Original Article
Anaesthetic consideration during laparoscopic bilateral simultaneous nephrectomy Manisha P Modi1,2, Kalpana S Vora1,2, Geeta P Parikh1,2, Pranjal R Modi3, Veena R Shah1,2 Department of Anaesthesia and Critical Care, GR. Doshi and KM Mehta Institute of Kidney Diseases and Research Centre, Departments of 2Anaesthesia and Critical Care, 3Urology, Dr. HL Trivedi Institute of Transplantation Sciences, Asarwa, Ahmedabad, Gujarat, India 1
Address for Correspondence: Dr. Manisha P Modi, Department of Anaesthesia and Critical Care, GR Doshi and KM Mehta Institute of Kidney Diseases and Research Centre and Dr. HL Trivedi Institute of Transplantation Sciences, Civil Hospital campus, Asarwa, Ahmedabad 380 016, Gujarat, India. E-mail: [email protected]
Abstract STUDY OBJECTIVE: To assess outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy. DESIGN: Retrospective study. MEASUREMENTS: Preoperative Hb%, serum potassium, coagulation profi le electrocardiography (ECG) changes, 2D Echography, x-ray chest, haemodynamic changes, end-tidal carbon dioxide (EtCO 2 ), fluid management and postoperative analgesia. RESULTS: The mean age was 24.75 ± 14.35 years. The mean duration of surgery was 120 ± 80 minutes. The Hb%, serum creatinine and serum potassium were 9.4 ± 1.04%, 6.79 ± 4.91 meq/L and 3.61 ± 0.51 meq/L, respectively. Pulse rate mean blood pressure and EtCO2 were recorded after creation of pneumoperitoneum and at 15, 30, 45 and after exsufflation of pneumoperitoneum. After pneumoperitoneum, there was increase in pulse rate, systolic blood pressure, diastolic blood pressure and EtCO2. After 30 minutes and throughout the surgery, these variables remained stable. Four patients required nitroglycerine infusion for intraoperative hypertention. Only one patient required packed cell volume (PCV) transfusion and total intravenous fluid was 1 ± 0.5 L. At the time of exsufflation, there was decrease in pulse rate, systolic and diastolic blood pressure and EtCO 2 . CONCLUSION: Because of advancement Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.124453
10
in anaesthetic agents and muscle relaxant, there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy. Key words: Anaesthesia, bilateral nephrectomy, laparoscopy
INTRODUCTION Prerenal transplant nephrectomy is indicated for calculus disease, reflux, uncontrolled hypertension and polycystic kidney disease. These patients are very sick in view of their medical condition. Anaesthesia for these patients requires thorough preoperative evaluation and stabilisation of their general condition. There is paucity of information regarding anaesthetic outcome in this anephric patients. Therefore, we conducted this retrospective study in chronic renal failure patients who underwent bilateral laparoscopic simultaneous nephrectomy. Their preoperative investigations, intraoperative haemodynamic and intravenous fluid management were noted and analysed.
