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Anesthesia for Kidney Anesthesia for Kidney Transplant SurgeryTransplant Surgery

台大 台大 B88401074 B88401074 戴逸承戴逸承中山醫學大學 陳信良中山醫學大學 陳信良

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History IHistory I NameName ：張陳○○ ：張陳○○ AgeAge ：： 4949 GenderGender ：： FemaleFemale HeightHeight ：： 146.6 cm146.6 cm WeightWeight ：： 38.8 kg38.8 kg Chart numberChart number ：： 28061382806138 Evaluation of living-related kidney Evaluation of living-related kidney

transplantationtransplantation

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History IIHistory II Dyspnea and decreased urine output Dyspnea and decreased urine output

noted 4 years agonoted 4 years ago No limb edema, skin dysaesthesia, or No limb edema, skin dysaesthesia, or

consciousness disturbance consciousness disturbance Atrophic kidney revealed by abdomen Atrophic kidney revealed by abdomen

ultrasound at ultrasound at 西園醫院 西園醫院 where she had where she had been regularly follow-up for CKDbeen regularly follow-up for CKD

By when she started to take herb-By when she started to take herb-medicinemedicine

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History IIIHistory III Progressing dyspnea and continuously Progressing dyspnea and continuously

BUN/Cre elevating since last month when BUN/Cre elevating since last month when she started dialysisshe started dialysis

To To 蔡孟昆’蔡孟昆’ s OPD for opinion of kidney s OPD for opinion of kidney transplantation last monthtransplantation last month

Her son was the donorHer son was the donor

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Past HistoryPast History Allergy:NKAAllergy:NKA Smoking (-)Smoking (-) Drinking (-)Drinking (-) DM deniedDM denied HTN deniedHTN denied Other systemic diseases deniedOther systemic diseases denied

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CKD Complications for CKD Complications for AnesthesiologyAnesthesiology

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CDK Complications ICDK Complications I AnemiaAnemia Platelet dysfunctionPlatelet dysfunction Altered OAltered O22-carrying capacity-carrying capacity

Cardiovascular abnormalitiesCardiovascular abnormalities HypertensionHypertension Peripheral neuropathyPeripheral neuropathy CNS dysfunctionCNS dysfunction Electrolyte and fluid disturbancesElectrolyte and fluid disturbances

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CDK Complications IICDK Complications II Acid-base abnormalitiesAcid-base abnormalities GI abnormalitiesGI abnormalities Endocrine disturbancesEndocrine disturbances Dialysis-related problemsDialysis-related problems

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Pre-OP EvaluationPre-OP Evaluation BPBP CV diseasesCV diseases

– CHFCHF– CADCAD

DM managementDM management Serum electrolytesSerum electrolytes

– Especially potassiumEspecially potassium Degree of anemiaDegree of anemia Coagulation statusCoagulation status

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Lab data ILab data I BP 126/74 (mean)BP 126/74 (mean) AC blood sugar 82; HbA1c ?AC blood sugar 82; HbA1c ? CBCCBC

– HB HB 6.26.2 g/dL g/dL– HCT HCT 20.220.2 % %– MCV 89.4 fLMCV 89.4 fL– PLT 222.0 K/μLPLT 222.0 K/μL– WBC 5.29 K/μLWBC 5.29 K/μL

• Seg 61.6 %, Eos. 3.0 %, Baso. 0.4 %, Mono. 8.9 Seg 61.6 %, Eos. 3.0 %, Baso. 0.4 %, Mono. 8.9 %, Lym. 26.1 %%, Lym. 26.1 %

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Lab data IILab data II ElectrolytesElectrolytes

– Na 138 mmol/LNa 138 mmol/L– K 4.5 mmol/LK 4.5 mmol/L– Cl 99 mmol/LCl 99 mmol/L– Ca 2.27 mmol/LCa 2.27 mmol/L

BiochemstryBiochemstry– UN UN 53.053.0 mg/dL mg/dL– CRE CRE 9.19.1 mg/dL mg/dL– ALP ALP 222222 U/L U/L– UA 7.5 mg/dLUA 7.5 mg/dL– Alb 4.3 g/dL Alb 4.3 g/dL

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CXRCXR CardiomegalyCardiomegaly No pleural effusionNo pleural effusion

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ECGECG LVH by voltageLVH by voltage

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Coronary Artery DiseaseCoronary Artery Disease Uremic cardiomyopathy is reversibleUremic cardiomyopathy is reversible

– Unless ventricular dysfunction with low C.O.Unless ventricular dysfunction with low C.O.

