ANESTHESIA FOR RENAL TRANSPLANTATION

DEVELOPMENTS IN CRITICAL CARE MEDICINE AND ANESTHESIOLOGY

Prakash, O. (ed.): Applied Physiology in Clinical Respiratory Care. 1982. ISBN 90-247-2662-X.

McGeown, Mary G.: Clinical Management of Electrolyte Disorders. 1983. ISBN 0-89838-559-8.

Scheck, P.A., Sjostrand, U.H., and Smith, R.B. (eds.): Perspectives in High Frequency Ventilation. 1983. ISBN 0-89838-571-7.

Stanley, T.H., and Petty, w.e. (eds.): New Anesthetic Agents, Devices and Monitoring Techniques. 1983. ISBN 0-89838-566-0.

Prakash, O. (ed.): Computing in Anesthesia and Intensive Care. 1983. ISBN 0-89838-602-0.

Stanley, T.H., and Petty, W.e. (eds.): Anesthesia and the Cardiovascular Sys­tem. 1984. ISBN 0-89838-626-8.

Van Kleef,].W., Burm, A.G.1., and Spierdijk,]. (eds.): Current Concepts in Regional Anaesthesia. 1984. ISBN 0-89838-644-6.

Prakash, o. (ed.): Critical Care of the Child. 1984. ISBN 0-89838-661-6. Stanley, T.H., and Petty, w.e. (eds.): Anesthesiology: Today and Tomor­

row. 1985. ISBN 0-89838-705-1. Rahn, H., and Prakash, o. (eds.): Acid-base Regulation and Body Tempera­

ture. 1985. ISBN 0-89838-708-6. Stanley, T.H., and Petty, w.e. (eds.): Anesthesiology 1986.

ISBN 0-89838-779-5. de Lange, S., Hennis, P.]., and Kettler, D. (eds.): Cardiac Anaesthesia: Prob­

lems and Innovations. 1986. ISBN 0-89838-794-9. de Bruijn, N.P., and Clements, F.M.: Transesophageal Echocardiography.

1987. ISBN 0-89838-821-X. Graybar, G.B., and Bready, 1.1. (eds.): Anesthesia for Renal Transplantation.

1987. ISBN-13: 978-1-4612-9211-1. Stanley, T.H., and Petty, W.E. (eds.): Anesthesia, the Heart, and the Vascular

System. 1987. ISBN 0-89838-851-1.

ANESTHESIA FOR RENAL TRANSPLANTATION

EDITED BY

GWENDOLYN B GRA YBAR, M.D. The University of Alabama at Birmingham

AND

LOISLBREADY, M.D. The University of Texas, San Antonio

Martinus Nijhoff Publishing a member of the Kluwer Academic Publishers Group Boston I Dordrecht I Lancaster

Distributors

for the United States and Canada: Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell, MA, 02061, USA

for the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited, Falcon House, Queen Square, Lancaster LAI lRN, UK

for all other countries: Kluwer Academic Publishers Group, Distribution Centre, P. O. Box 322, 3300 AH Dordrecht, The Netherlands

Library of Congress Cataloging-in-Publication Data

Anesthesia for renal transplantation.

(Developments in critical care medicine and anesthesiology) 1. Kidneys-Transplantation. 2. Anesthesia. 3. Critical care medicine. I. Graybar,

Gwendolyn B II. Bready, Lois L III. Series: Developments in critical care medicine and anesthesiology. [DNLM: 1. Anesthesia. 2. Kidney-transplantation. W] 368 A579) RD575.A541986 617'.967461 86-23567 ISBN-13: 978-1-4612-9211-1 e-ISBN-13: 978-1-4613-2035-7 DOl: 10.1007/978-1-4613-2035-7

Copyright

© 1987 by Martinus NijhoffPublishing, Boston Softcover reprint of the hardcover I st edition 1987 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher, Martinus NijoffPublishing, 101 Philip Drive, Assinippi Park, Norwell, MA 02061, USA

