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Transcript of Transplant patient for non TRANSPLANT SURGERY
ANAESTHESIA FOR RENAL
TRANSPLANT PATIENT FOR
NON-TRANSPLANT
SURGERY
MOD : DR. KAUMUDI
Dr.Arun
INTRODUCTION
n POST TRANSPLANT PATIENT
n INCREASED SURVIVAL• BETTER IMMUNOSUPPRESSIVE REGIMES,
• SURGICAL TECHNIQUES
• POSTOPERATIVE CARE.
n After successful kidney transplantation,
most patients are classified as having
National Kidney Foundation stage 2 or 3 CKD
with usual GFRs more than 30 mL/min.
n GFR typically deteriorates by 1.4 to 2.4
mL/min/yr in renal transplant recipients
PRE ANAESTHETIC
CONSIDERATIONS
1. IDENTIFICATION OF COMPLICATIONS &
THEIR ANAESTHETIC IMPLICATIONS
2. TOXICITY OF IMMUNOSUPPRESSANTS
3. RELEVANT DRUG INTERACTIONS WITH
IMMUNOSUPPRESSANTS
4. REJECTIONS
5. INFECTIONS
CONCERNS IN A
TRANSPLANT RECIPIENT1) ALTERED FUNCTION/ PHYSIOLOGY RELATED
TO TRANSPLANTED ORGAN
2) ALTERED FUNCTION DUE TO IMMUNO SUPPRESSION
1) INFECTIONS
2) MALIGNANCIES
3) TOXICITY OF IMMUNOSUPPRESSIVE DRUGS
4) POTENTIAL INTERACTION OF IMMUNOSUPPRESSIVE DRUGS WITH OTHER DRUGS
5) POTENTIAL FOR REJECTIONOF TRANSPLANTED ORGAN
n Progression of preexisting CAD as
immunosuppression contributes to the
development of de novo hyperlipidemia,
hypertension, and diabetes.
n Cardiovascular disease is the most common
cause of death in kidney transplant patients.
n GFR -usually reduced,(despite normal
creatinine) -electrolyte abnormalities and
altered drug metabolism
COMPLICATIONS AFTER
RENAL TRANSPLANTATION
n EARLY
• HEMORRHAGIC CYSTITIS
• CAPILLARY LEAK
• AGVHD
• PANCYTOPENIA
• CARDIOMYOPATHY
• VENO OCCLUSIVE LIVER DISEASE
• INTERSTITIAL PNEUMONITIS
COMPLICATIONS AFTER
RENAL TRANSPLANTATION
n LATE
• CGVHD
• LEUKO ENCEPHALOPATHY
• INFECTION
• SECONDARY MALIGNANCIES
• OBSTRUCTIVE/ RESTRICTIVE LUNG DISEASE
• HYPOTHYROIDISM
• CATARACT
IMMUNOSUPPRESSIVE
THERAPY FOR
TRANSPLANT RECIPIENTS
TRIPLE DRUG REGIMEN
1) CYCLOSPORIN / TACROLIMUS
2) GLUCOCORTICOIDS – METHYL
PREDNISOLONE
3) MYCOPHENOLATE MOFETIL/
AZATHIOPRINE
CYCLOSPORIN : started 7 days before transplantation of living donor kidney
1 day after for cadaver kidney
8mg/kg in 2 div doses
then tapered to 3 – 4 mg/kg
TACROLIMUS : starting 1 day after transplantation of both living & cadaver kidney transplantation
METHYL PREDNISOLONE : 250 mg IV 1hr before & 6 hrs after surgery
Tapered & maintained for 6 mths
MYCOPHENOLATE MOFETIL : 1 gm iv BD starting 1 day before Sx & continue for 6 mths
TOXICITY RELATED TO
IMMUNOSUPPRESSIVE
DRUGS
CYCLOSPORIN A
WATER SOLUBLE
ORAL ABSORPTION UNPREDICTABLE
IV DOSE 1/3 ORAL DOSE
TOXICITY
NEPHROTOXICITY
• RENAL VASC. RESISITANCE
• RBF
• APPARENT WITHIN A WEEK OF
INITIATION OF THERAPY
• CHRONIC TOXICITY
• AMINOGYCOSIDE + C/c Cs A THERAPY