Asymptomatic patient with DM may have Asymptomatic patient with DM may have a silent CADa silent CAD

Thallium test sensitivity decreasedThallium test sensitivity decreased– Increased adenosine enhances vasodilator Increased adenosine enhances vasodilator

effect of dipyridamoleeffect of dipyridamole

Dobutamine stress ECG is recommendedDobutamine stress ECG is recommended

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Congestive Heart FailureCongestive Heart Failure CHF in 50% of p’ts on chronic dialysisCHF in 50% of p’ts on chronic dialysis Ultrasound best for screeningUltrasound best for screening 3 major causes3 major causes

– Uremic cardiomyopathyUremic cardiomyopathy– AnemiaAnemia– A-V fistulaA-V fistula

Intraoperative hemodynamics not Intraoperative hemodynamics not significantly differentsignificantly different

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HypertensionHypertension Interruption of anti-HTN drugs will cause Interruption of anti-HTN drugs will cause

perioperative rebound hypertension, perioperative rebound hypertension, tachycardia, or MI.tachycardia, or MI.– CCB, beta blocker, diuretics, clonidineCCB, beta blocker, diuretics, clonidine

Uninterruption of ACEIUninterruption of ACEI– Severe hypotension after inductionSevere hypotension after induction– Life-threating hyperkalemiaLife-threating hyperkalemia

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DMDM Stiff joint syndromeStiff joint syndrome Autonomic neuropathyAutonomic neuropathy

– HypotensionHypotension– BradycardiaBradycardia– Labile blood pressureLabile blood pressure– gastroparesisgastroparesis

Silent MISilent MI Peripheral neuropathyPeripheral neuropathy Electrolyte imbalanceElectrolyte imbalance

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DMDM Diffuse atherosclerosisDiffuse atherosclerosis HyperglycemiaHyperglycemia

– hyperkalemiahyperkalemia

HypoglycemiaHypoglycemia ketoacidosisketoacidosis

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Uremic CoagulopathyUremic Coagulopathy Abnormal platelet functionAbnormal platelet function

– Ineffective production ofIneffective production of• factor VIIIfactor VIII• Von Willebrand factorVon Willebrand factor

– Preoperative dialysis improve platelet Preoperative dialysis improve platelet functionfunction

Wound hematoma progress to infectionWound hematoma progress to infection Conjugated estrogenConjugated estrogen

– Effective then FFP, cryoEffective then FFP, cryo DesmopressinDesmopressin

– Increases Increases factor VIII factor VIII andand Von Willebrand Von Willebrand factorfactor

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OthersOthers HyperkalemiaHyperkalemia AnemiaAnemia

– Right shift of oxyhemoglobin dissociationRight shift of oxyhemoglobin dissociation

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Premedication IPremedication I albumin↓ ↓, globulin ↓, protein-bound albumin↓ ↓, globulin ↓, protein-bound

drugs need lower dosedrugs need lower dose– Diazepam (albumin)Diazepam (albumin)– Non-depolarizing muscle relaxant (globulin)Non-depolarizing muscle relaxant (globulin)

ECF↑, water-soluble drug need larger ECF↑, water-soluble drug need larger dosedose– MidazolamMidazolam

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Premedication IIPremedication II Preoperative dialysis causes volume Preoperative dialysis causes volume

depletion, large decrease of BP occurs depletion, large decrease of BP occurs afterafter– Histamine releasing drugsHistamine releasing drugs

• Morphine (alfentanil recommended)Morphine (alfentanil recommended)• AtracuriumAtracurium

– Alpha-blockersAlpha-blockers• DroperidolDroperidol• labetalollabetalol

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Premedication IIIPremedication III Preoperative opioid prolongs GI emptyingPreoperative opioid prolongs GI emptying

– CisaprideCisapride– AntacidAntacid– MetoclopramideMetoclopramide

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Intra-OP Condition IIntra-OP Condition INaNa KK ClCl CO2CO2 CaCa MgMg GluGlu LacLac

141141 44 1010 33.233.2 0.90.9 99 105105 6.66.6

HbHb HctHct pHpH pOpO22 HCO3HCO3 BEBE SaO2SaO2

10.610.6 3232 7.5067.506 440440 26.426.4 +4.1+4.1 100100

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Intra-OP Condition IIIntra-OP Condition II