To our husbands, Andy Graybar and Joe Holahan

CONTENTS

Contributing authors ix

Foreword by LEROY D VANDAM Xll

Preface xiv

1. History of renal transplantation GWENDOLYN B GRAYBAR

2. Renal anatomy and pathophysiology 23 MARGARET TARPEY

3. The medical management of renal transplant patients 31 JOHN J CURTIS

4. Brain death and management of the cadaveric donor 47 PAMELA D VARNER AND ROBERT D MCKAY

5. The living related donor 69 LOIS L BREADY

6. Surgical aspects of renal transplantation 83 JOHN D WHELCHEL

7. Monitoring 99 LOIS L BREADY

8. Fluids, electrolytes, and blood transfusions 107 JAMES R BOYCE

viii Contents

9. Intravenous agents and renal failure 123 JOHN A YOUNGBERG

10. Choice of anesthesia 139 GWENDOLYN B GRAYBAR

11. Muscle relaxants and renal failure 157 GWENDOLYN B GRAYBAR

12. Postanesthetic recovery 177 LOIS L BREADY

13. Anesthesia-related morbidity 191 LOIS L BREADY

14. Anesthesia for pediatric renal transplantation 199 ELENA ADLER AND PATRICIA A GIBBONS

15. Anesthesia for vascular access and other procedures 213 GWENDOLYN B GRAYBAR AND HAMDI ERDEMIR

16. A game plan 247 GWENDOLYN B GRAYBAR AND LOIS L BREADY

Index 265

CONTRIBUTING AUTHORS

Elena Adler, M.D. Assistant Professor of Anesthesiology and

Pediatrics University of Cincinnati College of Medicine Elland at Bethesda Avenue Cincinnati, Ohio 45229

James R Boyce, M.D. Associate Professor of Anesthesiology The University of Alabama at Birmingham University Station Birmingham, Alabama 35294

Lois L Bready, M.D. Associate Professor of Anesthesiology The University of Texas Health Science Center at San Antonio 7703 Floyd Curl Drive San Antonio, Texas 78284-7838

JohnJ Curtis, M.D. Professor of Medicine The University of Alabama at Birmingham Nephrology Research and Training Center University Station Birmingham, Alabama 35294

Hamdi Erdemir, M.D. Professor of Anesthesiology Chief of Special Services The University of Alabama at Birmingham University Station Birmingham, Alabama 35294

x Contributing authors

Patricia A Gibbons, M.D. Assistant Professor of Anesthesiology University of Cincinnati College of Medicine Children's Hospital Medical Center Eiland at Bethesda Avenue Cincinnati, Ohio 45229

Gwendolyn B Graybar, M.D. Professor of Anesthesiology The University of Alabama at Birmingham University Station Birmingham, Alabama 35294

Robert D McKay, M.D. Associate Professor of Anesthesiology The University of Alabama at Birmingham University Station Birmingham, Alabama 35294

Margaret Tarpey, M.D. Instructor of Anesthesiology The University of Alabama at Birmingham University Station Birmingham, Alabama 35294

Leroy D Vandam, M.D. Professor of Anaesthesia, Emeritus Harvard Medical School Anesthesiologist, Brigham and Women's

Hospital 75 Francis Street Boston, Massachusetts 02115

Pamela D Varner, M.D. Assistant Professor of Anesthesiology The University of Alabama at Birmingham University Station Birmingham, Alabama 35294

John D Whelchel, M.D. Livingston Professor of Surgery Emory University School of Medicine 1634 Clifton Road, NE Atlanta, Georgia 30322

John A Youngberg, M.D. Associate Professor of Anesthesiology Director of Research Tulane University School of Medicine 1430 Tulane Avenue New Orleans, Louisiana 70112

"TO REMEMBER ME . .. "

The day will come when my body will lie upon a white sheet neatly tucked under four corners of a mattress located in a hospital busily occupied with the living and the dying. At a certain moment a doctor will determine that my brain has ceased to function and that, for all intents and purposes, my life has stopped.

When that happens, do not attempt to instill artificial life into my body by the use of a machine. And don't call this my deathbed. Let it be called the Bed of Life, and let my body be taken from it to help others lead fuller lives.