POTENTIATE NEPHROTOXICITY OF Cs A
CYCLOSPORIN A
NEUROTOXICITY
• HEADACHE
• PARESTHESIAS
• TREMOR
• CONFUSION
• FLUSHING
• NEUROPATHIES
• GENERALISED SEIZURES
CYCLOSPORIN A
VASCULAR EFFECTS
• HYPERTENSION (INCIDENCE 42-100%)
• DIABETOGENIC
• TOTAL CHOLESTEROL
CORONARY ARTERY DISEASE
CYCLOSPORIN A
METABOLIC EFFECTS• HYPERKALEMIA
• HYPOMAGNESEMIA
HIRSUITISM
GUM HYPERPLASIA
ANOREXIA
LYMPHOPROLIFERATIVE DISEASES
INFECTIOUS DISEASES
TACROLIMUS
INHIBIT T CELL PROLIFERATION
100 TIMES POTENT THAN CYCLOSPORINE
ADVERSE EFFECTS:-• NEPHROTOXIC
• DM
• NEUROLOGIC – TREMOR, HEADACHE
• ALOPECIA
• BONE MARROW SUPPRESSION
• LYMPHOPROLIFERATIVE DISEASES
• INFECTIOUS DISEASES
TACROLIMUS
USED IF NOT TOLERATING Cs A
Cs A STOPPED ONLY AFTER 24 HRS OF
STARTING TACROLIMUS
STERIODS
USED IN ALL TRANSPLANT FOR A PERIOD
OF TIME
USED TO PREVENT REJECTION AND AS
PULSE THERAPY FOR TREATMENT OF
ACUTE REJECTION
STERIODS
OBESITY
GLUCOSE INTOLERANCE
SERUM LIPID LEVELS
ACCELERATE CARDIOVASCULAR
DISEASE
MARKED SKIN FRAGILITY
• MINIMISE ADHESIVE TAPES
• PADDED BP CUFFS
• EYES LUBRICATED
STERIODS
DELAYED WOUND HEALING
RISK OF OSTEOPOROSIS
• CAREFUL MOVEMENT & POSITIONING
IRRITATE GASTRIC MUCOSA
ANTIMETABOLITES
AZATHIOPRINE
MYCOPHENOLATE MOFETIL
• ANTI-NUCLEOTIDE ANTIMETABOLITES
• INHIBIT LYMPHOCYTE PROLIFERATION &
ANTIBODY PRODUCTION
AZATHIOPRINE
• BONE MARROW DEPRESSION
• HEPATOTOXICITY
MYCOPHENOLATE
• NO INTERACTION WITH CsA &
PREDNISOLONE
• NEPHROTOXICITY
• HEPATOTOXICITY
• BM DEPRESSION
ANTIMETABOLITES
AZATHIOPRINE
MYCOPHENOLATE MOFETIL
• ANTI-NUCLEOTIDE ANTIMETABOLITES
• INHIBIT LYMPHOCYTE PROLIFERATION &
ANTIBODY PRODUCTION
DRUGS AFFECTING Cs A &
TACROLIMUS BLOOD
LEVELS
BLOOD LEVELS• METOCLOPRAMIDE
• VERAPAMIL
• NICARDIPINE
• CIMETIDINE
• DILTIAZEM
• BROMCRIPTINE
• ERYTHROMYCIN
• KETOCONAZOLE
• CHLOROQUINE
DRUGS AFFECTING Cs A &
TACROLIMUS BLOOD
LEVELS BLOOD LEVELS
• CARBAMAZEPINE
• PHENOBARBITAL
• PHENYTOIN
• RIFAMPICIN
• OCTREOTIDE
• TICLOPIDINE
DRUGS THAT MAY CAUSE
RENAL DYSFUNCTION
WHEN GIVEN WITH Cs A &
TACROLIMUSNSAIDs
RANITIDINE
CIMETIDINE
AMPHOTERICIN
COTRIMOXAZOLE
GENTAMICIN
MELPHALAN
TACROLIMUS/ Cs A
INFECTIONS IN
IMMUNOSUPPRESSEDMAJOR CAUSE OF MORBIDITY & MORTALITY
1ST MONTH - BACTERIAL INFECTIONS • WOUND INFECTION - STAPH. AUREUS
• URINARY CATHETER – E. COLI
• PNEUMONIA – PNEUMOCOCCI
OPPURTUNISTIC INFECTIONS MOST COMMON 30-180 DAYS AFTER SURGERY• CMV - COMMONEST
• HERPES
• VARICELLA ZOSTER
• PNEUMOCYSTIS CARINII
MYCOBACTERIAL INFECTIONS
SYSTEMIC MYCOSES
NOCARDIOSES
PARASITIC INFECTIONS
• STRONGYLOIDES
• ENTAMEBA
• ACANTHAMEBA
ANESTHETIC
CONSIDERATION
The main anesthetic goal is to maintain
renal perfusion and prevent harm to the
already compromised renal function by
avoiding hypoxia, hypovolemia and
hypotension.