MATERIALS AND METHODS The study group was composed of 10 patients aged 24.75 ± 14.56 years (adult male) with American Society of Anaesthesiologists (ASA II-III) who underwent elective laparoscopic retroperitoneal bilateral simultaneous nephrectomy for different indications over a 3-year period from 2006 to 2010. After thorough preoperative evaluation and preparation, all patients were scheduled for surgery. They all were underwent their regular haemodialysis 6 hours before the surgery. They were kept nil per oral for
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
Modi, et al.: Bilateral pretransplant nephrectomy and anaesthesia
overnight. On the day of surgery, morning serum potassium (S.K), electrocardiography ECG and coagulation profile were obtained. They were advised to take morning dose of regular treatment for hypertension and anticonvulsant. In operating room, after securing intravenous cannula and protection of arteriovenous fistula all patients were given general anaesthesia. They were premeditated with intravenous glycopyrolate 0.004 mg and 3 μg/kg fentanyl citrate. Injection thiopental sodium 3-4 mg/kg was used for induction and endotracheal intubation was facilitated with injection suxamethinium 1-1.5 mg/kg and maintained with gas, oxygen and isoflurane. Intermittant atracurium was used as muscle relaxant. They were monitored with ECG, Non-Invasive Blood Pressure (NIBP), Saturation of Peripheral Oxygen (SPO2), endtidal carbon dioxide (EtCO2) and temperature probe. Pulse rate, systolic blood pressure, diastolic blood pressure and EtCO2 were recorded after creation of pneumoperitoneum then after 15, 30, 45 minutes and after exsuffflation. Normal saline was given as intravenous fluid and blood loss was replaced with PCV followed by injection calcium gluconate. Nephrectomy was carried out using retroperitoneal approach in kidney position. After completion of one side of nephrectomy another side was performed. Total surgical time and total intravenous fluid were noted. Injection tramadol 2 mg/kg was given for postoperative analgesia along with inj ondansetron 2 mg. At the completion of surgery, all patients were reversed from neuromuscular blockade and shifted to intensive care unit.
from 91.3 ± 18.7/min to 97.7 ± 20.9/min (P < 0.506), systolic blood pressure from 142.3 ± 19.1 mmHg to 157 ± 35.6 mmHg (P < 0.838), diastolic blood pressure from 90.1 ± 1 mmHg to 98 ± 9.19 mmHg (P < 0.143) and EtCO2 from 28.6 ± 2.91 to 31.8 ± 3.68 (P < 0.475), [Table 3]. After 30 minutes, these variables remained stable throughout the surgery. Four patients required nitroglycerine infusion for intraopearative hypertention. Only one patient required PCV transfusion and total intravenous fluid was 1 ± 0.5 L. At the time of exsufflation, there was decrease in pulse rate, systolic and diastolic blood pressure and EtCO2. All patients were ventilated with tidal volume of 7-10 ml/kg and respiratory rate of 12-14/min which was adjusted to keep the EtCO2 between 35 mmHg and 40 mmHg. The hemodynemic and changes in EtCO2 during right and left nephrectomy were comparable. There was no change in temperature throughout the procedure. Three patients had mild-moderate pulmonary hypertension.
DISCUSSION Anaesthesia for bilateral simultaneous nephrectomy represents a significant challenge and successful management of these patients requires systemic approach to preoperative evaluation and careful selection of anaesthetic agents. End stage renal disease is a multisystem disorder and is associated Table 1: Demographic data and investigations
Statistical Analysis Statistical Analysis was performed using Statistical Package Of Social Sciences i.e. SPSS version 12. Data are expressed as mean ± SD (standard deviation) for Continuous variables and no (%) for categorical variables. Continuous variables were compared using independent t-test and Mann-Whitney U-test. Also related variables were compared using Paired sample t-test and Wilcoxon Signed ranks test. P < 0.05 is considered to be statistically significant.
