24
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, NO.1, JAN.-FEB., 1975
Aortic Valve Replacement in a Hemodialysis-Dependent Patient: Anesthetic Considerations-A Case Report LCDR MARK A. POSNER, MC, USNR* LCDR J. G. REVES, MC, USNR WILLIAM A. LELL, M.D. Bethesda, Marylandt
In the anesthetic management of a hemodialysis-dependent patient undergoing aortic\-alre replacement, technical and pathophysiologic problems considered included: 1. The presence of an arteriorenous hemodialysis fistula. 2. Hemodynamic alterations associated with aortic insufficiency,
3. Choice of anesthetic agents, fluid, and electrolyte balance in the presence of renal failure. 1. Postoperative management of hypertension and hyperkalemia. While there are many possible approaches, the authors present one successful technic for consideration.
T
of aortic insufficiency and a biopsy-proven diagnosis of diffuse membranous proliferative glomerulonephritis involving all glomeruli. Physical and laboratory findings were compatible with aortic insufficiency and renal failure.
are a number of excellent reviews on anesthesia for open-heart surgery' -:* and for the patient in renal f a i l ~ r e ; 4how-~ ever, there is little literature to guide the anesthesiologist faced with both prablems in a single patient. We have reports of 8i-11 patients in renal failure undergoing cardiopulmonary bypass; however, with a single exception,' there is essentially no discussion of the anesthetic considerations involved in their care. This report reviews the anesthetic problems associated with a hemodialysisdependent patient having aortic-valve surgery and presents a successful approach to such a patient. HERE
CASE REPORT A 58-kg., 19-year-old black man admitted for aortic-valve replacement prior to renal transplantation presented with a murmur
Cardiac catheterization revealed left-ventricular pressure, 130/40; aorta, 130/60; mean pulmonary artery wedge, 28; right ventricle, 48/ 12; and pulmonary artery, 48124. The cardiac index was 3.4 L.lmin.1 sq.m. There was severe aortic regurgitation with a competent mitral valve. During the week before operation, a forearm arteriovenous fistula was created in preparation for initial hemodialysis. Operation was scheduled for 24 hours after dialysis. Prernedication consisted of 0.6 mg. of atropine, 15 mg. of diazepam, and 15 mg. of
*Resident, Department of Anesthesia, National Naval Medical Center, and Research Fellow. Division of Experimental Anesthesia and Pharmacology, Naval Medical Research Institute, Bethesda, Md. 20014. ?Department of Anesthesia, National Naval Medical Center. The following are personal opinions and should not be considered to represent those of the Department of the Navy or the Department of Defense. Paper received: 5/3/74 Accepted for publication: 8/15/74
Hemodialysis-Dependent Patient.
. . Posner, et a1
morphine intramuscularly a t 90 minutes before anesthesia. On the morning of the operation, pertinent laboratory data were: hemoglobin, 8.1 gm./100 ml.; potassium, 4.4 mEq./L.; and glucose, 88 mg./100 ml. Auscultatory blood pressure was 190/80 and pulse 110. A central and a peripheral venous line were inserted. The central venous pressure was 15 cm. of water. Electrocardiogram limb electrodes were applied, and lead I1 was continuously monitored and recorded. After preoxygenation, 2 mg./kg. (125 mg.) of intravenous (I.V.) ketamine induced anesthesia. Muscle relaxation was obtained by 0.08 mg./kg. 15 mg.) of I.V. pancuronium. There were no significant changes in vital signs observed during induction, topicalization by lidocaine (160 mg.) , or intubation. A femoral-artery catheter was placed and the blood pressure continuously monitored and recorded. Anesthesia was maintained by 60 mg. of I.V. ketamine every 15 minutes and nitrous oxideoxygen (4:2), delivered via a semiclosedcircle system with soda lime. Thirty-five minutes after induction, following the sternal incision, the blood pressure rose to 210160 and was unaffected by the I.V. administration of 0.1 mg. (2 ml.) of fentanyl. The addition of 0.5 percent halothane produced a rapid fall in blood pressure to 180/35 and, because of the low diastolic pressure, the halothane was immediately discontinued and the pressure allowed to remain a t 200160. During the 90 minutes preceding cardiopulmonary bypass, the patient received a total of 485 mg. of ketamine, and 3 mg./kg. of I.V. heparin before cannulation of the aorta and right atrium. The TemptroP bubble oxygenator was primed with 50 mg. of heparin, 2 units of ACD whole blood, 1000 ml. of Travenol@ electrolyte solution (contains 2.5 percent