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Operation ProcedureOperation Procedure

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Pharmacokinetic&Pharmacokinetic&PharmacodynamicsPharmacodynamics

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Intravenous Induction AgentIntravenous Induction Agent Thiopental-a reduced dose is indicated Thiopental-a reduced dose is indicated

because of reduced protein binding because of reduced protein binding Etomidate- minimal CV effect and not affected Etomidate- minimal CV effect and not affected

significant by renal impairmentsignificant by renal impairment Ketamine-little affected by renal disease, but Ketamine-little affected by renal disease, but

undesireable for its hypertensive effectundesireable for its hypertensive effect Propofol-transient hemodynamic change but is Propofol-transient hemodynamic change but is

safely as a induction agent for uremia p’tsafely as a induction agent for uremia p’t

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Inhalation agentInhalation agent

ESRD have no significant effect on ESRD have no significant effect on clinical dosingclinical dosing

Isoflurance has been considered the Isoflurance has been considered the choice of inhalation agent for renal choice of inhalation agent for renal transplantation (Desflurane) transplantation (Desflurane)

The safety of Sevoflurance in p’t with The safety of Sevoflurance in p’t with impaired renal function is still impaired renal function is still controversial controversial

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Opoids Opoids Older-generation opoids( such as Older-generation opoids( such as

morphine, oxycodone and meperidine ) morphine, oxycodone and meperidine ) should be avoided because of drceased should be avoided because of drceased clearance in ESRD p’tclearance in ESRD p’t

Fentanyl, Sufentanil, Alfentanil and Fentanyl, Sufentanil, Alfentanil and Remifentanil are safe alternatives Remifentanil are safe alternatives

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Muscle relaxants in rapid Muscle relaxants in rapid intubationintubation

Succinylcholine is not contraindicated in Succinylcholine is not contraindicated in p’t with ESRD and it can be used in p’t p’t with ESRD and it can be used in p’t with serum potassium <5.5mEq /Lwith serum potassium <5.5mEq /L

Two non-depolarizing muscle relaxant –Two non-depolarizing muscle relaxant –Rocuronium and Rapacuronium are Rocuronium and Rapacuronium are alternatives to SCC for their rapid onset alternatives to SCC for their rapid onset and less metabolic influence by impaired and less metabolic influence by impaired renal functionrenal function

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Other Nondepolarizing muscle Other Nondepolarizing muscle relaxantrelaxant

Atracurium and Cisatracurium are Atracurium and Cisatracurium are common used because their metabolism common used because their metabolism is by Hoffman elimination, an organ-is by Hoffman elimination, an organ-independent pathway.independent pathway.

Vecuronium has a rapid hepatic Vecuronium has a rapid hepatic metabolism and can be also used in p’t metabolism and can be also used in p’t with ESRDwith ESRD

The long-acting muscle relaxant- The long-acting muscle relaxant- Pancuronium is predominant renal Pancuronium is predominant renal elimination and not suitable for ESRD p’telimination and not suitable for ESRD p’t

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Reversal agents Reversal agents Anticholinesterase drugs(eg neostigmine, Anticholinesterase drugs(eg neostigmine,

prostigmine)prostigmine) The half-time is prolonged in p’t with The half-time is prolonged in p’t with

uremia and hard to match the non-uremia and hard to match the non-depolarizing muscle relaxantsdepolarizing muscle relaxants

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Anesthetic management of Anesthetic management of kidney recipientkidney recipient

Early onset of urine output(90% of living Early onset of urine output(90% of living donor kidney transplantsdonor kidney transplants ；； 40-70% of 40-70% of cadaveric transplants) is most important and cadaveric transplants) is most important and as a prognosis factor of renal transplantationas a prognosis factor of renal transplantation

Several methods are used to stimulate urine Several methods are used to stimulate urine productionproduction

a. Intravascular volume expansiona. Intravascular volume expansion

b. Liberal use of albuminb. Liberal use of albumin c. Loop diureticsc. Loop diuretics d. Mannitol d. Mannitol e. Ca channel blockere. Ca channel blocker

f. Dopamine and Dopexaminef. Dopamine and Dopexamine

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Intravascular VolumeIntravascular Volume The most important intraoperative The most important intraoperative

measurement to ensure satisfactory measurement to ensure satisfactory perfusion of transplanted kidneyperfusion of transplanted kidney