Pre op Evaluation
History: Establish the cause of renal
failure and duration of treatment.
Need for dialysis postoperatively.
Enquire about fluid restriction if any and
daily urine output.
H/O comorbidities (Hypertension,
diabetes, IHD, connective tissue
disorders) and whether controlled and on
what treatment (dose, frequency).
Pre op Evaluation
Enquire about
Exercise Tolerance, Anemia, LVF, Electrolyte
Disturbance, Medications), Gastroesophageal
reflux.
Seek nephrology opinion regarding need for
dialysis in the postoperative period
ExaminationMeasure the patient’s blood pressure in
standing and in sitting position to R/O
autonomic neuropathy.
Flow murmur secondary to anemia and
pericardial rub due to uremic pericarditis.
Look for ankle or sacral edema which may
indicate either right ventricular failure or
hypoproteinemia or both.
Patient’s who are fluid overloaded may
have crepitations
REJECTION
MAIN CAUSE OF LATE MORTALITY
PROGRESSIVE DETERIORATION IN
ORGAN FUNCTION TESTS
• AZOTEMIA
• PROTEINURIA
• HYPERTENSION
REJECTION
SURGERY DURING PERIOD OF
REJECTION HAVE HIGHER MORBIDITY
REJECTION
PRESENTATION:-
PROGRESSIVE DETERIORATION OF ORGAN FUNCTION
OR
WITH MINIMAL SYMPTOMS FROM TRANSPLANTED ORGAN &
WITH NON SPECIFIC SYMPTOMS• POOR APPETITE
• IRRITABILITY
• FATIGUE
REJECTION
TIMING :-
MAJORITY WITHIN 3 MONTHS
PEAK TIME – 4-6 WEEKS POST TRANSPLANT
TREATMENT :-
INCREASING IMMUNOSUPPRESSIVE TREATMENT• ADDING ADDL. DRUGS LIKE METHOTREXATE
• AUGMENTATION OF STEROID USE
REJECTION
ADEQUATE LEVELS OF
IMMUNOSUPPRESSIVE AGENTS SHOULD
BE MAINTAINED THROUGHOUT THE
PERIOPERATIVE PERIOD
InvestigationsFull blood count: Normochromic, normocytic anemia
and infection are likely.
Clotting studies: are required if the uraemia is
severe.
Renal function tests (BUN, serum creatinine,
Electrolytes)
ECG: Look for ischemia, arrhythmia, LVH,
conduction blocks or hyperkalemia.
Chest radiograph: Pleural effusions, cardiomegaly,
pulmonary edema
ABG to evaluate the acid base status
LFT if a major surgery is planned; as a baseline value
Preoperative
optimization/preparationIf infection / rejection suspected postpone
elective surgery
Continue immunosuppressants
antihypertensive
Adjust dosage according to drug blood levels
For elective surgery, it is prudent to optimize
blood pressure, serum potassium level.
Preoperative
optimization/preparation
Avoid unnecessary blood transfusion
because of anemia to avoid sensitization
for future transplantation.
Metoclopramide and H2 receptor
antagonists should be administered if
patient has gastroesophageal reflux.