25 glucose and the folIowing mEq./L.: sodium, 102; potassium, 5; calcium, 5; magnesium, 2; chloride, 107; gluconate, 5; and phosphate, 2 ) , and an additional 25 gm. of glucose. Cardiopulmonary bypass was begun and the patient's esophageal temperature lowered to 28" C. (82.4" F.). The coronary arteries were not perfused while the aorta was cross-clamped. Two 50-mg. doses of ketamine were given during the 90-minute perfusion, as was a single, 1-mg. dose of pancuronium when the patient moved. No further ketamine or pancuronium was required during the remainder of the operation. Perfusion was a t 2.4 L./min./sq.m. and mean blood pressure remained between 100 to 110 during bypass. Frequent blood-gas analysis before and during bypass showed no evidence of hypoxemia or acidosis. A prosthetic aortic valve was inserted uneventfully. After warming to an esophageal temperature of 38" C. (100.4" F.), bypass was discontinued without the use of antiarrhythmic, vasopressor, or inotropic agents. The blood pressure was 120/78; pulse, 98 (normal sinus rhythm) ; mean left-atrial pressure, 6 mm. Hg; and central venous pressure, 4 cm. of water. Protamine was given slowly iprotamine:heparin, 2 mg.:l mg.). During the 2-hour operative interval following bypass, 60 percent nitrous oxide in oxygen and a total of 0.25 mg. ( 5 ml.) of fentanyl were administered. The blood pressure gradually rose to 160/100, with a leftatrial pressure of 15. Fluid balance is shown in the table. Two hours after perfusion, a t the end of the operation, the nitrous oxide was discontinued; muscle relaxants and narcotics were not reversed. On arrival in the intensive care unit, the patient's blood pressure was 195/160; pulse,
TABLE Fluid Balance Input
Clear fluids
Dextrose 2.5c/o, lactated Ringer's 50%
160 ml.
Medications"
175 ml.
Fresh blood
500 ml.
Extracorporeal pump oxygenator Crystalloid
1000 ml.
Whole blood
Whole blood
Totals *Primarily ketamibe and protarnine.
Balance
Output
Urine
70 ml.
+265 ml.
Suction
600 ml.
-100 ml.
Reservoir
400 ml.
+1600 ml.
1070 ml.
+1765 ml.
1000 ml.
2835 ml.
26
1975 ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, N O . 1, JA~v-FEB.,
115; left-atrial pressure, 25; and rectal temperature, 36" C. (96.8" F.). Morphine ( 8 mg.) and diazepam ( 5 mg.) I.V. in divided doses did not affect the blood pressure and, therefore, a sodium nitroprusside infusion (120 mg./150 ml.) was begun and titrated to maintain arterial pressure at 130/90, with a corresponding left-atrial pressure of 10. The rate of infusion was 10 ml./hr., or approximately 2 mcg./kg./min. of nitroprusside. This was necessary for 24 hours until the pressure remained in a normal range following hemodialysis. Blood gases 30 minutes after operation with controlled ventilation (100 percent oxygen) were: pH, 7.45; Pao,, 367; Paco,, 40.
After 4 hours in the intensive care unit, the patient was alert and demonstrated good muscle strength. At the end of a 90-minute trial of spontaneous ventilation with humidified 40 percent oxygen via endotracheal tube and T-piece, blood gases were: pH, 7.40; Pao,, 106; and Paco,, 40. Following extubation, the patient maintained normal blood gases breathing humidified 40 percent oxygen by mask. Twenty-four hours after operation, breathing 21 percent oxygen, blood gases were: pH, 7.45; Paol, 84; and Paco,, 41.
Electrolyte determinations postoperatively were normal with the exception of potassium, which, by 11 hours, was 6.5 mEq./L. This was initially treated with a sodium polystyrene sulfonate ( Kayexalates') enema and later controlled by hemodialysis started on the first postoperative day. The patient denied any dreaming or other untoward anesthetic complications and the remainder of his course was uncomplicated. He is now a renal transplantation candidate.
