transplant patient for non transplant surgery

Download Transplant patient for non TRANSPLANT SURGERY

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  1. 1. ANAESTHESIA FOR RENAL TRANSPLANT PATIENT FOR NON-TRANSPLANT SURGERY MOD : DR. KAUMUDI Dr.Arun
  2. 2. INTRODUCTION n POST TRANSPLANT PATIENT n INCREASED SURVIVAL BETTER IMMUNOSUPPRESSIVE REGIMES, SURGICAL TECHNIQUES POSTOPERATIVE CARE.
  3. 3. 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
  4. 4. PRE ANAESTHETIC CONSIDERATIONS 1. IDENTIFICATION OF COMPLICATIONS & THEIR ANAESTHETIC IMPLICATIONS 2. TOXICITY OF IMMUNOSUPPRESSANTS 3. RELEVANT DRUG INTERACTIONS WITH IMMUNOSUPPRESSANTS 4. REJECTIONS 5. INFECTIONS
  5. 5. CONCERNS IN A TRANSPLANT RECIPIENT 1) 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
  6. 6. 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
  7. 7. COMPLICATIONS AFTER RENAL TRANSPLANTATION n EARLY HEMORRHAGIC CYSTITIS CAPILLARY LEAK AGVHD PANCYTOPENIA CARDIOMYOPATHY VENO OCCLUSIVE LIVER DISEASE INTERSTITIAL PNEUMONITIS
  8. 8. COMPLICATIONS AFTER RENAL TRANSPLANTATION n LATE CGVHD LEUKO ENCEPHALOPATHY INFECTION SECONDARY MALIGNANCIES OBSTRUCTIVE/ RESTRICTIVE LUNG DISEASE HYPOTHYROIDISM CATARACT
  9. 9. IMMUNOSUPPRESSIVE THERAPY FOR TRANSPLANT RECIPIENTS TRIPLE DRUG REGIMEN 1) CYCLOSPORIN / TACROLIMUS 2) GLUCOCORTICOIDS METHYL PREDNISOLONE 3) MYCOPHENOLATE MOFETIL/ AZATHIOPRINE
  10. 10. 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
  11. 11. 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
  12. 12. TOXICITY RELATED TO IMMUNOSUPPRESSIVE DRUGS
  13. 13. CYCLOSPORIN A WATER SOLUBLE ORAL ABSORPTION UNPREDICTABLE IV DOSE 1/3 ORAL DOSE
  14. 14. 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
  15. 15. CYCLOSPORIN A NEUROTOXICITY HEADACHE PARESTHESIAS TREMOR CONFUSION FLUSHING NEUROPATHIES GENERALISED SEIZURES
  16. 16. CYCLOSPORIN A VASCULAR EFFECTS HYPERTENSION (INCIDENCE 42-100%) DIABETOGENIC TOTAL CHOLESTEROL CORONARY ARTERY DISEASE
  17. 17. CYCLOSPORIN A METABOLIC EFFECTS HYPERKALEMIA HYPOMAGNESEMIA HIRSUITISM GUM HYPERPLASIA ANOREXIA LYMPHOPROLIFERATIVE DISEASES INFECTIOUS DISEASES
  18. 18. 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
  19. 19. TACROLIMUS USED IF NOT TOLERATING Cs A Cs A STOPPED ONLY AFTER 24 HRS OF STARTING TACROLIMUS
  20. 20. STERIODS USED IN ALL TRANSPLANT FOR A PERIOD OF TIME USED TO PREVENT REJECTION AND AS PULSE THERAPY FOR TREATMENT OF ACUTE REJECTION
  21. 21. STERIODS OBESITY GLUCOSE INTOLERANCE SERUM LIPID LEVELS ACCELERATE CARDIOVASCULAR DISEASE MARKED SKIN FRAGILITY MINIMISE ADHESIVE TAPES PADDED BP CUFFS EYES LUBRICATED
  22. 22. STERIODS DELAYED WOUND HEALING RISK OF OSTEOPOROSIS CAREFUL MOVEMENT & POSITIONING IRRITATE GASTRIC MUCOSA
  23. 23. ANTIMETABOLITES AZATHIOPRINE MYCOPHENOLATE MOFETIL ANTI-NUCLEOTIDE ANTIMETABOLITES INHIBIT LYMPHOCYTE PROLIFERATION & ANTIBODY PRODUCTION
  24. 24. AZATHIOPRINE BONE MARROW DEPRESSION HEPATOTOXICITY MYCOPHENOLATE NO INTERACTION WITH CsA & PREDNISOLONE NEPHROTOXICITY HEPATOTOXICITY BM DEPRESSION
  25. 25. ANTIMETABOLITES AZATHIOPRINE MYCOPHENOLATE MOFETIL ANTI-NUCLEOTIDE ANTIMETABOLITES INHIBIT LYMPHOCYTE PROLIFERATION & ANTIBODY PRODUCTION
  26. 26. DRUGS AFFECTING Cs A & TACROLIMUS BLOOD LEVELS BLOOD LEVELS METOCLOPRAMIDE VERAPAMIL NICARDIPINE CIMETIDINE DILTIAZEM BROMCRIPTINE ERYTHROMYCIN KETOCONAZOLE CHLOROQUINE
  27. 27. DRUGS AFFECTING Cs A & TACROLIMUS BLOOD LEVELS BLOOD LEVELS CARBAMAZEPINE PHENOBARBITAL PHENYTOIN RIFAMPICIN OCTREOTIDE TICLOPIDINE
  28. 28. DRUGS THAT MAY CAUSE RENAL DYSFUNCTION WHEN GIVEN WITH Cs A & TACROLIMUS NSAIDs RANITIDINE CIMETIDINE AMPHOTERICIN COTRIMOXAZOLE GENTAMICIN MELPHALAN TACROLIMUS/ Cs A
  29. 29. INFECTIONS IN IMMUNOSUPPRESSED MAJOR 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
  30. 30. MYCOBACTERIAL INFECTIONS SYSTEMIC MYCOSES NOCARDIOSES PARASITIC INFECTIONS STRONGYLOIDES ENTAMEBA ACANTHAMEBA
  31. 31. 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.
  32. 32. 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).
  33. 33. 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
  34. 34. Examination Measure the patients 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. Patients who are fluid overloaded may have crepitations
  35. 35. REJECTION MAIN CAUSE OF LATE MORTALITY PROGRESSIVE DETERIORATION IN ORGAN FUNCTION TESTS AZOTEMIA PROTEINURIA HYPERTENSION
  36. 36. REJECTION SURGERY DURING PERIOD OF REJECTION HAVE HIGHER MORBIDITY
  37. 37. REJECTION PRESENTATION:- PROGRESSIVE DETERIORATION OF ORGAN FUNCTION OR WITH MINIMAL SYMPTOMS FROM TRANSPLANTED ORGAN & WITH NON SPECIFIC SYMPTOMS POOR APPETITE IRRITABILITY FATIGUE
  38. 38. 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
  39. 39. REJECTION ADEQUATE LEVELS OF IMMUNOSUPPRESSIVE AGENTS SHOULD BE MAINTAINED THROUGHOUT THE PERIOPERATIVE PERIOD
  40. 40. Investigations Full 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
  41. 41. Preoperative optimization/preparation If 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.
  42. 42. 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.
  43. 43. 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
  44. 44. 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.
  45. 45. 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.
  46. 46. Maintenance of anesthesia Atracurium is preferable as it undergoes Hoffmans 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 admini