Give my sight to the man who has never seen a sunrise, a baby's face or love in the eyes of a woman. Give my heart to a person whose own heart has caused nothing but endless days of pain. Give my blood to the teenager who was pulled from the wreckage of his car, so that he might live to see his grandchildren play. Give my kidneys to one who depends on a machine to exist from week to week. Take my bones, every muscle, every fiber and nerve in my body and find a way to make a crippled child walk.

Explore every corner of my brain. Take my cells, if necessary, and let them grow so that, someday, a speechless boy will shout at the crack of a bat and a deaf girl will hear the sound of rain against her window.

Burn what is left of me and scatter the ashes to the winds to help the flowers grow. If you must bury something, let it be my faults, my weaknesses and all prejudice

against my fellow man. Give my sins to the devil. Give my soul to God. If, by chance, you wish to remember me, do it with a kind deed or word to someone

who needs you. If you do all I have asked, I will live forever. Robert N Test in Cincinnati Post

xi

FOREWORD

This treatise commemorates the 32nd anniversary of the first successful allogenic kidney transplant in a human being and the beginning of a con­tinuing challenge for well over a generation of anesthesiologists. If compari­sons can be permitted, this epoch-making event can be ranked with the first pulmonary lobectomy and subsequently the initial ligation of a patent ductus arteriosus in the late 1930s when thoracic and cardiac surgery began. Was it merely a coincidence that brought these events to the fore so close upon one another after many years of ideation and frustration? Not so, according to Lewis Thomas, for this was the time of medicine's second revolution-its transformation from an empirical art into a powerfully effective science. The remote Galenic conception of disease with its emphasis on disturbed body humors was about to be supplanted by effective therapeutics, as signified by the introduction of the sulfonamides and antibiotics for the specific treatment of infection.

Anesthesiology had been dormant up to that era, still relying upon a few agents, more or less utilized from the beginning, and purveyed by a handful of specialists who had not yet begun to ask the scientific questions necessary for their maturation into a bona fide discipline. However, anesthesiology was in­evitably caught in the ferment, for as Peter Caws observed, "It serves to re­mind us that the development of science is a step-wise process: nobody starts from scratch and nobody gets very far ahead of the rest. At any point in his­tory there is a range of possible discovery: the trailing edge of i:he range is defined by everything known at the time and the leading edge is a function of what is already known, together with variables representing available instru-

xii

Foreword xiii

mentation, the capacity of human brains and so on." The introduction of curare to anesthetic practice in 1942 was undoubtedly a manifestation of this credo.

In 1954, the situation was unparalleled. A patient in terminal chronic renal failure required anesthesia for a lifesaving operation, to say nothing about the anesthetization of a living kidney donor. Never mind the choice of anesthesia; one could only employ that at hand in as conscientious a manner as possible, and it became a matter of trial and error from then on. With the advent of dialysis and prolongation of life for the patient in renal failure, new problems arose. The endocrine functions of the kidney became apparent in relation to the development of hypertension, erythropoiesis, and vitamin D metabolism. Never before had anesthesiologists been made so aware of the role of the kid­ney in drug elimination. Changes in surgical management dictated by the complications that arose and the use of immunosuppressive drugs added to the anesthesia dilemma. Fortunately, and in keeping with Caws' doctrine, the sci­entific foundations of anesthesiology were being established in the interval: comprehension of the pharmacodynamics and pharmacokinetics of the old as well as the new anesthetics; the discovery that inhalation anesthetics were not inert substances, thereby raising the spectre of toxicity, pharmacogenetics, the concept of MAC, and the realization that anesthetic care might possibly playa role in the spread of infection to the immunosuppressed patient.

This comprehensive collection of essays, mainly for the edification of anesthesiologists, provides the living substance to the skeletal outline of the developments noted above. Since history must always be conjured with, medicine, surgery, microbiology, genetics, immunology, bioethics, and bio­engineering have all played their part in the transplant drama. And last but not least, anesthesiology, in its usual but quite professional manner, has con­tributed immeasurably to the success of the enterprise.

Leroy D Vandam, M.D.

