|Year : 2009 | Volume
| Issue : 4 | Page : 489-491
Paediatric Auto Renal Transplantation-Anaesthetic Challenge
PA Saravanan1, Rebecca Jacob2, Raj Sahajanandan1, Anita Shirley Joselyn1
1 Asst Professor, Department of Anaesthesia and critical care, Christian Medical College & Hospital, Vellore-632004, India
2 Professor, Department of Anaesthesia and critical care, Christian Medical College & Hospital, Vellore-632004, India
|Date of Web Publication||3-Mar-2010|
P A Saravanan
Department of Anaesthesia and critical care, Christian Medical College & Hospital, Vellore-632004
Source of Support: None, Conflict of Interest: None
Takayasu's arteritis is described to be the single most important cause of renovascular hypertension. Anaesthetising a child with Takayasu's arteritis for auto renal transplantation is a challenge as it is complicated by severe uncontrolled hypertension, end-organ dysfunction resulting from hypertension, stenosis of major blood vessels affecting regional circulation, and difficulties encountered in monitoring arterial blood pressure. Abalanced anaesthetic technique, maintenance of stable haemodynamics with monitoring is required for a successful outcome. We describe the anaesthetic management of a child with Takayasu's arteritis and severe hypertension refractory to medical treatment requiring auto renal transplantation.
Keywords: Takayasu′s arteritis, Paediatric, Auto renal transplantation, Anaesthesia
|How to cite this article:|
Saravanan P A, Jacob R, Sahajanandan R, Joselyn AS. Paediatric Auto Renal Transplantation-Anaesthetic Challenge. Indian J Anaesth 2009;53:489-91
|How to cite this URL:|
Saravanan P A, Jacob R, Sahajanandan R, Joselyn AS. Paediatric Auto Renal Transplantation-Anaesthetic Challenge. Indian J Anaesth [serial online] 2009 [cited 2020 Dec 2];53:489-91. Available from: https://www.ijaweb.org/text.asp?2009/53/4/489/60324
| Introduction|| |
Severe persistent hypertension in childhood is mainly due to renal parenchymal disease with renovascular lesions being the second most common cause. Takayasu's arteritis is the single mostimportant cause of renovascular hypertension in non white children  . Takayasu's arteritis is characterizedby a focal stenosis process involving the aorta and the proximal segment of its major branches  . We present the anaesthetic management of a child with Takayasu's arteritis and severe hypertension refractoryto medical ireatmentrequiring auto renal transplantation.
| Case report|| |
A 4-year-old male child weighing 13 kg, presented withhistory ofdyspnoea on exertion for 3 month duration. On examination, all peripheral pulses were palpable except on the right upperlimb. His blood pressure was 1401100 mm Hg in the left upper limb and was not recordable on the right upper limb. He was evaluated for secondary hypertension and foundto have Type III Takayasu's arteritis with aortography revealing 99% stenosis of left main renal artery and 60% stenosis of the right main renal artery as well as occlusion of the right subclavian artery [Figure 1]. He had clinical and echocardiographic evidence of left ventricular dysfunction with normal renal functions. He was stabilized on tab.nifedepine 5mg Q4H, prazosinlmg Q6H, aldomet250mg Q8H, minoxidil 5mg Q12H, fiusemide 10 mg, digoxin 0.25 mg and aspirin once a day. He underwent balloon angiop las ty and stenting of left renal artery. He presented subsequently with a history of recurrent episodes of seizures and persistently elevated blood pressure. IVIRI brain revealed vasculitis induced multiple infarcts. Right auto renal transplantation was considered due to refractory hypertension and ongoing complication. Preoperative vitals revealed GCS of 14/15, heart rate of 96,lmin, absent right radial pulse with blood pressure in left upper limb of 170/110mmHg. His blood investigations were normal with serum creatinine of 0.9mg%. Chest roentgenogram revealed cardiomegaly and electrocardiogram left ventricular hypertrophy.