Variables
RESULTS
Table 2: ECG, X-ray & 2D Echocardiography findings in patients
Among 10 patients, six patients were on antihypertensive drugs, one on anticoagulant, one on digoxin and one was diabetic on insulin. The mean age was 24.75 ± 14.35 years. The mean duration of surgery was 120 ± 80 minutes. The Hb%, serum creatinine and SK were shown in Table 1. ECG, 2D Echo and x-ray chest finding were presented in Table 2. Pulse rate mean blood pressure and EtCO2 were recorded after creation of pneumoperitoneum and at 15, 30, 45 and after exsufflation of pneumoperitoneum. After pneumoperitoneum, there was increase in pulse rate
Mean±SD
Age Weight Hemoglobin Random blood sugar S. Creatinine S. Potassium Chronic renal failure MHD
27.2±13.44 47.8±10.24 9.4±1.04 106±40.9 6.79±4.91 3.61±0.51 921.5±487.2 days 757.2±435.9 days
ECG
XRAY-CHEST ECHO
WNL LVH WNL WNL T in V1-V3 WNL LAD WNL T in lateral lead TV2,3,6
N N N N N N CM N CM N
EF-60%, LVH EF-55%, LVH, RVSP 30 EF-55%, RVSP 55 EF-55%, RVSP 55 EF-55% EF-60% EF-50% EF-30%, LVH, Global dysfunction 55% 55%
WNL: Within normal limits, LVH: Left ventricular hypertrophy, T: T wave inversion, LAD: Left axis deviation, EF: Ejection fraction, RVSP: Right ventricular systolic pressure
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
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Modi, et al.: Bilateral pretransplant nephrectomy and anaesthesia Table 3: Comparison between right and left nephrectomy (% increase in values of all variables with baseline)
Baseline to after CO2 Pulse SBP DBP ETCO2 Baseline to after 15 min Pulse SBP DBP ETCO2 Baseline to after 30 min Pulse SBP DBP ETCO2 Baseline to after 45 min Pulse SBP DBP ETCO2 Baseline to after pneumoperitoneum Pulse SBP DBP ETCO2
Right Nephrectomy (n=10)
Left Nephrectomy (n=10)
P-value
8.7±20.7 14.9±15.3 10±14.3 11.1±6.17
8.9±19.3 10.5±20.7 11.1±17.2 7.6±6.11
0.982 0.622 0.468 0.254
4.4±15.5 3.2±17.3 0.5±17.3 14±12.5
8.8±20.4 5.2±23.4 14.6±16.02 16.6±8.89
0.520 0.849 0.075 0.642
0.6±16.07 2.5±18.8 -3.3±12.7 13.3±11.8
10.8±19.2 2.3±23.4 7±12.7 11.8±9.21
0.150 0.879 0.058 0.819
2.6±19.2 -1.8±18.03 -3.9±11.4 12.3±11.4
3.6±19.5 -0.90±25.6 0.80±15.6 6.3±8.48
0.790 0.703 0.518 0.123
-1.0±17.3 -10.5±11.5 -11±9.58 2.1±8.13
-1.5±19.9 -9.8±18.4 -6.1±13.4 9.1±6.79
0.732 0.819 0.879 0.042
SBP: Systolic blood pressure, DBP: Diastolic blood pressure, ETCO2: End tidal CO2
with increased risk of cardiovascular co morbidity and increased severity of cardiovascular disease. Apart from the impact of surgery and co morbidity, the main perioperative care issues to be considered in this patient population are impact of haemodialysis and anephric state. The problems associated with haemodialysis are increased bleeding complications, arrthymias, and poor blood pressure control including hypertension and hypotension which may be aggravated by laparoscopic surgery. We have observed same hemodynamic and EtCO2 changes after creation of pneumoperitoneum as in healthy population.[1] In our study, four patients required injection nitroglycerine for control of hypertension, this might be due to pneumoperitonium. The most common cardiovascular issues in these patients are arteriosclerosis mediated hypertension, ischemic heart disease, impaired systolic and/or diastolic ventricular function and arrhythmogenic sudden cardiac death. [2] Our three patients had Left ventricular hypertrophy (LVH), two had low ejection fraction and global left ventricular dysfunction. None of our patient had arrhythmias or any adverse cardiac event. The presence of severe pulmonary 12
hypertension should be determined preoperatively as it will have a significant impact on the anaesthetic management of the patient. [3] Management goals should centre on the avoidance of hypoxia, hypercapnia, acidosis and hypotension as each of these factors will increase pulmonary vascular resistance. Our three patients had mild-moderate pulmonary hypertension. Close attention should be paid to establishing the correct dry weight for the patient. If the patient is above their dry weight preoperatively, they risk for pulmonary oedema and poorly controlled hypertension perioperatively and poor tissue healing postoperatively. If under their dry weight, they may become profoundly hypotensive during surgery which will be exacerbated by blood loss and anaesthetic agents. An arteriovenous access may be at risk for thrombosis from hypotention. Access function should be checked as part of the postoperative evaluation. Careful consideration