PREFACE

The number of kidney transplants performed continues to increase each year. With the growing public awareness of the need for organ donation, the in­crease has primarily been in the number of cadaveric transplants. In many ways anesthesia has become both simpler and safer since Dr. Leroy Vandam anesthetized identical twins for the first successful living related kidney trans­plant three decades ago. However, the body of knowledge relating to anesthe­sia for renal transplantation has become sufficiently specific that it seemed an appropriate time for a book devoted to anesthesia for renal transplantation to be published. We are pleased and honored that Dr. Vandam has written the foreword for our book.

The chapter authors represent six university renal transplant centers. Thus the book is as non parochial as possible and stresses the need to be reasonably flexible. However, half the authors are from the University of Alabama (UAB) at Birmingham and, therefore, cannot help but reflect the philosophy and approaches that have been developed there. For the past 20 years, the UAB renal transplant program has been directed by Dr. Arnold G Diethelm, Professor and Chairman of the Department of Surgery. He has built the pro­gram so that it is now the third largest in the world. Although his name does not appear in the list of authors, he has nonetheless been an important contri­butor to this book. The frequent appearance of "Diethelm AG: Personal Com­munication" in all the bibliographies of the UAB contributors is but a small

xiv

Preface xv

reflection of his actual sharing of his time and knowledge in the making of this book.

Our medical and surgical colleagues, Drs. John Curtis and John Whelchel, have added crucial background knowledge from their perspectives to aid the anesthesiologist who takes care of patients with renal failure. Without a sound understanding of the basic diseases and medical management as well as the surgical techniques, the anesthetic management is greatly impaired.

The anesthesiologist contributors have concisely and succinctly described the relevant literature within their areas of expertise. Dr. Youngberg has laboriously compiled tables on the pharmacology of our drugs, concisely sum­marizing data from many different authors. Dr. Tarpey has succinctly re­viewed renal anatomy and pathophysiology, areas quite difficult for many anesthesiologists. Drs. Varner and McKay have elegantly reviewed the con­cept and diagnosis of brain death, followed by the management of the cadaveric organ donor. Dr. Boyce has taken the vast literature of an area with everyday familiarity to the anesthesiologist and concisely applied it to our pa­tients with end-stage renal disease. Drs. Adler and Gibbons have reviewed the pediatric aspects of renal disease. Only a few years ago renal transplantation in infants was considered too hazardous. Now with pediatric anesthesiologists as an invaluable part of the transplant team, renal transplantation is "the only realistic choice" for infants and small children with end-stage renal disease.

We are particularly grateful that Dr. Erdemir, who has taught his technique of supraclavicular brachial plexus block to a generation of faculty and residents at UAB, has published it in our book for the first time.

We are indebted to Alana Bass who cheerfully spent many overtime hours, at work and at home, typing, proofreading, and retyping this manuscript, and for the able assistance of Peggy Tortomase. We know all of our contributors share our feelings of gratitude to their secretaries. Our UAB anesthesia libra­rian, AJ Wright with his master's degree in library science and his mastery of that field, has made an enormous contribution in obtaining our references and ensuring their accuracy. Paula Dennis, head of graphics for anesthesiology at UAB, has also spent countless hours preparing the graphics and photography contained in this book.

Dr. Edward Ernst, Professor and Chairman of Anesthesiology at UAB, provided the resources, support services, and the people just mentioned. With­out this environment and his philosophy, that people are most productive when they like what they are doing, this book would have been immeasurably more difficult in every way. We are grateful to our residents whose questions made us want to learn more about anesthesia for renal transplantation.

Our husbands, Andy Graybar and Joe Holahan, have been the best supports of all, although neither is anxious for a second edition too soon. They both spent weekends alone with the children and tolerated our long hours away, while we practiced anesthesia full time, as well. Ben Graybar helped keep home more pleasant by doing extra chores. Abby and Katy Holahan helped

xvi Preface

by playing quietly at home and at the office and by contributing lots of sug­gestions for future books.

As with so many areas of medicine, anesthesiologists are increasingly play­ing greater roles. Renal transplantation is no longer a rare and exotic proce­dure. A successful program requires a coordinated effort with many people from community hospitals, the regional organ bank, nephrologists, immu­nologists, surgeons, and anesthesiologists. By working closely together, we can help continue the steady progress of the past three decades.

Gwendolyn B Graybar, M.D. Lois L Bready, M.D.