Anesthetic Management of a Patient Undergoing Robotic Assisted Renal Transplant

Abstract

A 29 years old female patient weighing 40kgs with known case of Systemic Lupus Erythematosus for the last 15 years with recent development of membranous nephropathy with end stage renal disease was scheduled for living related allograft robotic assisted left renal transplant. We highlighted the anesthetic management involved in performing robotic assisted renal transplant (RAT) at our institute.

Keywords: Robotic; Renal transplant; Anesthetic; Systemic lupus erythematosus

Introduction

Urology has been in forefront for performing robot assisted techniques in prostatectomy, cystectomy and nephron sparing surgery. Robotic assistance for renal transplant is a new technique and gives dexterity in fine movements required for the complex anastomosis of renal transplant without the need of opening the abdomen [1,2]. This leads to less surgical morbidity and decrease in hospital stay with similar patient and graft survival [2]. However to deliver anesthesia in such surgeries is a new challenge and these test the very skills of an anaesthetist.

Here we highlight the anesthetic management involved inperforming the maiden robotic assisted renal transplant (RAT) at our institute.

Case Presentation

A 29 years old female patient weighing 40kgs presented to us with a known case of Systemic Lupus Erythematosus since 2001 and was on treatment with oral wysolone with a recent development of membranous nephropathy with end stage renal disease (ESRD) [3] months back in November 2015.

She was posted for living related allograft robotic assisted left renal transplant. She was on hemodialysis twice a week. Her recent hemogram, biochemical profile, serum electrolytes, electrocardiogram, chest x-ray and echocardiograghy were within normal limits except blood urea of 57mg% and serum creatinine of 4.1mg%. She was hypertensive and her blood pressure was controlled (110/76mm of Hg during preoperative check-up) with oral amlodipine 10mg once daily, metoprolol 50mg twice daily and moxonidine 0.2 mg once daily. She was also on sevelamer carbonate 800mg for chronic renal disease.

On the day of surgery, an 18G intravenous cannula was secured in the right hand. Standard American Socitey of Anesthesiologists monitoring, such a 5 lead electrocardigram, non-invasive blood presssure and pulse oximetry probe were attached to the patient. General anesthesia was induced with 2mcg/kg intravenous fentanyl and 2-3 mg/kg intravenous propofol and muscle relaxation was achieved by intravenous atracurium at a dose of 0.5mg/kg after confirmation of adequate mask ventilation. Airway was secured by a 7.5mm ID cuffed endotracheal tube and anesthesia was maintained with isoflurane, air and oxygen targeting a end-tidal isoflurane concentration of 1-1.2 MAC. We used neuromuscular monitoring in the form of train-of-four to judge adequate muscle relaxation and to avoid the overuse of muscle relaxant.

Right radial artery was cannulated by a 20G arterial cannula for invasive blood pressure monitoring and right internal jugular vein was cannulated with 7.5Fr tripple lumen catheter for central venous pressure measurement. Intraoperative analgesia was provided with intravenous fentanyl at a dose of 0.5-1 mcg/kg. At the end of surgery, residual neuromuscular blocked was reversed with neostigmine and glycopyrrolate and trachea was extubated when she was following commands and generating adequate regular tidal volume.

Intravenous fluid boluses were initiated before completetion of vascular anaostomosis of the graft targeting a CVP of 10-12 mm Hg. After completetion of vascular anastomosis, 100-120 ml of urine output per hour was obtained.

Discussion

Apart from the pathophsyiological changes in end stage renal disease, the biggest challenge for an anesthesiologist is to work in a congested operating room environment with a robot [3]. It is very important that there should not be any patient movement during docking of the robot and insertion of camera and instruments through the laparoscopic ports otherwise tearing could occur at port sites [4]. Adequate muscle relaxation is of utmost importance in these cases. The operating table should not be moved after docking. We used neuromuscular monitoring in our patients to ensure adequate muscle relaxation. Beat to beat invasive blood pressure monitoring is important as there is a possibility of tachycardia and hypertension during port insertion and creation of pneumoperitoneum [5]. As many patients with ESRD have a compromised left ventricular systolic and diastolic function, they may poorly tolerate these hemodynamic changes. Together with tredelendburg position required for the surgery, it makes anesthesia management more challenging. The pathophysiological changes in ESRD relevant to the anesthesiologists have been depicted in table [1].

  

    
Cardiovascular    system 
    
↑ systemic vascular    resistance 
      
↑ mean arterial pressure 
      
↑ myocardial oxygen    consumption 
      
↓ renal, portal, and    sphlanchnic flow 
  
  

    
Respiratory    system 
    
↑ ventilation–perfusion    mismatch 
      
↓ functional residual    capacity 
      
↓ vital capacity 
      
↓ compliance 
      
↑ peak airwaypressure 
      
Pulmonary    congestion and oedema 
      
Hypercarbia,    respiratory acidosis 
  
  

    
Central    nervous system 
    
↑ intracranial pressure 
      
↑ cerebral blood flow 
      
↑ intraocular pressure 
  
  

    
Endocrine 
    
Catecholamine    release 
      
Activation    of renin–angiotensin system 
  
  

    
Others 
    
Gastro-oesophageal    regurgitation 
      
Venous    air embolism 
      
Neuropraxia,    especially brachial 
      
Tracheal    tube displacement 
      
Facia    and airway oedema 
  

Table 1: Pathopysiological changes in ESRD patients.