should be given to the type and quantity of fluid to be administered during surgery. This will be determined by the preoperative hydration status of the patient, duration of surgery and the estimated fluid losses during surgery. We had infused normal saline to maintain hydration and surgical loss. In anephric patients, there is failure to normally excrete and/or metabolise anaesthetics and analgesics leading to toxic levels of these agents and difficulty in adjusting fluid and electrolytes in the perioperative period. Potential alterations in volume of distribution, protein binding, drug metabolism and excretion must be considered carefully before deciding upon a particular anaesthetic technique. We have used fentanyl as premedication as it is safe in renal failure. [4] A significant hyperkalemic response to suxamethonium is not observed in chronic renal failure provided the preoperative serum potassium level is within normal limit. In our all patients’ serum potassium level was normal so we had used suxamethonium to facilitate endotracheal intubation and we did not observed hyperkalemic response. Our result was similar with the study of Thapa et al.,[5] Sevoflurance has been used in renal disease and it appears safe from serum inorganic fluoride levels and elimination rate than the healthy control.[6,7] We used atracurium as muscle relaxant. Anephric patients distribute and eliminate atracurium much as normal patients do. Pharmacodynamic measurements show almost identical times for duration and recovery from neuromuscular blockade in normal and anephric patients under isoflurane anaesthesia.[8] Our all patients had smooth recovery from neuromuscular blockade. Vecuronium and rocuronium are significantly prolonged in renal failure because of reduced clearance.[9] Intravenous access and blood pressure monitoring should be avoided in the
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
Modi, et al.: Bilateral pretransplant nephrectomy and anaesthesia
arteriovenous fistula arm. Crystalloid/colloid can be used for maintenance or replacement fluid. In this patient population, maintenance fluid must be o restricted, however, ongoing sequestration or overt losses should be replaced with either crystalloid, colloid or blood products. The choice of fluid depends on patients electrolytes. We have used 0.9 normal saline but we can used ringer’s lactate if serum potassium is low. Blood loss can be replaced with packed cell volume/washed RBCs.
3.
4. 5. 6.
7.
CONCLUSION 8.
Because of advancement in anaesthetic agents and muscle relaxant, there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy.
REFERENCES 1.
2.
Nadu A, Ekstein P, Szold A, Friedman A, Nakache R, Cohen Y, et al. Ventilatory and hemodynamic changes during retroperitoneal and transperitoneal laparoscopic nephrectomy: A prospective real-time comparison. J Urol 2005;174:1013-7. Miller LM, Sood MM, Sood AR, Reslerova M, Komenda P, Rigatto C, et al. Cardiovascular disease in end-stage renal disease: The challenge of assessing and managing cardiac disease in dialysis patients. Int Urol Nephrol
9.
2010;42:1007-14. Price LC, Wort SJ, Finney SJ, Marino PS, Brett SJ. Pulmonary vascular and right ventricular dysfunction in adult critical care: Current and emerging options for management: A systematic literature review. Crit Care 2010;14:R169. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage 2004;28:497-504. Thapa S, Brull SJ. Succinylcholine-induced hyperkalemia in patients with renal failure: An old question revisited. Anesth Analg 2000;91:237-41. Mazze RI, Callan CM, Galvez ST, Delgado-Herrera L, Mayer DB. The effects of sevoflurane on serum creatinine and blood urea nitrogen concentrations: A retrospective, twenty-two-center, comparative evaluation of renal function in adult surgical patients. Anesth Analg 2000;90:683-8. Nishiyama T, Aibiki M, Hanaoka K. Inorganic fluoride kinetics and renal tubular function after sevoflurane anesthesia in chronic renal failure patients receiving hemodialysis. Anesth Analg 1996;83:574-7. deBros FM, Lai A, Scott R, deBros J, Batson AG, Goudsouzian N, et al. Pharmacokinetics and pharmacodynamics of atracurium during isoflurane anesthesia in normal and anephric patients. Anesth Analg 1986;65:743-6. Lynam DP, Cronnelly R, Castagnoli KP, Canfell PC, Caldwell J, Arden J, et al. The pharmacodynamics and pharmacokinetics of vecuronium in patients anesthetized with isoflurane with normal renal function or with renal failure. Anesthesiology 1988;69:227-31.
