Dr. M. Kannan md da



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tarix09.12.2016
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Coronary artery disease

  • Coronary artery disease

  • Congestive cardiac failure

  • Systemic Hypertension

  • Diabetes Mellitus



Coronary artery disease



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




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