ANESTESIA EN TRANSPLANTE RENAL

CARLOS MIGUEL GARCIA CORZO

RESIDENTE ANESTESIOLOGIA Y REANIMACION - UIS

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Frecuencia

Morbimortalidad - supervivencia
Implicaciones en pediatra

NEFROPATIA TERMINAL

Causas

D.M. (44%) Otras G.N. (23%) E.F.Q. (6%) P.N.Crnica (5%) Otras

NEFROPATIA TERMINAL UREMIA

Sobrecarga hdrica
Acidemia Disfuncin Orgnica

Alteracion H-E.

Stockall C, et Al. Renal transplantation. In: Sharpe M D, Gelb A W (eds) Anesthesia and transplantation. Boston: Butterworth Heinemann, 1999: 241274

Stockall C, et Al. Renal transplantation. In: Sharpe M D, Gelb A W (eds) Anesthesia and transplantation. Boston: Butterworth Heinemann, 1999: 241274

NEFROPATIA TERMINAL Infeccin

HIGADO Metabolismo

SISTEMA GASTROINTESTINAL
Current Anaesthesia and Critical Care (1999) 10, 286290

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CONTRAINDICACIONES

Generales Especificas

Malignidad incurable Edad (?) Infx. Sistmica incurable Otra enfermedad sistmica Obesidad mrbida Abuso OH, tabaco, drogas Inestabilidad emocional Ambiente no solidario

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CONTRAINDICACIONES

Generales Especificas

Alta probabilidad recidiva en injerto: G.N.M.P. Sndr. Hemoltico Urmico

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CONSIDERACIONES PRE ANESTESICAS
Procedimiento programado / semiprogramado Pruebas cruzadas / HLA Dilisis previa

Accesos dilisis Valoracin preqx

TABLE 1 -- PATHOPHYSIOLOGIC CONSEQUENCES OF CHRONIC RENAL FAILURE IMPORTANT FOR THE ANESTHESIOLOGIST Abnormality Anemia Mechanism of Abnormality/Clinical Presentation Decreased erythropoetin production, diminished erythrocyte survival (normochromic, normocytic anemia), diminished erythrocyte production (fibrosis of the bone marrow) Qualitative dysfunction (normal platelet count, decreased platelet factor III activity, abnormal platelet aggregation), bleeding diathesis Balanced between reduced O2 -carrying capacity (anemia) and improved O2 capacity (shift of oxyhemoglobin dissociation curve to the right) CHF (primary: uremic cardiomyopathy; secondary: fluid overload), CAD (accelerated atherosclerosis), uremic pericarditis, cardiac tamponade, dysrhythmias (hyperkalemia, hypocalcemia)

Platelet dysfunction

Altered O2 -carrying capacity Cardiovascular abnormalities

TABLE 1 -- PATHOPHYSIOLOGIC CONSEQUENCES OF CHRONIC RENAL FAILURE IMPORTANT FOR THE ANESTHESIOLOGIST

Arterial hypertension

Left ventricular hypertrophy, hypertensive cardiomyopathy, hypertensive crises (malignant hypertension)

Muscle weakness (peroneal nerve palsy with foot drop) Behavioral changes, loss of memory, neuromuscular irritability, lethargy coma (uremic encephalopathy), myoclonus, convulsions Hyperkalemia (cardiac dysrhythmias), hypocalcemia (osteodystrophic abnormalities, osteoporosis, pathologic bone fractures), hypermagnesemia (hypotension, potentiation of depolarizing muscle relaxants, coma), hypervolemia (CHF, pulmonary edema, pleural effusion, hypertension)

Peripheral neuropathy Central nervous system dysfunction

Electrolyte and fluid disturbances

TABLE 1 -- PATHOPHYSIOLOGIC CONSEQUENCES OF CHRONIC RENAL FAILURE IMPORTANT FOR THE ANESTHESIOLOGIST Acidbase abnormalities Gastrointestinal abnormalities Endocrine disturbances Dialysis-related problems Metabolic acidosis Uremic gastroenteritis, nausea and vomiting, peptic ulcer disease, gastrointestinal bleeding Secondary hyperparathyroidism, osteomalacia, renal osteodystrophy (bone pain, fractures) Dialysis dementia, dysequilibrium syndrome after acute dialysis (cerebral edema), hypovolemia (hypotension after anesthetic induction following recent dialysis), peritonitis (peritoneal dialysis), systemic anticoagulation (after dialysis)

Anesthesiology Clinics of North America, Vol 18 (4) Dec 2000

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CONSIDERACIONES PRE ANESTESICAS
Comorbilidad
DM HTA ICC EAC Enf. pulmonar - Malignidad 20 60% Morbilidad < 2% Mortalidad rara Rgos postqx Edios preqx Protocolo autotransfusin Premedicacin

Donantes vivos*

TABLE 2 -- PERIOPERATIVE PROBLEMS IN PATIENTS WITH DIABETES IMPORTANT FOR THE ANESTHESIOLOGIST Abnormality Clinical Relevance Treatment/Precautions