Cite this article as: Modi MP, Vora KS, Parikh GP, Modi PR, Shah VR. Anaesthetic consideration during laparoscopic bilateral simultaneous nephrectomy. J Min Access Surg 2014;10:10-3. Date of submission: 17/03/2013, Date of acceptance: 27/05/2013 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
13
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Anaesthetic consideration during laparoscopic bilateral simultaneous nephrectomy Manisha P Modi1,2, Kalpana S Vora1,2, Geeta P Parikh1,2, Pranjal R Modi3, Veena R Shah1,2 Department of Anaesthesia and Critical Care, GR. Doshi and KM Mehta Institute of Kidney Diseases and Research Centre, Departments of 2Anaesthesia and Critical Care, 3Urology, Dr. HL Trivedi Institute of Transplantation Sciences, Asarwa, Ahmedabad, Gujarat, India 1
Address for Correspondence: Dr. Manisha P Modi, Department of Anaesthesia and Critical Care, GR Doshi and KM Mehta Institute of Kidney Diseases and Research Centre and Dr. HL Trivedi Institute of Transplantation Sciences, Civil Hospital campus, Asarwa, Ahmedabad 380 016, Gujarat, India. E-mail: [email protected]
Abstract STUDY OBJECTIVE: To assess outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy. DESIGN: Retrospective study. MEASUREMENTS: Preoperative Hb%, serum potassium, coagulation profi le electrocardiography (ECG) changes, 2D Echography, x-ray chest, haemodynamic changes, end-tidal carbon dioxide (EtCO 2 ), fluid management and postoperative analgesia. RESULTS: The mean age was 24.75 ± 14.35 years. The mean duration of surgery was 120 ± 80 minutes. The Hb%, serum creatinine and serum potassium were 9.4 ± 1.04%, 6.79 ± 4.91 meq/L and 3.61 ± 0.51 meq/L, respectively. Pulse rate mean blood pressure and EtCO2 were recorded after creation of pneumoperitoneum and at 15, 30, 45 and after exsufflation of pneumoperitoneum. After pneumoperitoneum, there was increase in pulse rate, systolic blood pressure, diastolic blood pressure and EtCO2. After 30 minutes and throughout the surgery, these variables remained stable. Four patients required nitroglycerine infusion for intraoperative hypertention. Only one patient required packed cell volume (PCV) transfusion and total intravenous fluid was 1 ± 0.5 L. At the time of exsufflation, there was decrease in pulse rate, systolic and diastolic blood pressure and EtCO 2 . CONCLUSION: Because of advancement Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.124453
10
in anaesthetic agents and muscle relaxant, there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy. Key words: Anaesthesia, bilateral nephrectomy, laparoscopy
INTRODUCTION Prerenal transplant nephrectomy is indicated for calculus disease, reflux, uncontrolled hypertension and polycystic kidney disease. These patients are very sick in view of their medical condition. Anaesthesia for these patients requires thorough preoperative evaluation and stabilisation of their general condition. There is paucity of information regarding anaesthetic outcome in this anephric patients. Therefore, we conducted this retrospective study in chronic renal failure patients who underwent bilateral laparoscopic simultaneous nephrectomy. Their preoperative investigations, intraoperative haemodynamic and intravenous fluid management were noted and analysed.