DISCUSSION The patient with multisystem disease presents many problems to the anesthesiologist. Our patient, with both cardiac and renal disease, presented both technical and pathophysiologic problems. Among the technical considerations is protection of the arteriovenous fistula from trauma and constricting bandages. The use of a tourniquet or frequent blood-pressure cuff inflations above the shunt should be avoided, and the arm properly padded and positioned at all times to prevent stasis and clotting. Since creation of new dialysis sites is frequently necessary, the forearm veins should be spared if possible; likewise, cannulation of radial or brachial arteries should
be avoided, since this has been associated with a significant incidence of thrombosis.1 2 1.3 For these reasons, we chose the use of a femoral-artery catheter for pressure monitoring, and an external jugular vein as one of the I.V. routes. The two major pathophysiologic changes of concern are aortic insufficiency and renal failure. The primary hemodynamic alteration in aortic insufficiency is regurgitation of ejected blood into the left ventricle. The amount of regurgitation is proportionate to the area of the aortic-valve defect, the aorticleft ventricular diastolic pressure gradient, and the duration of diastole.14 The compensatory mechanisms to maintain adequate forward flow with aortic insufficiency are to increase heart rate and stroke volume. Increased stroke volume is associated with increased end diastolic volume and pressure. Both compensatory mechanisms result in increased myocardial oxygen utilization, which must be met by augmented coronary blood supply. Coronary perfusion depends in part on maintenance of diastolic perfusion pressure, which is lowered in aortic inOxygen delivery is further compromised in aortic insufficiency because of left-ventricular hypertrophy, increased ventricular diastolic pressure that impairs coronary flow per unit of muscle mass, and, in this patient, anemia of chronic renal disease. The primary problems of renal failure are anemia, electrolyte balance, fluid administration, choice of muscle relaxant, and anesthetic agent. Although fluid balance is controlled by hemodialysis preoperatively, this therapy is not readily available in the immediate postoperative period because of hazards of heparinization. The metabolism and excretion of anesthetic agents must be considered, and drugs that are primarily excreted in the urine should be administered judiciously.
Choice of Anesthetics. -Ketamine was used for induction and maintenance of anesthesia prior to bypass in this patient because: (1) it maintains peripheral resistance in renal failurelGand (2) heart rate is maintained or increased. These considerations are important because they assure adequate cardiac output and coronary-artery perfusion pressure and minimize the amount of fluid administration needed. Vasodilatation that occurs with other anesthetic agents might necessitate greater fluid administration to maintain cardiac output.l7 As an
Hemodialysis-Dependent Patient
. . . Posner, et a1
alternative to volume expansion, the alpha and mixed alpha-beta vasopressor agents are not the ideal therapy for hypotension in aortic insufficiency.18 Pancuronium maintains blood pressure and minimizes fluid administration. Miller and coworkerslg found that pancuronium in dosages up to 3.6 mg.1sq.m. produces a 20 to 40-minute longer block in patients with compromised renal function than in control patients, but had no difficulty in reversing muscle relaxation with appropriate drugs. In the present case, no reversal was attempted, and 4 hours postoperatively, the patient was spontaneously ventilating adequately. Fluid Administration.-Fluid and blood products were restricted, to minimize the problems of hypervolemia, serum hepatitis, and the sensitization of a potential renal transplant recipient to antigens in homologous blood. If available, frozen or buffycoat-poor blood should be used.4 Because intraoperative fluid shifts and blood loss make assessment of preload difficult,’O a left-atrial or pulmonary wedge pressure catheter is an invaluable guide to maintaining optimal filling pressure of the left ventricle.2 Hypertension. - The technic used was complicated by hypertension, which is potentially undesirable because of increased myocardial oxygen requirementsz2 and increased regurgitant flow associated with increased afterload. This was treated intraoperatively initially with fentanyl and then with halothane, which caused a drop in diastolic pressure to unacceptable levels. Halothane was discontinued because the adequacy of coronary perfusion at this pressure was doubtful. Hypertension was again a problem postoperatively. This complication has been reported with many types of heart especially after myocardial revascularization.24 The etiology in the present case is not clear. It is unlikely that elevated catecholamines from ketamine and pancuronium played a significant role.25 Common causes of postoperative hypertension, for example, hypothermia, hypoxia, hypercarbia, acidosis, hypoglycemia, and pain, were ruled out. The hypertrophied left ventricle with a now-competent aortic valve could have augmented cardiac output, contributing to the hypertension in this case; however, the associated high left-atrial pressure suggests impaired ventricular performance. Sodium nitroprusside was effective in decreasing the
27
afterload, and cardiac performance improved, reflected by a decreased left-atrial pressure. The only other postoperative complication was hyperkalemia. This was not unexpected and occurred 11hours after operation when the serum potassium was 6.5. Initial treatment, using Kayexalate@enemas, was followed by hemodialysis 1 day later, which was definitive in maintaining not only normokalemia but also normotension in this patient. In summary, the presence of renal failure complicates the anesthetic management of the patient requiring aortic-valve replacement. Optimal anesthesia should maintain the cardiac output in the absence of myocardial ischemia and minimize fluid and electrolyte imbalances. The technics described met these objectives and contributed to a successful outcome.