GENERAL ANAESTHETIC
CONSIDERATIONS
Induction of anesthesia
Preoxygenate
Administer induction drugs slowly to minimize
hemodynamic disturbances. If hypotension occurs
despite above, vasopressors can be given titrated
to mean arterial pressure.
If rapid sequence induction is necessary,
suxamethonium can be used if the serum
potassium is < 5.5 mEq/ L,
modified rapid sequence induction can be done
with rocuronium
If difficult airway is anticipated;
inhalational induction is a safer option.
.f there is any doubt regarding airway
adequacy, always intubate.
Regional anesthesia can be administered
after weighing the risks and the benefits.
Concern with epidural anesthesia is
platelet dysfunction; increasing the risk of
epidural hematoma.
Maintenance of anesthesia
Nitrous oxide can be administered
safely as it does not affect the renal
function.
Isoflurane is the inhalational agent of
choice as only 0.2% undergoes
metabolism and produces low levels of
fluoride ions.
Ventilation should be controlled for
long procedures.
Maintenance of anesthesia
Atracurium is preferable as it undergoes Hoffman’s
elimination.
Vecuronium and rocuronium can be used but
smaller top-up doses are required less frequently.
Neuromuscular blockade should be monitored using
a nerve stimulator and top-up doses administered
accordingly.
Fentanyl can be administered safely; half life may be
prolonged particularly if used as an infusion.
Morphine can be used with care as clearance is
reduced
If morphine is administered patient should
be monitored for respiratory depression in
the postoperative period.
It should never be used as a continuous
infusion
Cs A potentiate :-
• Barbiturates
• Fentanyl
• NDMRs esp. atrac/ vec
So smaller doses & recovery time
prolonged
AZATHIOPRINE
• antagonise NDMR
– Use larger dose
• It may prolong SCh effect
Seizure threshold reduced in patients
treated with Cs A & Tacrolimus
• Avoid hyperventilation
Massive fluid infusion periop.
• Dilute Cs A / Tacrolimus
NSAIDs avoided
• Risk of GI hge, nephrotoxicity, hepatic
dysfn
Regional techniques :-
• If coagulation status & Platelet count normal
• Azathioprine can cause Thrombocytopenia
SPECIFIC ANAES.
CONSIDERATIONSRENAL FUNCTION SHOULD BE ASSESSED• ESP IN PTS ON Cs A / TACROLIMUS
IF IMPAIRED• PROLONG DRUG ACTION EXCRETED BY
RENAL ROUTE
RISK OF CARDIOVASCULAR DISEASE• ESP IN DM/ ELDERLY
HIGH INCIDENCE OF HYPERTENSION• ON C/c ANTIHYPERTENSIVES
ADEQUATELY FUNCTIONING KIDNEY
RECIPIENTS
• NORMAL Cr. LEVELS
• GFR lower
CHOOSE DRUGS INDEPENDENT OF
KIDNEY FOR EXCRETION
AVOID NEPHROTOXIC DRUGS
MONITORING
Monitor ECG, BP, end-tidal capnometry, pulse
oximetry, temperature and neuromuscular
monitoring.
If large fluid shifts or blood loss is anticipated;
invasive monitoring (central venous pressure
and invasive arterial BP) should be established
to guide fluid replacement.
A urinary catheter should be passed to
monitor urine output hourly and should be
maintained at 0.5–1 mL/kg/hr.
If the urine output is low despite good
hydration and BP; mannitol should be
administered as first line treatment
followed by frusemide
.IV fluids should be administered
cautiously,
central venous monitoring may be done to
guide volume replacement.
Starches should be avoided in these
patients as it can accumulate and worsen
the renal impairment, gelatine is safe.
Ringer’s lactate can be used if serum
potassium is within the normal limits.
..
Forced air warmer and fluid warmer
should be used mandatorily to maintain
normothermia.
Over transfusion of blood to correct
anemia should be avoided as increase in
hematocrit can decrease renal perfusion
and further compromise the renal
function.
.NSAID’s are contraindicated in these
patients, paracetamol can be administered
safely
Reversal of neuromuscular
block
Neuromuscular blockade can be reversed
with neostigmine.
Recurarization can occur in the postop and
the recovery staff should be warned about
the same.
