlcs shorLen Lhe duraLlon of A8l
reduce Lhe subsequenL requlremenL for dlalysls
or lmprove ouLcomes ln paLlenLs wlLh A8l
Dopam|ne |n kena| 1ransp|ant
W low dose dopamlne ls commonly used Lo
sLlmulaLe uA
1
dopamlnerglc recepLors ln Lhe
kldney vasculaLure Lo lnduce vasodllaLaLlon
and lncreased urlne ouLpuL
W Dti/ityothisoroochisuestionedinthoto
new/ytrons/onteddenerotedkidneymoy
notresondto/owdosedoomine
Intraoperat|ve ro|ems
W ntrooerotieyotensionCommon
problem ln Lhese paLlenLs Causes are
W Pypovolemla
W Acldosls
W Myocardlal dysfuncLlon
W llsLula effecL of Lhe grafLed kldney
W 8elease of lnflammaLory medlaLors from Lhe
lschemlc llmb
Lxcess|ve |ntraoper|ve |eed|ng
W Causes are
W laLeleL dysfuncLlon uesmopressln
(003lD/kg) of Su lnfuslon
W CoagulopaLhy CryopreclplLaLe or ll
lnfuslon
W Acldosls
W PypoLhermla
coose of bleeJloq sboolJ be coofltmeJ by 1C
ost operat|ve are
W All renal LransplanL paLlenLs should have
muscle relaxanLs fully reversed be exLubaLed
and Laken Lo Lhe posLoperaLlve recovery area
W 8enal LransplanL paLlenLs generally have a low
lncldence of posLoperaLlve lCD admlsslon
around 1
lmmedlaLe osLoperaLlve CompllcaLlon
W uelayed reversal (uue Lo acldosls
hypermagnesemla)
W PypoLenslon (uue Lo hypovolemla acldosls)
W erloperaLlve Ml
W lnadequaLe grafL funcLlon
W ulmonary edema
W lnLracLable nausea and vomlLlng
W Lxcesslve bleedlng
ostoperat|ve a|n Management
W osLoperaLlve paln ls usually mlld Lo moderaLe
afLer kldney LransplanLaLlon
W Cholce of lnLraoperaLlve anesLheLlc lnfluenced
posLoperaLlve paln conLrolpaLlenLs who
recelved propofol had beLLer recovery of
psychomoLor funcLlon and used CA more
effecLlvely Lhan paLlenLs recelvlng lsoflurane
W CA wlLh fenLanyl or sufenLanll ls Lhe cholce
W nSAlus are conLralndlcaLed
W Avold morphlne and peLhldlne
W lnLercosLal nerve blocks dld noL change Lhe
use of paLlenLconLrolled analgesla or paln
scores afLer surgery
8ole of 8eglonal AnaesLhesla
W 8lsk of eplduaral/ lnLraLhecal hemaLoma due
Lo preexlsLlng coagulopaLhy or plaLeleL
dysfuncLlon
W aLlenL dlscomforL also a concern for
prolonged surgery
W noL preferred nowadays