The patient was fasted and premedicated with Syp.Triclofos 75mg.kg -l . Under standard monitoring (Sp0 2 , non-invasive blood pressure, ECGy end-tidal CO, monitor, temperature), anaesthesia was induced with au; oxygen and sevoflurane. The trachea was intubated following atracurium administration and the patient mechanically ventilated. Underultrasound guidance, a SF triple lumen catheter was sited in the right internal jugular vein. The left femoral artery was selected for direct arterial pressure monitoring. Anaesthesia was maintained with 50% mixture of air and oxygen, end-tidal is of lurane concentration of 1% with morphine, fentanyl and atracurium boluses as needed. Normocarhia was maintained to preserve cerebral perfusion. Surgery was done in supine position. A good perfusion pressure of the transplanted kidney was ensured by maintaining a systolic blood pressure of 130 mm Hg, C VP of 13-15 mmHg. Mannito10.5g.kg -1 was infused 20 minutes before clamp release. Blood loss was replaced with fresh whole blood. Urine output was more than 0.5 ml.kg -l .hr -1 after the anastamosis. The intraoperative period was uneventful. Arterialblood gas analysis was within normal knit and trachea extubated at the end of the procedure. Postoperatively, the child was monitored in the high dependency unit and had an unremarkable stay. Outpatient visit at 8 weeks revealed improved sensorium and blood pressure of 130 / 85mmHg in left upperlimb. Diethylene Tetramine Penta Acetate(D'1'PA) scan done at 8 weeks showed functioning of auto transplanted kidney [Figure 2] and antihypertensives were tapered. Colour doppler revealed good peifusion of transplanted kidney as characterizedby the reduction in the peaksystolic velocity from 244.1 cm/sec to 120.5 cm/sec. [Figure 3]
| Discussion|| |
Patients with Takayasu's arteritis (TA) present for surgery either incidentally or more frequently for correction of the consequences ofvascularocclusive disease. Anaesthetising such a child for auto renal transplantation is a challenge as it is complicated by severe uncontrolled hypertension, end-organ dysfunction resulting from hypertension, steno sis ofmajor blood vessels affecting regional ciiwlation, and difficulties encountered in monitoring arterial blood pressure  . Surgery is indicated in patients with uncontrolled hypertension, deteriorating renal function, lesions not amenable to angioplasty and transient response to angioplasty . In our patient, auto renal transplantation was resorted to as he was not responding to antihypertensives and stenting of the steno sed left renal artery. Regional analgesia with epidural was not initiated in our patient as the risk of decrease in blood pressuremay be hazardous in ap atient with compromised regional circulation because of stenosed arteries , . This haemodynamic instability can also result in reduced graft function  .We used isoflurane to maintain the blood pressure at basal preoperative levels, decrease the cerebral metabolic rate of oxygen and produce cerebral vasodilatation.
Sudden hypertensive orhypotensive episodes are avoided intraopemtively so as to prevent possible cerebro vascular or cardiovascular crises  . Invasive arterial and venous pressuremonitoring is considered mandatory as excessive hemo dynamic variations could have serious consequences for regional organ perfusion. However, pulmonary artery catheterization was not performed in view of the potential risks exceeding the possible benefits in a small child , .The factors affectingthe transplanted kidney's viability are intravascular volume and perfusion pressure. Adequate intravascularvolume is the single most important determinant of immediate graft function. ACVP of 12- 14 mmHg is recommended to maintain optimal intravascular volume . Acute tubular necrosis can result from inadequate hydration and leads to delayed graft function, decreased graft survival and increased patient morbidity. Mannitol when combined with volume expansion has been shown to decrease the incidence of acute tubular necrosis after transplantation.Routine use of inotropes is not warranted and vasopressors should be given as the last resort . Unexplained hypotension and inadequateresp onse to inotropes may be due to underlying metabolic acidosis and should be corrected. These patients warrant intensive care stay in post operative period. Our patient had stable haemodynamics during the intraoperative period probably due to a balanced anaesthetic technique and CVP guided volume replacement.
Anaesthetising a child with Takayasu's arteritis for an auto renal transplantation is a challenge due to the various pathological and hemodynamic changes involved. Successful outcome depends on preoperative optimisation, intra operative maintenance of stable hemodynamics and invasive monitoring during perioperative period.
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[Figure 1], [Figure 2], [Figure 3]