Inadequate reversal -it is safer to ventilate
the patient for short-term till complete
neuromuscular recovery occurs
POST OPERATIVE CARE.Oxygen
. ECG, BP and SPO2
ANALGESIA.
WITH ACETAMINOPHEN AVOID NSAIDs
EPIDURAL BLOCK
WOUND INFILTRATION
PERIPHERAL NERVE BLOCK
Early mobilization and physiotherapy
POST OP. CARE
Dosages of medications should administered
as per creatinine clearance. :
Cockcroft–Gault equation (eCCr = estimated
creatinine clearance)
eCCr = (140 - Age) × Mass (inkilograms) [0.85
if female] /72 × Serumcre atinine (inmg/dL)
AVOID PREGNANCY FOR A PERIOD OF
2 YRS AFTER TRANSPLANTATION.
Contraceptive counselling should begin immediately
after transplantation, (ovulatory cycles may begin within
1–2 months of transplantation )
Low dose oestrogen–progesterone OCP.
The risk of infection from the use of intrauterine devices
is increased in immunocompromised patients.
EFFECT OF PREG. ON ALLOGRAFT
MINIMAL BUT FETAL OUTCOME LESS
FAVOURABLE
45% PREG. BEYOND 28 WKS – ADVERSE OUTCOME
LIMIT NUMBER OF PREGNANCIES
PREGNANCY
Factors that are associated with favorable pregnancy outcomes
include the following:
Good general health for about 2 years after
transplantation
No graft rejection in the last year
Adequate and stable graft function
No acute infections that might affect the fetus
Maintenance immunosuppression at stable doses
Patient compliance with treatment and follow-up
Normal blood pressure or blood pressure that is well
controlled with one medication
Normal allograft ultrasonography results
Factors that may worsen
pregnancy outcomesEtiology of the original disease
Chronic allograft dysfunction
Renal insufficiency
Cardiopulmonary diseases
Hypertension
Diabetes mellitus
Obesity
Maternal infection with hepatitis B (HBV) or C
(HCV) or cytomegalovirus (CMV)
EFFECT OF PREGNANCY
ON RENAL ALLOGRAFT
Pregnancy does not appear to cause
excessive or irreversible problems
with graft function if the function of
transplant organ is stable prior to
pregnancy
EFFECT ON FETUS
GOOD PROGNOSIS SEEN WITH:-1. GOOD GENERAL CONDITION FOR 2 YRS
AFTER SURGERY
2. STATURE COMPATIBLE WITH GOOD OBSTETRICAL OUTCOME
3. NO PROTEINURIA
4. NO SIGNIFICANT HYPERTENSION
5. NO e/o GRAFT REJECTION
6. NO e/o PELVICALYCEAL DISTENSION
7. DRUG THERAPY– PREDISOLONE 15 mg/d or less
– AZATHIOPRINE 2mg/kg/d or less
Immunosuppressive drugs in
pregnancy
Glucocorticoids : Adrenal insufficiency and thymic
hypoplasia cleft palate or mental retardation in infants.
(unlikely if the dose of prednisone has been decreased
to 15 mg ).
MOTHER : PROM,infections,aggrevate hypertension.
Azathioprine : low birth weights, prematurity,
jaundice, respiratory distress syndrome and aspiration
,myelosuppression in the fetus.
leukopenia is not usually a problem in the neonate if the
maternal white blood count is maintained at values
higher than 7500/mm3
Immunosuppressive drugs in
pregnancycyclosporin low birth weights and a higher incidence of
maternal diabetes, hypertension and renal allograft dysfunction.
Cyclosporin metabolism increased during pregnancy -higher
doses may be required.
pregnancies in cyclosporin‐treated women were complicated by
pre‐eclampsia.
Tacrolimus:premature labour,renal dysfunction
FEW DETAILS AVAILABLE WITH USE OF OTHER
DRUGS.
Patient self-monitoring of daily blood pressure
Aggressive management of hypertension:
DOC methyldopa
Second-line agents i:clonidine and calcium
channel ,alpha blockers.
contraindicated drugs : angiotensin-converting
enzyme inhibitors and angiotensin receptor
blockers.