ACKNOWLEDGMENT The authors are indebted to Dr. Mitchell Mills, Chief of Thoracic and Cardiovascular Surgery, for his suggestions and cooperation in the management of this case. We express gratitude to Drs. Robert Van Houten, Raymond Tobey, and Roger Catlin for their assistance in the preparation and review of this manuscript. We thank Ms. Linda Porter for her secretarial expertise. REFERENCES 1. Gilston A: Anaesthesia for cardiac surgery. Brit J Anaesth 43:217-232, 1971
2. Tarhan S, Moffitt E: Anesthesia and supportive care during and after cardiac surgery. Ann Thorac Surg 11:64-89, 1971 3. Lowenstein E, Bland J: Anesthesia for cardiac surgery, Cardiac Surgery. Second edition. Edited by J Norman. New York, Appleton-CenturyCrofts, 1972, chapter 4, pp 75-102 4. LeVine DS, Virtue R: Anaesthetic agents and techniques for renal homotransplants. Canad Anaesth SOCJ 11:425-428, 1964 5. Daughety MJ, Peters PC: Anesthesia for uremic patients, Clinical Anesthesia: Common and Uncommon Problems. Edited by MT Jenkins. Philadelphia, FA Davis Company, 1969, pp 336-344 6. Samuel JF, Powell D: Renal transplantation: anaesthetic experience of 100 cases, Anaesthesia 26: 165-176, 1970
7. Aldrete JA, Pappas G: Anesthetic implications for simultaneous cardiorenal transplant: a case report. Anesth & &alp 48:928-932, 1969
8. Lansing A, Leb D, Berman L: Cardiovascular surgery in end-stage renal failure. JAMA 204:134-138, 1968
.
ANESTHESIA AND ANALGESIA . . Current Researches VOL.54, NO.1, JAN.-FEB,,1975
28
9. Manhas D, Merendino A: The management of cardiac surgery in patients with chronic renal failure. J Thorac Cardiovasc Surg 63: 235-239, 1972
17. Stanley TM, Gray NH, Isei-n-Amoral JH, et al: Comparison of blood requirements during morphine and halothane anesthesia for open-heart surgery. Anesthesiology 41:34-38, 1974
10. Mensoian J, Davis R, Idelson B, et al: Coronary artery bypass surgery and renal transplantation: a case report. Ann Surg 178:63-64, 1974
18. Hopkins BE, Taylor RR: Influence of various catecholamines on aortic regurgitation, J Appl Physiol 39:309-317, 1973
11. Ribot S, Gilbert L, Rothfeld E, et al: Bacterial endocarditis with pulmonary edema necessitating mitral valve replacement in a hemo&alysis dependent patient. J Thorac Cardiovasc Surg 62: 59-62, 1971
19. Miller RD, Stevens WC, Way WL: The effect of renal failure and hyperkalemia on the duration of pancuronium neuromuscular blockade in man. Anesth & Analg 52:661-666, 1973
12. Bedford R, Wollman H: Complications of percutaneous radial artery cannulation. Anesthesiology 38:228-236, 1973
20. Pacific0 A, Digerness S, Kirklin J: Acute alterations of body composition after open intracardiac operations. Circulation 41:331-341, 1970
13. Downs JB, Rackstein AD, Klein EF, et al: Hazards of radial-artery catheterization. Anesthesiology 38:283-286, 1973
21. Lappas D, Lell W, Gabel J, et al: Indirect measurement of left-atrial pressure in surgical patients. Anesthesiology 38:394-397, 1973
14. Brawley RK, Morrow AG: Direct determination of aortic blood flow in patients with aortic regurgitation: effects of alterations in heart rate, increased ventricular preload, and afterload. Circulation 35:32-45. 1967
22. Cohn J N : Blood pressure and cardiac performance. Amer J Med 55: 351-361, 1973 23. Kouchoukos NT, Sheppard LC, KirMin JW: Effects of alterations in arterial pressure on cardiac performance early after open intracardiac operations. J Thorac Cardiovasc Surg 64:563-572, 1972
15. Tambe A, Zimmerman HA: Chronic rheumatic valvular disease, Cardiac and Vascular Diseases. Edited by MH Conn, 0 Horowitz. Philadelphia, Lea and Febiger, 1971, p 814
24. Estafanous FG, Tarazi RC, Viljoen J F , et al: Systemic hypertension following myocardial revascularization. Amer Heart J 85:732-738, 1973
16. Hobika G, Evers J, Mostert J , et al: Comparison of hemodynamic effects of glucagon and ketamine in patients with chronic renal failure. Anesthesiology 37: 654-658, 1972
25. Matsuki A, Zsigmond EK, Kelsch RC, et al: The effect of pancuronium bromide on plasma norepinephrine concentrations during ketamine induction. Canad Anaesth SOCJ 21:315-320, 1974
Good will plus good service brings sales success t h a t no competition can possibly undersell.
-Hany
*
*
F . Banks
*
A “tired businessman” is one whose business is usually not a successful one.
-Joseph
*
*
R . Gwmdy
*
The surest foundation of a manufacturing concern is quality. After that, and a long way after, comes cost.
