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Anesthesia for Kidney Transplant:

Ans:
Definition:
o Cold ischemic time: the time when kidney is cooled with cold
perfusion solution and ends after organ reaches physiological
temperature during implantation procedures.
o Warm ischemic time:
Donor: after the application of clamp beginning of cold
storage.
Recepient: After the initiation of circulatory arrest to
anastomosis of veins.
o Longer ischemic times associated with higher incidence of delayed
graft function.
Management of transplant depends on: cadaveric or living donor.
Cadaveric kidney:
o Preparation of recipient and optimization
o Short preparation time
o High induction dose of immune-modulative drugs
o PAC:
CV system instability:
Upto 25% of patient at risk of having CAD full CV
workup needed
o The incidence of longer ischemia times is high.
o Considerations for emergency surgery acid prophylaxis
o Correction of preexisting derangements:
Acidosis
Azotaemia
Anemia
Electrolyte disturbance: chloride, calcium, potassium
Fluids: hypovolemia and hypotension post extraction
dialysis; Mannitol and diuretics
Thymoglobulin infusion: accentuates hypotension if given at
high rates
o Intraop:
Hypothermia: d/t cold perfusion
Fluid: type and amount of fluid infused
o Methylprednisolone: infusion during anastomosis and it
completion before reperfusion
o Reperfusion of grafted kidney
o Goals of management:
Early immunosuppressive therapy
Adequate volume
Adequate perfusion pressure
Avoidance of vasopressors as far as possible
Achieving short cold ischemic time as possible.
Living renal transplant
o Considerations both for donor and recipient
o Elective surgery
o Preparation starts months before: selection of donor,
optimization and assessment
o Immunosuppressive therapy started few days prior
o Preparation for Donor:
ASA I and II
Full preop assessment
ABO blood group, tissue typing, leucocyte crossmatch
Inv: CBC, Coagulation profile, RFT, FBS, viral markers
including CMV, lipid profile, urine R/E and C/S, CXray, ECG
>50 yrs: colonoscopy
>40 yrs female: mammogram
Pap test and pelvic exam for females
Mantoux test for TB
o Organ matching:
Major blood group compatibility (ABO)
HLA profile
Preformed reactive antibodies (PRA) against donor antigens
o Preparation for Recepient:
Investigations: CBC, platelet, electrolytes, glucose, RFT,
urine, ECG, CXRay, Echo
Coagulation profile
ABG
Screening for HCV, HIC, CMV
Pneumococcal, meningococcal and HIB vaccination
Immunosuppression strategies aim to prevent graft
rejection

Perioperative fluid management:


