Dr. M. Kannan md da

• Dr.M.Kannan MD DA

• Professor and HOD of Anaesthesiology

• Tirunelveli Medical College

Coronary artery disease

• Coronary artery disease

• Congestive cardiac failure

• Systemic Hypertension

• Diabetes Mellitus

Coronary artery disease

• Coronary artery disease

• Incidence 17%-34%

• Coronary angiography & re-vascularisation

• Irreversible LV dysfunction with very low cardiac output

Congestive cardiac failure

• Congestive cardiac failure

• CCF is present before dialysis

• CCF Associated with CRF

• IHD Hypoalbuminemia

• Old age Uremic cardiomyopathy

• Diabetes

• Anaemia AV-fistula

Systemic Hypertension

• Systemic Hypertension

• 70% of ESRD patients

• ACE-inhibitors

• Calcium channel blockers

• Beta-blockers

• Diuretics

Diabetes Mellitus

• Diabetes Mellitus

• Cardiac complications gets doubled

• Revised cardiac risk index

• 1.High-risk surgical procedure.

• 2.h/o IHD(excluding previous coronary re-vascularization)

• 3.Heart failure

• 4.h/o stroke or transient ischemic attacks

• 5.Pre-operative insulin therapy

• 6.Pre-operative creatinine levels higher than 2 mg/dl.

Anaemia

• Anaemia

• -Transfusion

• Uremic Coagulopathy

• Uremic Cardiomyopathy

• Se.K+& acid-base status

• Delayed gastric emptying

Optimize fluid and electrolyte balance

• Optimize fluid and electrolyte balance

• Correct hemostatic abnormalities

• Post dialysis weight loss of >2 kg

• -Indicate intra-vascular volume depletion

• -Thromboplastin time is checked for residual heparin

• -Hepatitis can be endemic

Adequate BP control

• Adequate BP control

• Adequate control of blood glucose

• Correction of se.K+ levels.

• Correction of anaemia

• Correction of coagulopathy

Thiopental

• Thiopental

• Propofol

• Isoflurane

• -peripheral vaso-dilatation

• -minimal cardio-depressive effects -preservation of RBF

• -low renal toxicity

• Desflurane

Fluoride

• Fluoride

• CompoundA

• Fresh gas flow rates >4 L/min

Morphine

• Morphine

• Pethedine

• Fentanyl, sufentanil, alfentanil, remifentanyl

-Succinyl choline ? -not contra-indicated in

• -Succinyl choline ? -not contra-indicated in

• pts. with ESRD

Pancuronium

• Pancuronium

• Vecuronium

• Atracurium

• Rocuronium

5-lead ECG.

• 5-lead ECG.

• Arterial BP

• SpO2

• EtCo2

• Temperature .

• Urine output

CVP monitoring

• CVP monitoring

• Direct arterial pressure monitoring

• Pulmonary artery occlusion pressure

• TEE

• Contrast-Enhanced Perfusion USG

Management of the kidney donor(living or cadaveric).

• Management of the kidney donor(living or cadaveric).

• How well the harvested organ is preserved.

• Peri-operative management of the kidney recipient.

Venous return due to the kidney

• Venous return due to the kidney

• -adequate hydration

• V/Q mismatching due to positioning

• Mannitol and IV heparin (3000-5000) units before cross-clamping the renal vessels.

• Administration of protamine to normalize coagulation

Selection -Stable hemodynamics

• Selection -Stable hemodynamics

• Adequate respiratory parameters

• Absolute contra-indications

• Prolonged hypotension Hypothermia

• Collagen vascular diseases

• Congenital or acquired metabolic disorders

• Malignancies, Generalized viral or bacterial infections

• DIC’ Hep B, HIV.

Age above 70 years

• Age above 70 years

• Diabetes mellitus

• High serum creatinine before organ harvesting

• Excessive pre-terminal use of vaso-pressors.

A systolic BP >100 mm Hg

• A systolic BP >100 mm Hg

• PaO2 >100 mm Hg

• Urine output >100 ml/hr

• Hemoglobin concentration >100 g/l

• Central venous pressure between 5 and 10 mm Hg

Vasodilators -Phentolamine

• Vasodilators -Phentolamine

• Hypotension- Fluid administration Pharmacological support

• Bradycardia - Iso-prenaline (a direct acting chronotrope) and not atropine.

General Anaesthesia with controlled ventilation

• General Anaesthesia with controlled ventilation

• -Good hemodynamic stability

• -Better patient comfort.

• Regional Anaesthesia

• Dis-advantages:

• Systemic blood pressure -viability of the kidney donated.

• Large volumes of IVF precipitate acute LVF.

• Advantages

• It is cost-effective

• Complete abolition of stress response

• Less exposure to anaesthetic drugs

Positioning – Care of the AV Fistula

• Positioning – Care of the AV Fistula