To keep To keep 1.CVP in10-15mmHg 1.CVP in10-15mmHg

2.blood volume>70mL/kg2.blood volume>70mL/kg

plasma volume>45mL/kgplasma volume>45mL/kg

3.PAP>20/diastolic 3.PAP>20/diastolic

PAP>15PAP>15mmHgmmHg

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Albumin Loop DiureticsAlbumin Loop Diuretics Volume expansion Volume expansion

and presumably and presumably binding toxic agentsbinding toxic agents

Dosage :Dosage :

0.8g/kg->improve outcome0.8g/kg->improve outcome

advocated the use of 1.2-advocated the use of 1.2-1.6g/kg1.6g/kg

Inhibition of the Na-K Inhibition of the Na-K ATPase pump and ATPase pump and may result in may result in resistance against resistance against ischemic injury ischemic injury

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MannitolMannitol CCBCCB1.1. Protection against renal Protection against renal

cortical and increasing cortical and increasing tubular flowtubular flow

2.2. Diminishing potential for Diminishing potential for tubular obstructiontubular obstruction

3.3. Acting as a radical Acting as a radical scavenger scavenger

4.4. Risk for heart failure or Risk for heart failure or pulmonary edemapulmonary edema

5.5. Low dose:0.25-0.5mg/kgLow dose:0.25-0.5mg/kg

1.1. Restore and Restore and maintain renal blood maintain renal blood flow and minimized flow and minimized renal injuryrenal injury

2.2. Ex:VerapamilEx:Verapamil

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Dopamine and DoxamineDopamine and Doxamine Low dose Dopamine has been proved neither a Low dose Dopamine has been proved neither a

reduction in acute renal failure nor an reduction in acute renal failure nor an improvement in renal function in p’t with renal improvement in renal function in p’t with renal failurefailure

It also did not demonstrate improved renal It also did not demonstrate improved renal protection when used in cadaveric renal protection when used in cadaveric renal transplantation.transplantation.

Doxamine has been shown some renal Doxamine has been shown some renal protection during aortic surgery but its potential protection during aortic surgery but its potential benefit during renal transplant has not been benefit during renal transplant has not been evaluated. evaluated.

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Intraoperative complicationIntraoperative complication Cardiovascular complicationsCardiovascular complications Intraoperative hemodynamicsIntraoperative hemodynamics Potassium and Glucose levelsPotassium and Glucose levels

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Cardiovascular complicationCardiovascular complication Many p’t undergoing renal transplant are Many p’t undergoing renal transplant are

in poor general health, especially with in poor general health, especially with diabetes and CV complicationsdiabetes and CV complications

CAD, CHF, Dysrhythmia and HTNCAD, CHF, Dysrhythmia and HTN AMI may occur when intraoperative fluid AMI may occur when intraoperative fluid

loading increase LVEDP excessivelyloading increase LVEDP excessively

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Intraoperative hemodynamicsIntraoperative hemodynamics HTNHTN1.Because of hypervolemia and augmented 1.Because of hypervolemia and augmented

sympathoadrenal discharge caused by ESRDsympathoadrenal discharge caused by ESRD2.Tx:short-acting IV antihypertensive drug-the first 2.Tx:short-acting IV antihypertensive drug-the first

drug choice is IV NTGdrug choice is IV NTG HypotensionHypotension1.May predispose to delay or fail renal function, 1.May predispose to delay or fail renal function,

especially after revascularization of the graftespecially after revascularization of the graft2.Tx:Maintaining adequate intravascular volume2.Tx:Maintaining adequate intravascular volume ；；

vasopressors should be used as a last resortvasopressors should be used as a last resort

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Potassium and Glucose levelsPotassium and Glucose levels ESRD can cause hyperkalemia by itselfESRD can cause hyperkalemia by itself ACEI and ß-blocker also increase the risk of ACEI and ß-blocker also increase the risk of

hyperkalemiahyperkalemia Tx:Tx: 1.50mL of 50% glucose +12U insulin IV1.50mL of 50% glucose +12U insulin IV and 50mEq of sodium bicarbonateand 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 PaO2in 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

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Postoperative CarePostoperative Care Closely monitor of the urine output Closely monitor of the urine output Re-exploration of wound should not be Re-exploration of wound should not be

delayed, if kinking of vessel or obstruction delayed, if kinking of vessel or obstruction of ureter are suspected of ureter are suspected