Close monitoring of graft function; if rejection is
suspected, consider biopsy .
In cases of acute rejection, steroids are the
preferred drugs
SHOULD CONTINUE
• PREDNISOLONE
• AZATHIOPRINE
• Cs A
• FEAR OF ACUTE REJECTION
REQT. OF Cs A INCREASED DURING PREGNANCY
• INCREASED METABOLISM
GUIDELINES FOR MX
Obstetric management of
pregnant transplant recipients Frequent evaluations, preferably every 2 weeks
Vaginal delivery (preferred): Usually delayed until
labor onset unless maternal/fetal indications for
induction exist
Cesarean delivery is only indicated for obstetric
reasons .
Avoid injury to the allograft by knowing its exact
location
Antibiotic prophylaxis for all surgical procedures [1]
Increased steroid dose at labor onset to overcome
the stress of labor and prevent postpartum transplant
rejection
EMERGENCY SURGERY
WITH ACUTE GRAFT
REJECTION
SPECIAL PREANAESTHETIC
CONSIDERATIONS ARE :-
1. RISK OF ASPIRATION
-GI HGE/PERFORATION
2. TOXICITY OF IMMUNOSUPPRESSANTS
& RELEVANT DRUG INTERACTIONS
3. RISK OF INFECTIONS
4. AVOIDANCE & CURTAILMENT OF
NEPHROTOXIC INSULT
EVALUTE FOR CAD
• Cs A – HYPERTENSION,HYPERGLYCEMIA &
HYPERLIPIDEMIA
PTS ON C/c STEROID THERAPY
• STRESS DOSE OF STEROIDS
INTRAOPERATIVELY
STRICT ASEPSIS FOR INVASIVE
PROCEDURES
BROAD SPECTRUM ANTIBIOTICS
Anesthesia for patients after liver
transplantationGraft function must be assessed
PT-INR excellent marker of synthetic
function
Sterile techniques should be used
Complications due to immunosupressants.
Regional anesthesia is an option if clotting
status is acceptable
A stress dose of corticosteroids may be
needed.
Hepatic blood flow should be maintained.
Anesthesia for patients after
lung transplantation Recipients may require months to achieve peak
pulmonary function.
Transplanted lung is especially susceptible to
infection and rejection as a result of its unique
exposure to the external environment.
Careful preoperative evaluation with PFTs
Postponement of elective surgical procedures
when allograft rejection or infection is suspected.
OTHER CONSIDERATIONS
Airway hyper responsiveness,
Loss of the cough reflex,
Potential for injury to the airway anastomosis
with intubation.
Increased risk for pulmonary edema, D/T
disruption of the lymphatic drainage in the
transplanted lung
Anesthesia for patients after
HEART transplantation
Most issues relate to the absence of autonomic
innervation in the transplanted heart.
Denervation has multiple physiologic effects,
Higher than normal resting HR (from absence of
vagal tone);
Absence of cardiac baroreflexes;
Lack of response to carotid sinus massage,
Valsalva maneuver, laryngoscopy, or tracheal
intubation. .
Anesthesia for patients after
HEART transplantation
Denervation also affects responses to
medications;
the allograft demonstrates a normal or
augmented response to direct-acting
drugs (e.g., epinephrine),
A blunted response to indirect-acting
agents (e.g., ephedrine),
And no response to vagolytic agents.
Chronic allograft rejection
Manifest as accelerated coronary heart disease
and as both systolic and diastolic dysfunction.
Allograft denervation causes any myocardial
ischemia to be silent.
Typical manifestations of chronicrejection
include fatigue, ventricular dysrhythmias,
congestive heart failure, and silent MI on the
ECG.
Patient’s recent cardiac testing must be reviewed.
Anesthesia for patients after
HEART transplantation Routine periodic evaluation for CAD (stress
testing or coronary angiography) and cardiac
function (echocardiogram or radionuclide
angiography).
PreoperativeECGs often reveal conduction
abnormalities and may show two P waves (a non
conducted P wave from the native atria and a
conducted P wave from the donor atria).
Many heart transplant recipients also require
permanent pacemakers, and pacemaker function
should be confirmed during the preoperative
assessment.
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