MATERIALS AND METHODS The study group was composed of 10 patients aged 24.75 ± 14.56 years (adult male) with American Society of Anaesthesiologists (ASA II-III) who underwent elective laparoscopic retroperitoneal bilateral simultaneous nephrectomy for different indications over a 3-year period from 2006 to 2010. After thorough preoperative evaluation and preparation, all patients were scheduled for surgery. They all were underwent their regular haemodialysis 6 hours before the surgery. They were kept nil per oral for
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
Modi, et al.: Bilateral pretransplant nephrectomy and anaesthesia
overnight. On the day of surgery, morning serum potassium (S.K), electrocardiography ECG and coagulation profile were obtained. They were advised to take morning dose of regular treatment for hypertension and anticonvulsant. In operating room, after securing intravenous cannula and protection of arteriovenous fistula all patients were given general anaesthesia. They were premeditated with intravenous glycopyrolate 0.004 mg and 3 μg/kg fentanyl citrate. Injection thiopental sodium 3-4 mg/kg was used for induction and endotracheal intubation was facilitated with injection suxamethinium 1-1.5 mg/kg and maintained with gas, oxygen and isoflurane. Intermittant atracurium was used as muscle relaxant. They were monitored with ECG, Non-Invasive Blood Pressure (NIBP), Saturation of Peripheral Oxygen (SPO2), endtidal carbon dioxide (EtCO2) and temperature probe. Pulse rate, systolic blood pressure, diastolic blood pressure and EtCO2 were recorded after creation of pneumoperitoneum then after 15, 30, 45 minutes and after exsuffflation. Normal saline was given as intravenous fluid and blood loss was replaced with PCV followed by injection calcium gluconate. Nephrectomy was carried out using retroperitoneal approach in kidney position. After completion of one side of nephrectomy another side was performed. Total surgical time and total intravenous fluid were noted. Injection tramadol 2 mg/kg was given for postoperative analgesia along with inj ondansetron 2 mg. At the completion of surgery, all patients were reversed from neuromuscular blockade and shifted to intensive care unit.
from 91.3 ± 18.7/min to 97.7 ± 20.9/min (P < 0.506), systolic blood pressure from 142.3 ± 19.1 mmHg to 157 ± 35.6 mmHg (P < 0.838), diastolic blood pressure from 90.1 ± 1 mmHg to 98 ± 9.19 mmHg (P < 0.143) and EtCO2 from 28.6 ± 2.91 to 31.8 ± 3.68 (P < 0.475), [Table 3]. After 30 minutes, these variables remained stable throughout the surgery. Four patients required nitroglycerine infusion for intraopearative hypertention. Only one patient required PCV transfusion and total intravenous fluid was 1 ± 0.5 L. At the time of exsufflation, there was decrease in pulse rate, systolic and diastolic blood pressure and EtCO2. All patients were ventilated with tidal volume of 7-10 ml/kg and respiratory rate of 12-14/min which was adjusted to keep the EtCO2 between 35 mmHg and 40 mmHg. The hemodynemic and changes in EtCO2 during right and left nephrectomy were comparable. There was no change in temperature throughout the procedure. Three patients had mild-moderate pulmonary hypertension.
DISCUSSION Anaesthesia for bilateral simultaneous nephrectomy represents a significant challenge and successful management of these patients requires systemic approach to preoperative evaluation and careful selection of anaesthetic agents. End stage renal disease is a multisystem disorder and is associated Table 1: Demographic data and investigations
Statistical Analysis Statistical Analysis was performed using Statistical Package Of Social Sciences i.e. SPSS version 12. Data are expressed as mean ± SD (standard deviation) for Continuous variables and no (%) for categorical variables. Continuous variables were compared using independent t-test and Mann-Whitney U-test. Also related variables were compared using Paired sample t-test and Wilcoxon Signed ranks test. P < 0.05 is considered to be statistically significant.