-Andrew
Camegie
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, NO.1, JAN.-FEB., 1975
Aortic Valve Replacement in a Hemodialysis-Dependent Patient: Anesthetic Considerations-A Case Report LCDR MARK A. POSNER, MC, USNR* LCDR J. G. REVES, MC, USNR WILLIAM A. LELL, M.D. Bethesda, Marylandt
In the anesthetic management of a hemodialysis-dependent patient undergoing aortic\-alre replacement, technical and pathophysiologic problems considered included: 1. The presence of an arteriorenous hemodialysis fistula. 2. Hemodynamic alterations associated with aortic insufficiency,
3. Choice of anesthetic agents, fluid, and electrolyte balance in the presence of renal failure. 1. Postoperative management of hypertension and hyperkalemia. While there are many possible approaches, the authors present one successful technic for consideration.
T
of aortic insufficiency and a biopsy-proven diagnosis of diffuse membranous proliferative glomerulonephritis involving all glomeruli. Physical and laboratory findings were compatible with aortic insufficiency and renal failure.
are a number of excellent reviews on anesthesia for open-heart surgery' -:* and for the patient in renal f a i l ~ r e ; 4how-~ ever, there is little literature to guide the anesthesiologist faced with both prablems in a single patient. We have reports of 8i-11 patients in renal failure undergoing cardiopulmonary bypass; however, with a single exception,' there is essentially no discussion of the anesthetic considerations involved in their care. This report reviews the anesthetic problems associated with a hemodialysisdependent patient having aortic-valve surgery and presents a successful approach to such a patient. HERE
CASE REPORT A 58-kg., 19-year-old black man admitted for aortic-valve replacement prior to renal transplantation presented with a murmur
Cardiac catheterization revealed left-ventricular pressure, 130/40; aorta, 130/60; mean pulmonary artery wedge, 28; right ventricle, 48/ 12; and pulmonary artery, 48124. The cardiac index was 3.4 L.lmin.1 sq.m. There was severe aortic regurgitation with a competent mitral valve. During the week before operation, a forearm arteriovenous fistula was created in preparation for initial hemodialysis. Operation was scheduled for 24 hours after dialysis. Prernedication consisted of 0.6 mg. of atropine, 15 mg. of diazepam, and 15 mg. of
*Resident, Department of Anesthesia, National Naval Medical Center, and Research Fellow. Division of Experimental Anesthesia and Pharmacology, Naval Medical Research Institute, Bethesda, Md. 20014. ?Department of Anesthesia, National Naval Medical Center. The following are personal opinions and should not be considered to represent those of the Department of the Navy or the Department of Defense. Paper received: 5/3/74 Accepted for publication: 8/15/74
Hemodialysis-Dependent Patient.
. . Posner, et a1
morphine intramuscularly a t 90 minutes before anesthesia. On the morning of the operation, pertinent laboratory data were: hemoglobin, 8.1 gm./100 ml.; potassium, 4.4 mEq./L.; and glucose, 88 mg./100 ml. Auscultatory blood pressure was 190/80 and pulse 110. A central and a peripheral venous line were inserted. The central venous pressure was 15 cm. of water. Electrocardiogram limb electrodes were applied, and lead I1 was continuously monitored and recorded. After preoxygenation, 2 mg./kg. (125 mg.) of intravenous (I.V.) ketamine induced anesthesia. Muscle relaxation was obtained by 0.08 mg./kg. 15 mg.) of I.V. pancuronium. There were no significant changes in vital signs observed during induction, topicalization by lidocaine (160 mg.) , or intubation. A femoral-artery catheter was placed and the blood pressure continuously monitored and recorded. Anesthesia was maintained by 60 mg. of I.V. ketamine every 15 minutes and nitrous oxideoxygen (4:2), delivered via a semiclosedcircle system with soda lime. Thirty-five minutes after induction, following the sternal incision, the blood pressure rose to 210160 and was unaffected by the I.V. administration of 0.1 mg. (2 ml.) of fentanyl. The addition of 0.5 percent halothane produced a rapid fall in blood pressure to 180/35 and, because of the low diastolic pressure, the halothane was immediately discontinued and the pressure allowed to remain a t 200160. During the 90 minutes preceding cardiopulmonary bypass, the patient received a total of 485 mg. of ketamine, and 3 mg./kg. of I.V. heparin before cannulation of the aorta and right atrium. The TemptroP bubble oxygenator was primed with 50 mg. of heparin, 2 units of ACD whole blood, 1000 ml. of Travenol@ electrolyte solution (contains 2.5 percent