o To prevent graft failure one of the important preventions is:
Maintenance of appropriate renal perfusion pressure.
o In transplantation:
Denervation adds to the deterioration in hemodynamic
auto-regulation of the kidney graft.
Even a mild decrease in BP can further reduce RPP and
result in repeat ischemia to transplanted kidneys
Must ensure restoration and maintenance of IV volume.
o Important components are:
Avoidance of hypovolemia
Type of fluids
Administration of mannitol
o Avoidance of hypovolemia
Hypovolemia d/t:
Fluid extraction during dialysis
Preoperative fasting
In awake patient:
May not be reflected by BP: d/t intact autonomic
compensatory mechanisms (volume contraction)
During anesthesia:
Inhibition of autonomic compensation thus the
effect of volume status will be reflected by BP
(linearly)
Amount of fluid to be administered:
Liberal vs restrictive fluid therapy
o Upto 30 ml/kg/h and CVP>15 mm Hg (caution
in cardiac patients)
Targets of hemodynamics: to maintain CO and RBF
o SBP: 130-160 mm Hg
o MAP >80 mm Hg
o CVP 10-15 mm Hg
o Mean PAP 18-20 mm Hg
o SVV: <15%
o Total IV fluids: 30-50 ml/kg/hr
o Higher infusion rates given during ischemic
times (at time of donor clamping)
o Graft turgidity as assessed by surgeon
o Cautious in CV compromise
Timing of fluid administration:
Biphasic hydration regimen vs constant infusion
regimen
Biphasic (Othman et al)
o Pre-ischemic CVP: 5 mm Hg
o Ischemic CVP: 15 mm Hg (about 50 ml/min for
ischemia time < 1 hr)
o More favorable post-ischemia hemodynamics
o Better graft turgidity
o Less tissue edema
o Earlier graft function
o Lower serum creatinine
o Higher creatinine clearance at POD1
o Othman et al also used:
40 mg Furosemide and 150 ml 10%
Mannitol intraop before ischemia
(clamping of donor renal artery)
Constant infusion regimen:
o 10-12 ml/kg/h
Other modalities:
o SVV: a guide
Initial target of SVV <15%
Type of fluids:
Non-potassium containing crystalloids solution
Hartmanns solution vs isotonic saline: Hartmanns
also didnt cause significant hyperkalemia as
previously thought
Balance crystallod: Plasma-Lyte better
If not: mixture of isotonic saline and Hartmann
solution better than normal saline alone
Continuous monitoring of electrolytes perioperatively
important.
Periods of hypotension intra-op:
o After bolus IV anesthetic solution
o Reperfusion of grafted kidney (drop of CVP
>50% seen within 2 hours after reperfusion
d/t sudden shift of 25% of CO to grafted kidney,
release of mediators accumulated during
ischemia times)
May require infusion of colloids as well
Dextrans and gelatins (not better than
albumin)
Medium molecular weight HES with low
molar substitution (130/0.4) (50
ml/kg/day)
Better recovery of renal function
immediately after transplantation
Administration of Mannitol, Furosemide and Dopamine:
Mannitol:
Improved outcome with Hydration + Mannitol than
without mannitol
Donor:
o Increased renal flow through local PG
production, reduction in renin release
o To be effective Mannitol must be administered
before ischemic insult (before arterial clamping
in donor nephrectomy)
For recipient:
o Mannitol acts through: reduction of post-
ischemic endothelial cell swelling and decrease
in ischemic-reperfusion injury through
scavenging of hydroxyl and other free radicals.
o Administration of 200-250 ml Mannitol 20%
immediately before reperfusion
Furosemide:
o Studies have not shown any benefit
Dopamine:
o Detrimental effect of dopamine on renal
function in ARF, increased mortality and longer
ICU stay.
Vasopressors (Ephedrine/Phenylephrine)
o Should be avoided as far as possible
o But may be used as an interim measure to
treat refractory hypotension in the initial
stages
o Should be considered when risk of low
perfusion outweigh risk of renal
vasoconstriction.
Blood:
o Transfusion should be performed reluctantly:
lower transfusion triggers compared to non
renal failure patients.
Donor:
Preop hydration: 100 ml/hr from night before surgery
IV bolus colloid: 5 ml/kg before induction
Invasive hemodynamic monitoring: arterial line only
Mannitol infusion: 0.5 g/kg after induction up to time
of nephrectomy
Intra-op infusion of 20 ml/kg/hr crystalloids
Target MAP normal+20% of patients normal
Aim for urine output of at least 100 ml/hr
IV Dexona 8 mg
Recepient:
IV hydrocortisone, Chlorpheniramine, Antibiotics and
immunosuppressant from wards
IV infusion of Thymoglobulin (over 4-6 hrs) after CVP
Arterial line
IV infusion of 20% Mannitol 0.5 g/kg 30 minutes prior
to unclamping
IV Methylprednisolone 500 mg to be infused at start
of anastomosis (over 30 minutes) completed before
arterial unclamping
Total IV fluid: 30-50 ml/kg/hr.
Analgesia:
o Various measures:
Regional:
Donor
PCA: Morphine 1 mg/bolus
Epidurals:
o Problem: segmental sympathectomy affects
perfusion pressures d/t uncompensated
vasodilatation
o Lateral position: may affect dependent
segmental spinal root and not provide effective
analgesia for non-depended incision site.
TAP block or Fascia transversalis block
Quadratus Lumborum Block
Thoracic Paravertebral block
Recipient:
PCA: Fentanyl 10 mcg/bolus
TAP block
Systemic:
NSAIDs, PCM, COX inhibitors used with caution
Opioids: Fentanyl, Morphine