Stiff joint syndrome

Autonomic neuropathy

Difficult tracheal intubation caused by fixation of the atlanto-occipital joint

Hypotension, bradycardia, labile blood pressure during anesthesia Gastroparesis with delayed gastric emptying (acid aspiration precautions)

Careful laryngoscopy; consider awake fiberoptic intubation

Vasopressors, atropine, resuscitation; consider invasive monitoring of blood pressure Sodium citrate, metoclopramide, H2 blockers Increased myocardial infarctio surveillance Careful positioning andprevention of pressure

Functional sympathetic denervation Peripheral neuropathy

Silent myocardial infarction

Stocking-glove distribution: loss of sensation in lower

Electrolyte imbalance

Cardiac dysrhythmias

Treat underlying condition

Diffuse Vascular insufficiencies: Surgical or medical atherosclero myocardial infarction, stroke, therapy; close sis peripheral vascular occlusive perioperative surveillance disease, and so forth Systolic arterial hypertension Hyperglyc. Hyperosmolarity, hyperkalemia, dehydration, coma Sweating, tachycardia, hypertension, coma Antihypertensives Frequent determinations of serum glucose; insulin, hydration Frequent determinations of serum glucose; glucose

Hypoglyc.

Ketoacidosis

Hyperosmolarity, hyperglycemia, hyperkalemia, metabolic acidosis, coma

Insulin, bicarbonate, correct electrolyte dysbalance, hydration

Anesthesiology Clinics of North America, Vol 18 (4) Dec 2000

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CONSIDERACIONES PRE ANESTESICAS
Regional Tcnica anestsica General

Premedicacin
Monitoreo

Sedacin Profilaxis B/A

-Bsico -CVC -ENP

-LA -CAP -ETE -US perf. renal

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INDUCCION Posicin de paciente

Prevencin hipotermia
Induccin Rpida? Tiopental Etomidato Propofol Fraccin libre duplicada V1/2 depuracin sin Cambio (TIVA)

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INDUCCION

Relajante Muscular - v1/2b (hr) Rocuronio 1.2 1.6 Vecuronio 1.3 1.6 Atracurio 0.3 0.4 Cis-atracurio 0.5 0.6 Mivacurio 2 min 2 min
Sch 2 min 2 min

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INDUCCION

Opioides Fentanyl
Sulfentanyl Alfentanyl

farmacocintica estable
depresion ventilatoria > Fr. Libre y V.D.

Remifentanyl metabolito GR90291

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INDUCCION

Manejo de V.A. Mscara Larngea vs TOT < requerim. Anestsico < rgo infeccin V.R. < rgo atelectasia < cambio hemodinmico

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MANTENIMIENTO

Halogenados Isofluorane
Desfluorane Halotano Enfluorane Sevofluorane Biotransformacin, Depr. Miocardica, fl. renal Hepatitis (dialisis crnica) > Incidencia rechazo

Compuesto A

N2O?

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MANTENIMIENTO

T.I.V.A. Alfentanyl Remifentanyl

Cisatracurio Uso en aumento

Propofol

Droperidol?
Pediatric Surgery International. 17(2-3):175-9, 2001 Mar.

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FACTORES QUE AFECTAN LA VIABILIDAD RENAL
*Manejo de donante *Preservacin del injerto *Manejo de receptor Vivo Cadver

Hidratacin
TA

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FACTORES QUE AFECTAN LA VIABILIDAD RENAL PO2>100 *Manejo de donante Vivo Normocapnia Cadver TAS>100 *Preservacin del GU>100 injerto Heparina *Manejo de receptor

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FACTORES QUE AFECTAN LA VIABILIDAD RENAL
*Manejo de donante *Preservacin del injerto *Manejo de receptor Tiempos isquemia

Caliente Fra

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FACTORES QUE AFECTAN LA VIABILIDAD RENAL
*Manejo de donante *Preservacin del injerto *Manejo de receptor

*Diuresis temprana

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FACTORES QUE AFECTAN LA VIABILIDAD RENAL
*Manejo de donante *Preservacin del injerto *Manejo de receptor Oligoanuria

F. mecnicos
F. no mecnicos

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MANEJO INTRAOPERATORIO Oligo-anuria F. mecnicos Pre-renal
Post-renal

vasculares

F. no mecnicos

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MANEJO INTRAOPERATORIO Oligo-anuria F. mecnicos Pre-renal
Post-renal obstructiva

F. no mecnicos

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MANEJO INTRAOPERATORIO Oligo-anuria F. mecnicos
Hipovolemia Hipotensin NTA Rechazo agudo

F. no mecnicos

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MANEJO INTRAOPERATORIO
Vol. Intravascular Albmina Diurticos Manitol Calcio antagonistas Dopamina dopexamina Coctel renal

Prevencin N.T.A.

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MANEJO INTRAOPERATORIO
PVC 10-15 TAS > 120 PMAP > 20

Vol. Intravascular Prevencin N.T.A.