25 glucose and the folIowing mEq./L.: sodium, 102; potassium, 5; calcium, 5; magnesium, 2; chloride, 107; gluconate, 5; and phosphate, 2 ) , and an additional 25 gm. of glucose. Cardiopulmonary bypass was begun and the patient's esophageal temperature lowered to 28" C. (82.4" F.). The coronary arteries were not perfused while the aorta was cross-clamped. Two 50-mg. doses of ketamine were given during the 90-minute perfusion, as was a single, 1-mg. dose of pancuronium when the patient moved. No further ketamine or pancuronium was required during the remainder of the operation. Perfusion was a t 2.4 L./min./sq.m. and mean blood pressure remained between 100 to 110 during bypass. Frequent blood-gas analysis before and during bypass showed no evidence of hypoxemia or acidosis. A prosthetic aortic valve was inserted uneventfully. After warming to an esophageal temperature of 38" C. (100.4" F.), bypass was discontinued without the use of antiarrhythmic, vasopressor, or inotropic agents. The blood pressure was 120/78; pulse, 98 (normal sinus rhythm) ; mean left-atrial pressure, 6 mm. Hg; and central venous pressure, 4 cm. of water. Protamine was given slowly iprotamine:heparin, 2 mg.:l mg.). During the 2-hour operative interval following bypass, 60 percent nitrous oxide in oxygen and a total of 0.25 mg. ( 5 ml.) of fentanyl were administered. The blood pressure gradually rose to 160/100, with a leftatrial pressure of 15. Fluid balance is shown in the table. Two hours after perfusion, a t the end of the operation, the nitrous oxide was discontinued; muscle relaxants and narcotics were not reversed. On arrival in the intensive care unit, the patient's blood pressure was 195/160; pulse,
TABLE Fluid Balance Input
Clear fluids
Dextrose 2.5c/o, lactated Ringer's 50%
160 ml.
Medications"
175 ml.
Fresh blood
500 ml.
Extracorporeal pump oxygenator Crystalloid
1000 ml.
Whole blood
Whole blood
Totals *Primarily ketamibe and protarnine.
Balance
Output
Urine
70 ml.
+265 ml.
Suction
600 ml.
-100 ml.
Reservoir
400 ml.
+1600 ml.
1070 ml.
+1765 ml.
1000 ml.
2835 ml.
26
1975 ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, N O . 1, JA~v-FEB.,
115; left-atrial pressure, 25; and rectal temperature, 36" C. (96.8" F.). Morphine ( 8 mg.) and diazepam ( 5 mg.) I.V. in divided doses did not affect the blood pressure and, therefore, a sodium nitroprusside infusion (120 mg./150 ml.) was begun and titrated to maintain arterial pressure at 130/90, with a corresponding left-atrial pressure of 10. The rate of infusion was 10 ml./hr., or approximately 2 mcg./kg./min. of nitroprusside. This was necessary for 24 hours until the pressure remained in a normal range following hemodialysis. Blood gases 30 minutes after operation with controlled ventilation (100 percent oxygen) were: pH, 7.45; Pao,, 367; Paco,, 40.
After 4 hours in the intensive care unit, the patient was alert and demonstrated good muscle strength. At the end of a 90-minute trial of spontaneous ventilation with humidified 40 percent oxygen via endotracheal tube and T-piece, blood gases were: pH, 7.40; Pao,, 106; and Paco,, 40. Following extubation, the patient maintained normal blood gases breathing humidified 40 percent oxygen by mask. Twenty-four hours after operation, breathing 21 percent oxygen, blood gases were: pH, 7.45; Paol, 84; and Paco,, 41.
Electrolyte determinations postoperatively were normal with the exception of potassium, which, by 11 hours, was 6.5 mEq./L. This was initially treated with a sodium polystyrene sulfonate ( Kayexalates') enema and later controlled by hemodialysis started on the first postoperative day. The patient denied any dreaming or other untoward anesthetic complications and the remainder of his course was uncomplicated. He is now a renal transplantation candidate.
