Anesthesia Management for Kidney Transplantation

Indications for anesthesia management of kidney transplantation: ESRD (end-stage renal disease) glomerular disease caused by various diseases, congenital diseases and polycystic kidney--high blood pressure and diabetes-related nephropathy are common in young patients ESRD pathophysiology: renal Main functions: 1.
Regulate plasma electrolyte concentration and acid-base balance 2.
Maintain normal body fluid volume 3.
Remove chlorine-containing metabolites and drugs in the blood 4.
Synthesize erythropoietin and regulate plasma PH When the function is severely damaged -- - Significant decrease in GFR, decreased urine output - Uremia A.
Fluid volume, electrolytes - Oliguria (increase in extracellular fluid, edema, hypertension), hyperparathyroidism, vascular calcification, hyperkalemia, acid replacement B.
Heart disease Vascular -- the leading cause of death 1.
Increased incidence of myocardial infarction, congestive heart failure, and atrial fibrillation 2.
Accelerated AS process -- coronary, cerebrovascular, and peripheral vascular ischemic diseases 3.
Hypertension causes ERSD, which in turn ERSD Associated hyperreninemia, hypervolemia and renal vascular changes also cause hypertension C.
Hematology, coagulation 1.
Decreased EPO production - normocytochrome anemia 2.
Coagulation abnormalities: due to platelet activation, aggregation and adhesion 3.
Hypercoagulation--enhanced coagulation activity is related to endothelial cell activation D.
Gastrointestinal tract--abnormal gastric motility E.
Decreased clearance of nitrogen compounds can cause central nervous system and neuromuscular dysfunction Preoperative evaluation General principle: Pay attention to the function of each organ of ERSD patients, clarify the risk classification, and make the patient achieve the best condition before surgery --Elective 2.
The most ideal solution for dialysis patients--Preoperative dialysis, especially for patients with excessive volume or clear hyperkalemia and acidosis 3.
Involving large blood vessels--blood preparation - Significant hypovolemia and intraoperative hypotension may occur - appropriate amount of normal saline or colloid before surgery can effectively prevent hypotension during anesthesia induction.
.
Activity tolerance--moderate risk surgery--Comprehensive cardiovascular history, presence or absence of signs and symptoms of advanced heart disease, cardiac function classification and other risk factors 7.
Coronary heart disease + kidney transplantation risk factors--diabetes, cardiovascular, more than Years of dialysis history, left ventricular hypertrophy, age over 60, smoking, hypertension, dyslipidemia 8.
Incidence of occult pulmonary hypertension in patients undergoing dialysis
.

Screening ECG can be used to identify pulmonary hypertension
.

9.
Perioperative use of beta-blockers significantly reduces myocardial infarction morbidity and mortality in high- and intermediate-risk patients, and reduces short-term and long-term mortality in renal failure patients undergoing vascular surgery
.

 Intraoperative management 1.
The preferred method of anesthesia in most kidney transplantation centers during general anesthesia for tracheal intubation 2.
Purpose of anesthesia: to achieve sufficient depth of anesthesia, while maintaining hemodynamic stability and providing good muscle relaxation to facilitate surgical operations
.

3.
Improved rapid sequential induction: Rocu 0.
8-1.
2mg/kg4.
Laryngoscope placement in ESRD patients with chronic hypertension may cause hemodynamic fluctuations, combined use of opioids, esmolol, lidocaine Alternatively, nitroglycerin attenuates stress-induced tachycardia and hypertension
.

5.
The placement of a central venous catheter provides reliable venous access for fluid infusion and administration of immunosuppressive and vasoactive drugs
.

Large-bore venous access is necessary for perioperative volume management
.

6.
Sevoflurane metabolite complex A and fluoride ions have potential nephrotoxicity, but their effects on renal impairment in patients with renal insufficiency have not been proven
.

7.
Morphine, oxycodone and meperidine should be used with caution in patients with renal failure, because their active metabolites mainly rely on renal clearance and may accumulate in the body
.

8.
In patients with renal failure, vecuronium bromide and rocuronium bromide have prolonged muscle relaxation time because their clearance depends on renal and hepatic metabolism
.

And ShunA can be suitable without liver and kidney clearance
.

9.
Surgical procedure: The transplanted kidney is placed in the left or right iliac fossa
.


Graft renal blood vessels and external iliac arteriovenous anastomosis and give heparin before clamping the blood vessels - first clip the external iliac vein and renal vein anastomosis - then clip the external iliac artery and renal artery anastomosis - during the vascular anastomosis, it should be given Normal saline volume expansion—furosemide and mannitol (to reduce the incidence of acute tubular necrosis) to stimulate diuresis before reperfusion Inhaled oxygen concentration---prevent renal hypoperfusion leading to ischemic injury and thrombus
.

11.
Adrenaline vasopressors should be avoided in hypotension, which can cause renal vasoconstriction
.

Dopamine is controversial and is not recommended for perioperative use
.

12.
Monitoring muscle relaxation and giving corresponding antagonists is very important to avoid postoperative pulmonary complications
.

13.
ESRD patients may experience delayed recovery from anesthesia and increased sensitivity to opioids and sedatives
.

 Postoperative management 1.
It is very important to pay close attention to the urine output in the early postoperative period.
When the urine output decreases acutely, the cause should be immediately found and dealt with accordingly
.

2.
Postoperative complications include intravascular thrombosis (1-2%), wound hematoma (1-2%), and infection
.

3.
Use synthetic opioids without active metabolites for postoperative analgesia, uremic coagulopathy - not epidural analgesia, and TAP blockade is effective
.