Variables
RESULTS
Table 2: ECG, X-ray & 2D Echocardiography findings in patients
Among 10 patients, six patients were on antihypertensive drugs, one on anticoagulant, one on digoxin and one was diabetic on insulin. The mean age was 24.75 ± 14.35 years. The mean duration of surgery was 120 ± 80 minutes. The Hb%, serum creatinine and SK were shown in Table 1. ECG, 2D Echo and x-ray chest finding were presented in Table 2. Pulse rate mean blood pressure and EtCO2 were recorded after creation of pneumoperitoneum and at 15, 30, 45 and after exsufflation of pneumoperitoneum. After pneumoperitoneum, there was increase in pulse rate
Mean±SD
Age Weight Hemoglobin Random blood sugar S. Creatinine S. Potassium Chronic renal failure MHD
27.2±13.44 47.8±10.24 9.4±1.04 106±40.9 6.79±4.91 3.61±0.51 921.5±487.2 days 757.2±435.9 days
ECG
XRAY-CHEST ECHO
WNL LVH WNL WNL T in V1-V3 WNL LAD WNL T in lateral lead TV2,3,6
N N N N N N CM N CM N
EF-60%, LVH EF-55%, LVH, RVSP 30 EF-55%, RVSP 55 EF-55%, RVSP 55 EF-55% EF-60% EF-50% EF-30%, LVH, Global dysfunction 55% 55%
WNL: Within normal limits, LVH: Left ventricular hypertrophy, T: T wave inversion, LAD: Left axis deviation, EF: Ejection fraction, RVSP: Right ventricular systolic pressure
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
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Modi, et al.: Bilateral pretransplant nephrectomy and anaesthesia Table 3: Comparison between right and left nephrectomy (% increase in values of all variables with baseline)
Baseline to after CO2 Pulse SBP DBP ETCO2 Baseline to after 15 min Pulse SBP DBP ETCO2 Baseline to after 30 min Pulse SBP DBP ETCO2 Baseline to after 45 min Pulse SBP DBP ETCO2 Baseline to after pneumoperitoneum Pulse SBP DBP ETCO2
Right Nephrectomy (n=10)
Left Nephrectomy (n=10)
P-value
8.7±20.7 14.9±15.3 10±14.3 11.1±6.17
8.9±19.3 10.5±20.7 11.1±17.2 7.6±6.11
0.982 0.622 0.468 0.254
4.4±15.5 3.2±17.3 0.5±17.3 14±12.5
8.8±20.4 5.2±23.4 14.6±16.02 16.6±8.89
0.520 0.849 0.075 0.642
0.6±16.07 2.5±18.8 -3.3±12.7 13.3±11.8
10.8±19.2 2.3±23.4 7±12.7 11.8±9.21
0.150 0.879 0.058 0.819
2.6±19.2 -1.8±18.03 -3.9±11.4 12.3±11.4
3.6±19.5 -0.90±25.6 0.80±15.6 6.3±8.48
0.790 0.703 0.518 0.123
-1.0±17.3 -10.5±11.5 -11±9.58 2.1±8.13
-1.5±19.9 -9.8±18.4 -6.1±13.4 9.1±6.79
0.732 0.819 0.879 0.042
SBP: Systolic blood pressure, DBP: Diastolic blood pressure, ETCO2: End tidal CO2
with increased risk of cardiovascular co morbidity and increased severity of cardiovascular disease. Apart from the impact of surgery and co morbidity, the main perioperative care issues to be considered in this patient population are impact of haemodialysis and anephric state. The problems associated with haemodialysis are increased bleeding complications, arrthymias, and poor blood pressure control including hypertension and hypotension which may be aggravated by laparoscopic surgery. We have observed same hemodynamic and EtCO2 changes after creation of pneumoperitoneum as in healthy population.[1] In our study, four patients required injection nitroglycerine for control of hypertension, this might be due to pneumoperitonium. The most common cardiovascular issues in these patients are arteriosclerosis mediated hypertension, ischemic heart disease, impaired systolic and/or diastolic ventricular function and arrhythmogenic sudden cardiac death. [2] Our three patients had Left ventricular hypertrophy (LVH), two had low ejection fraction and global left ventricular dysfunction. None of our patient had arrhythmias or any adverse cardiac event. The presence of severe pulmonary 12