DISCUSSION The patient with multisystem disease presents many problems to the anesthesiologist. Our patient, with both cardiac and renal disease, presented both technical and pathophysiologic problems. Among the technical considerations is protection of the arteriovenous fistula from trauma and constricting bandages. The use of a tourniquet or frequent blood-pressure cuff inflations above the shunt should be avoided, and the arm properly padded and positioned at all times to prevent stasis and clotting. Since creation of new dialysis sites is frequently necessary, the forearm veins should be spared if possible; likewise, cannulation of radial or brachial arteries should
be avoided, since this has been associated with a significant incidence of thrombosis.1 2 1.3 For these reasons, we chose the use of a femoral-artery catheter for pressure monitoring, and an external jugular vein as one of the I.V. routes. The two major pathophysiologic changes of concern are aortic insufficiency and renal failure. The primary hemodynamic alteration in aortic insufficiency is regurgitation of ejected blood into the left ventricle. The amount of regurgitation is proportionate to the area of the aortic-valve defect, the aorticleft ventricular diastolic pressure gradient, and the duration of diastole.14 The compensatory mechanisms to maintain adequate forward flow with aortic insufficiency are to increase heart rate and stroke volume. Increased stroke volume is associated with increased end diastolic volume and pressure. Both compensatory mechanisms result in increased myocardial oxygen utilization, which must be met by augmented coronary blood supply. Coronary perfusion depends in part on maintenance of diastolic perfusion pressure, which is lowered in aortic inOxygen delivery is further compromised in aortic insufficiency because of left-ventricular hypertrophy, increased ventricular diastolic pressure that impairs coronary flow per unit of muscle mass, and, in this patient, anemia of chronic renal disease. The primary problems of renal failure are anemia, electrolyte balance, fluid administration, choice of muscle relaxant, and anesthetic agent. Although fluid balance is controlled by hemodialysis preoperatively, this therapy is not readily available in the immediate postoperative period because of hazards of heparinization. The metabolism and excretion of anesthetic agents must be considered, and drugs that are primarily excreted in the urine should be administered judiciously.
Choice of Anesthetics. -Ketamine was used for induction and maintenance of anesthesia prior to bypass in this patient because: (1) it maintains peripheral resistance in renal failurelGand (2) heart rate is maintained or increased. These considerations are important because they assure adequate cardiac output and coronary-artery perfusion pressure and minimize the amount of fluid administration needed. Vasodilatation that occurs with other anesthetic agents might necessitate greater fluid administration to maintain cardiac output.l7 As an
Hemodialysis-Dependent Patient
. . . Posner, et a1
alternative to volume expansion, the alpha and mixed alpha-beta vasopressor agents are not the ideal therapy for hypotension in aortic insufficiency.18 Pancuronium maintains blood pressure and minimizes fluid administration. Miller and coworkerslg found that pancuronium in dosages up to 3.6 mg.1sq.m. produces a 20 to 40-minute longer block in patients with compromised renal function than in control patients, but had no difficulty in reversing muscle relaxation with appropriate drugs. In the present case, no reversal was attempted, and 4 hours postoperatively, the patient was spontaneously ventilating adequately. Fluid Administration.-Fluid and blood products were restricted, to minimize the problems of hypervolemia, serum hepatitis, and the sensitization of a potential renal transplant recipient to antigens in homologous blood. If available, frozen or buffycoat-poor blood should be used.4 Because intraoperative fluid shifts and blood loss make assessment of preload difficult,’O a left-atrial or pulmonary wedge pressure catheter is an invaluable guide to maintaining optimal filling pressure of the left ventricle.2 Hypertension. - The technic used was complicated by hypertension, which is potentially undesirable because of increased myocardial oxygen requirementsz2 and increased regurgitant flow associated with increased afterload. This was treated intraoperatively initially with fentanyl and then with halothane, which caused a drop in diastolic pressure to unacceptable levels. Halothane was discontinued because the adequacy of coronary perfusion at this pressure was doubtful. Hypertension was again a problem postoperatively. This complication has been reported with many types of heart especially after myocardial revascularization.24 The etiology in the present case is not clear. It is unlikely that elevated catecholamines from ketamine and pancuronium played a significant role.25 Common causes of postoperative hypertension, for example, hypothermia, hypoxia, hypercarbia, acidosis, hypoglycemia, and pain, were ruled out. The hypertrophied left ventricle with a now-competent aortic valve could have augmented cardiac output, contributing to the hypertension in this case; however, the associated high left-atrial pressure suggests impaired ventricular performance. Sodium nitroprusside was effective in decreasing the
27
afterload, and cardiac performance improved, reflected by a decreased left-atrial pressure. The only other postoperative complication was hyperkalemia. This was not unexpected and occurred 11hours after operation when the serum potassium was 6.5. Initial treatment, using Kayexalate@enemas, was followed by hemodialysis 1 day later, which was definitive in maintaining not only normokalemia but also normotension in this patient. In summary, the presence of renal failure complicates the anesthetic management of the patient requiring aortic-valve replacement. Optimal anesthesia should maintain the cardiac output in the absence of myocardial ischemia and minimize fluid and electrolyte imbalances. The technics described met these objectives and contributed to a successful outcome.