Albmina

40-70 ml/kg plasma 0.8 1.6 g/kg

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MANEJO INTRAOPERATORIO Na-K ATPasa
Diurticos Umbral isqumico

Prevencin N.T.A.
Manitol

FUROSEMIDA
Proteccin (temprana?)

Riesgos

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MANEJO INTRAOPERATORIO Verapamilo Ca-antagonistas I.O. P.O. Dopamina (Discutida proteccin) Prevencin N.T.A. Dopexamina (Beneficio?) Coctel Renal Dx 0.45%+SS 0.45 N Albumina 37.5 g Manitol 37.5 g Furosemida 80 mg

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MANEJO INTRAOPERATORIO Complicaciones Hipertensin
Hipotensin NTG IECA

Arritmias
Hiperkalemia

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MANEJO INTRAOPERATORIO Implicaciones
D.M. IAM silente Disautonoma

Anemia cel. falciformes

HbS < 40%

Inmunosupresores Tamao Injerto

Tqk E.P.A. OKT3 Ciclosporina

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MANEJO POST OPERATORIO
Extubacin: mayora despiertos Reversin RNM Analgesia P.O. MORFINA

Tbosis. A. renal

Depuracin metabolitos afectada 2-6%....Heparina? Inmunosupresores

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MANEJO POST OPERATORIO
Anuria oliguria P.O. NTA!! Donante cadaver volemia Vasopresor nefrotx. inotrpicos Tiempo preservacin ciclosporina Rechazo ag. Causa QX

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MANEJO POST OPERATORIO
H.T.A. TAS > 160 mmHg Dolor? Hipoxemia? Volemia?

Falla cardiaca -I.A.M. Ed. Pulmonar - A.C.V. Sangrado suturas

No tto especfico recomendado

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MANEJO DEL DONANTE
VIVO

Contraindicaciones: DM, HTA, enf. sistmicas

Compatibilidad ABO

Posicin: puede inducir hipotensin, alteraciones de perfusin y ventilacin.

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MANEJO DEL DONANTE
VIVO

Mandatoria adecuada hidratacin Manitol: previo a clampeo vascular

Hipotensin: preferible no vasopresores directos (dopamina, efedrina)

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MANEJO DEL DONANTE
VIVO En general sin complicaciones a largo plazo (aun si son donantes de alto riesgo)
Siebels M et al. Nephrol Dial Transplant (2003) 18: 26482654

Tcnica anestsica: acorde a protocolos de cada entidad y tipo de intervencin (nefrectoma laparoscpica vs abierta)

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MANEJO DEL DONANTE
CADAVERICO

Contraindicaciones: Absolutas Relativas

Hipotensn Hipotermia Tr. Colgeno Alt. Metablicas Malignidad Infx. Bacteriana o viral C.I.D. Hs B - HIV

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MANEJO DEL DONANTE
CADAVERICO

Contraindicaciones: Absolutas Relativas

Edad > 70 aos DM Vasculopatia Creatinina elevada Excesivos vasopresores

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MANEJO DEL DONANTE
PO2 >100, normocapnia CADAVERICO Volemia adecuada Manejo intraoperatorio Hto 30% TAS > 100 GU > 100 c/hr Heparina Vasopresores NTA

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RESULTADOS LARGO PLAZO SOBREVIDA INJERTO 1 AO Donante vivo: HLA identico 95% no idnt. 90% D. cadavrico: primer transpl. 80% retranspl. 70% Muertes: 1% hemorragia cerebral

Sobrevida global 95%

TABLE 4 -- PERIOPERATIVE PROBLEMS AND ANESTHESIARELATED ADVERSE EVENTS THAT CAN WORSEN SICKLING PROCESS IN PATIENT WITH SICKLE CELL DISEASE Abnormality Presence of hemoglobin S Clinical Relevance Increased tendency for sickling under conditions of reduced oxygen tension (hypoxia) Excessive hemolysis Decreased red cell lifespan Aplastic crises Vaso-occlusive phenomena Painful crises caused by microinfarcts Therapy/Prevention Preoperative exchange transfusion to decrease hemoglobin S concentration to less than 40% Transfusions as needed Avoid sickling conditions (see below) Folic acid supplementation Analgesics

Chronic anemia

Anesthesiology Clinics of North America, Vol 18 (4) Dec 2000

Vasoocclusive phenomena

Thromboembolic phenomena (impairment of pulmonary function, increased shunting with reduced PaO2 ), renal microinfarcts (hypostenuria or inability to concentrate urine leads to dehydration, which promotes further sickling and hemolysis) Worsens sickling process

Avoid hypothermia; replace blood loss and intravascular volume promptly

Systemic hypoxia

Acidosis (metabolic, respiratory)

Worsens sickling process (because of the shift of oxyhemoglobin dissociation curve to the right)
Worsens sickling process

Correct with alkali; maintain adequate circulating volume and adequate ventilation
Maintain normothermia

Hypothermia