hypertension should be determined preoperatively as it will have a significant impact on the anaesthetic management of the patient. [3] Management goals should centre on the avoidance of hypoxia, hypercapnia, acidosis and hypotension as each of these factors will increase pulmonary vascular resistance. Our three patients had mild-moderate pulmonary hypertension. Close attention should be paid to establishing the correct dry weight for the patient. If the patient is above their dry weight preoperatively, they risk for pulmonary oedema and poorly controlled hypertension perioperatively and poor tissue healing postoperatively. If under their dry weight, they may become profoundly hypotensive during surgery which will be exacerbated by blood loss and anaesthetic agents. An arteriovenous access may be at risk for thrombosis from hypotention. Access function should be checked as part of the postoperative evaluation. Careful consideration should be given to the type and quantity of fluid to be administered during surgery. This will be determined by the preoperative hydration status of the patient, duration of surgery and the estimated fluid losses during surgery. We had infused normal saline to maintain hydration and surgical loss. In anephric patients, there is failure to normally excrete and/or metabolise anaesthetics and analgesics leading to toxic levels of these agents and difficulty in adjusting fluid and electrolytes in the perioperative period. Potential alterations in volume of distribution, protein binding, drug metabolism and excretion must be considered carefully before deciding upon a particular anaesthetic technique. We have used fentanyl as premedication as it is safe in renal failure. [4] A significant hyperkalemic response to suxamethonium is not observed in chronic renal failure provided the preoperative serum potassium level is within normal limit. In our all patients’ serum potassium level was normal so we had used suxamethonium to facilitate endotracheal intubation and we did not observed hyperkalemic response. Our result was similar with the study of Thapa et al.,[5] Sevoflurance has been used in renal disease and it appears safe from serum inorganic fluoride levels and elimination rate than the healthy control.[6,7] We used atracurium as muscle relaxant. Anephric patients distribute and eliminate atracurium much as normal patients do. Pharmacodynamic measurements show almost identical times for duration and recovery from neuromuscular blockade in normal and anephric patients under isoflurane anaesthesia.[8] Our all patients had smooth recovery from neuromuscular blockade. Vecuronium and rocuronium are significantly prolonged in renal failure because of reduced clearance.[9] Intravenous access and blood pressure monitoring should be avoided in the
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
Modi, et al.: Bilateral pretransplant nephrectomy and anaesthesia
arteriovenous fistula arm. Crystalloid/colloid can be used for maintenance or replacement fluid. In this patient population, maintenance fluid must be o restricted, however, ongoing sequestration or overt losses should be replaced with either crystalloid, colloid or blood products. The choice of fluid depends on patients electrolytes. We have used 0.9 normal saline but we can used ringer’s lactate if serum potassium is low. Blood loss can be replaced with packed cell volume/washed RBCs.
3.
4. 5. 6.
7.
CONCLUSION 8.
Because of advancement in anaesthetic agents and muscle relaxant, there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy.
REFERENCES 1.
2.
Nadu A, Ekstein P, Szold A, Friedman A, Nakache R, Cohen Y, et al. Ventilatory and hemodynamic changes during retroperitoneal and transperitoneal laparoscopic nephrectomy: A prospective real-time comparison. J Urol 2005;174:1013-7. Miller LM, Sood MM, Sood AR, Reslerova M, Komenda P, Rigatto C, et al. Cardiovascular disease in end-stage renal disease: The challenge of assessing and managing cardiac disease in dialysis patients. Int Urol Nephrol
9.
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Cite this article as: Modi MP, Vora KS, Parikh GP, Modi PR, Shah VR. Anaesthetic consideration during laparoscopic bilateral simultaneous nephrectomy. J Min Access Surg 2014;10:10-3. Date of submission: 17/03/2013, Date of acceptance: 27/05/2013 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1
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