ACKNOWLEDGMENT The authors are indebted to Dr. Mitchell Mills, Chief of Thoracic and Cardiovascular Surgery, for his suggestions and cooperation in the management of this case. We express gratitude to Drs. Robert Van Houten, Raymond Tobey, and Roger Catlin for their assistance in the preparation and review of this manuscript. We thank Ms. Linda Porter for her secretarial expertise. REFERENCES 1. Gilston A: Anaesthesia for cardiac surgery. Brit J Anaesth 43:217-232, 1971
2. Tarhan S, Moffitt E: Anesthesia and supportive care during and after cardiac surgery. Ann Thorac Surg 11:64-89, 1971 3. Lowenstein E, Bland J: Anesthesia for cardiac surgery, Cardiac Surgery. Second edition. Edited by J Norman. New York, Appleton-CenturyCrofts, 1972, chapter 4, pp 75-102 4. LeVine DS, Virtue R: Anaesthetic agents and techniques for renal homotransplants. Canad Anaesth SOCJ 11:425-428, 1964 5. Daughety MJ, Peters PC: Anesthesia for uremic patients, Clinical Anesthesia: Common and Uncommon Problems. Edited by MT Jenkins. Philadelphia, FA Davis Company, 1969, pp 336-344 6. Samuel JF, Powell D: Renal transplantation: anaesthetic experience of 100 cases, Anaesthesia 26: 165-176, 1970
7. Aldrete JA, Pappas G: Anesthetic implications for simultaneous cardiorenal transplant: a case report. Anesth & &alp 48:928-932, 1969
8. Lansing A, Leb D, Berman L: Cardiovascular surgery in end-stage renal failure. JAMA 204:134-138, 1968
.
ANESTHESIA AND ANALGESIA . . Current Researches VOL.54, NO.1, JAN.-FEB,,1975
28
9. Manhas D, Merendino A: The management of cardiac surgery in patients with chronic renal failure. J Thorac Cardiovasc Surg 63: 235-239, 1972
17. Stanley TM, Gray NH, Isei-n-Amoral JH, et al: Comparison of blood requirements during morphine and halothane anesthesia for open-heart surgery. Anesthesiology 41:34-38, 1974
10. Mensoian J, Davis R, Idelson B, et al: Coronary artery bypass surgery and renal transplantation: a case report. Ann Surg 178:63-64, 1974
18. Hopkins BE, Taylor RR: Influence of various catecholamines on aortic regurgitation, J Appl Physiol 39:309-317, 1973
11. Ribot S, Gilbert L, Rothfeld E, et al: Bacterial endocarditis with pulmonary edema necessitating mitral valve replacement in a hemo&alysis dependent patient. J Thorac Cardiovasc Surg 62: 59-62, 1971
19. Miller RD, Stevens WC, Way WL: The effect of renal failure and hyperkalemia on the duration of pancuronium neuromuscular blockade in man. Anesth & Analg 52:661-666, 1973
12. Bedford R, Wollman H: Complications of percutaneous radial artery cannulation. Anesthesiology 38:228-236, 1973
20. Pacific0 A, Digerness S, Kirklin J: Acute alterations of body composition after open intracardiac operations. Circulation 41:331-341, 1970
13. Downs JB, Rackstein AD, Klein EF, et al: Hazards of radial-artery catheterization. Anesthesiology 38:283-286, 1973
21. Lappas D, Lell W, Gabel J, et al: Indirect measurement of left-atrial pressure in surgical patients. Anesthesiology 38:394-397, 1973
14. Brawley RK, Morrow AG: Direct determination of aortic blood flow in patients with aortic regurgitation: effects of alterations in heart rate, increased ventricular preload, and afterload. Circulation 35:32-45. 1967
22. Cohn J N : Blood pressure and cardiac performance. Amer J Med 55: 351-361, 1973 23. Kouchoukos NT, Sheppard LC, KirMin JW: Effects of alterations in arterial pressure on cardiac performance early after open intracardiac operations. J Thorac Cardiovasc Surg 64:563-572, 1972
15. Tambe A, Zimmerman HA: Chronic rheumatic valvular disease, Cardiac and Vascular Diseases. Edited by MH Conn, 0 Horowitz. Philadelphia, Lea and Febiger, 1971, p 814
24. Estafanous FG, Tarazi RC, Viljoen J F , et al: Systemic hypertension following myocardial revascularization. Amer Heart J 85:732-738, 1973
16. Hobika G, Evers J, Mostert J , et al: Comparison of hemodynamic effects of glucagon and ketamine in patients with chronic renal failure. Anesthesiology 37: 654-658, 1972
25. Matsuki A, Zsigmond EK, Kelsch RC, et al: The effect of pancuronium bromide on plasma norepinephrine concentrations during ketamine induction. Canad Anaesth SOCJ 21:315-320, 1974
Good will plus good service brings sales success t h a t no competition can possibly undersell.
-Hany
*
*
F . Banks
*
A “tired businessman” is one whose business is usually not a successful one.
-Joseph
*
*
R . Gwmdy
*
The surest foundation of a manufacturing concern is quality. After that, and a long way after, comes cost.
-Andrew
Camegie
