An account of the anesthetist's vigilance and prevention of adversity during donor nephrectomy.

Here, we present the case of a 42 year old female patient, ASA1 and donor for renal transplant surgery of her husband. The pre-anesthesia visit did not reveal any co-morbidity on history and the physical examination was also within normal limits. The patient was taken to the operating room and routine monitoring in the form of non-invasive blood pressure (NIBP), SpO2 probe and five lead electrocardiogram were applied. Anesthesia was induced with midazolam 1mg intravenous (i/v), fentanyl 100 μg i.v, propofol 100mg i/v and vecuronium bromide 5 mg. i/v. At the end of surgery, anesthesia was reversed and breathing attempts were observed. Suddenly the monitor displayed a drop in the ETCO2 to 5-6 mmHg. Immediately the ventilator circuit was checked which was found to be in place and on chest auscultation, bilateral equal air entry was heard. Sudden bradycardia with heart beat dropping to 32 beats per minute and a blood pressure reading of 90/50 mmHg was displayed on the monitor. Surgeons were informed about the possibility of an intra-abdominal bleed. On surgical exploration, the renal artery pedicle ligature was found to have slipped away resulting in torrential amount of bleeding. The bleeder having been identified was secured and a complete inspection of other possible bleeding sites was done. Post operatively, the patient was shifted to the intensive care unit with inotropic support. It was decided to keep the patient mechanically ventilated on volume control mode of ventilation. The patient remained stable on post-operative day 5, the patient was shifted to the ward.

INTRODUCTION

Living kidney donors are powerful resources owing to the increasing incidence of end-stage renal disease, for which renal transplant is the best option. Patients posted for donor nephrectomy are usually a group who are extremely low risk for developing perioperative complications. Patients are completely assessed before being taken as potential candidates for surgery. The risk of perioperative mortality is estimated to be 0.03–0.06%. The common causes are pulmonary embolism, hepatitis, myocardial infarction, and arrhythmias.[1]

CASE REPORT

Here, we present the case of a 42-year-old female patient, American Society of Anaesthesiologists 1 and donor for renal transplant surgery of her husband. The preanesthesia visit did not reveal any co-morbidity on history and the physical examination was also within normal limits.

The weight recorded was 50 kg and the height corresponded to 1.50 m, and the body mass index was calculated as 20.8 kg/m2. Blood investigations revealed hemoglobin of 11.5 g/dL, total leukocyte count of 8600 mm3, and platelet count of 156,000 mm3.

Random blood sugar was 86 mg dL. Renal function tests and serum electrolytes were within normal limits. Electrocardiogram and chest X-ray done preoperatively were normal.

The patient was taken to the operating room, and routine monitoring in the form of noninvasive blood pressure, SpO2 probe, and five-lead electrocardiogram were applied. The vital parameters had noted before induction were within normal limits.

Intravenous access was secured with one 16-gauge (G) and one 18-G cannula.

Anesthesia was induced with intravenous midazolam 1 mg intravenous (i.v.), fentanyl 100 μg i.v., propofol 100 mg i.v., and vecuronium bromide 5 mg i.v. The patient was mask ventilated by a mechanical ventilator to achieve normocarbia with O2, N2O, and isoflurane (0.9–1 minimum alveolar concentration [MAC]) for 3 min approximately. The trachea was intubated using endotracheal tube no 7.0 mm internal diameter. After confirming the position of endotracheal tube, the patient was mechanically ventilated with a tidal volume of 400 ml, respiratory rate of 12/min, and maintaining an ETCO2 between 32 and 35 mmHg, and an esophageal temperature probe was inserted. The patient was maintained on O2, N2O (50:50%), and isoflurane (MAC 1).

Donor nephrectomy for the left side was completed in 3 h. At the end of the surgery, anesthesia was reversed, and breathing attempts were observed. Suddenly, the monitor displayed a drop in the ETCO2 to 5–6 mmHg. Immediately, the ventilator circuit was checked which was found to be in place and on chest auscultation, bilateral equal air entry was heard. Sudden bradycardia with heartbeat dropping to 32 beats/min (bpm) and a blood pressure reading of 90/50 mmHg was displayed on the monitor.

Injection atropine 0.6 mg i.v. was given and a second dose repeated after 2 min following that arise in the heart rate to 120 bpm was observed, and a blood pressure of 90/60 mmHg was noted. On examination, patient's conjunctiva was pale. Surgeons were informed about the possibility of an intra-abdominal bleed.

An emergency laparotomy was planned while resuscitation with crystalloids, colloids, and packed red blood cells was instituted. On surgical exploration, the renal artery pedicle (at the hilum of the kidney) ligature was found to have slipped away resulting in torrential amount of bleeding. The bleeder having been identified was secured, and a complete inspection of other possible bleeding sites was done. Meanwhile, hemodynamic status stability was ensured with inotropic support. A total of 5 liters (L) of crystalloids, 1 L of colloids, 4 units of packed red blood cells, and 2 units of fresh frozen plasma were transfused during the entire re-open laparotomy. The estimated blood loss was 2500 ml approximately, and urine output of 2800 ml was noted.

Postoperatively, the patient was shifted to the Intensive Care Unit with inotropic support. It was decided to keep the patient mechanically ventilated on volume control mode of ventilation. All blood investigations including complete blood count, liver function tests, kidney function tests, arterial blood gas, coagulation profile, and chest X-ray were sent postoperatively. Extubation was planned to take place only when hemodynamic stability would be achieved without inotropic support.

Next day, the patient's condition improved significantly. Inotropic support was switched off, and vitals were stable. The hemoglobin was 7 g/dL and other parameters were within normal limits. Two units of packed red blood cells were transfused on the 1st postoperative day. Weaning from mechanical ventilation was commenced and subsequently, postoperative day 3, extubation was planned with patients general condition have improved and a hemoglobin of 9 g/dL. The patient remained stable on postoperative day 5; the patient was shifted to the ward.

DISCUSSION

Living donor nephrectomy is low-risk procedure and relatively safe. Therefore, major hemorrhage, although infrequent, is a potentially fatal complication and is largely preventable. Significant hemorrhagic complications occur with both open and laparoscopic forms of donor nephrectomy.

The overall incidence of vascular complications was almost 30% during the initial stages of development of transplant methodology,[2] however due to advent of improvement in surgical and diagnostic approach, it is currently rated at 0.8-6% as per different sources.[345]

Friedman et al.[6] in a study conducted a survey in which a questionnaire was sent to the American Society of Transplant Surgeons to help ascertaining the various causes of hemorrhagic complications and the incidence of events such as transfusion and deaths in donor nephrectomies. A survey of 213 surgeons showed 66 and 39 episodes of arterial and venous bleeding, respectively. Among arterial bleeding, 19 required transfusion and 2 resulted in death. Hence, prevention and prompt detection of such a complication could be life-saving.

Mjøen et al.[7] in their study assessed 1022 laparoscopic donor nephrectomies performed over a duration of 12 years. They concluded that perioperative bleeding occurred in 1.6% of cases and there were 7 cases of renal artery laceration.

Bleeding constitutes a major risk in living donor nephrectomies as is further observed in a study conducted by Akoh et al.[8] In this study, among 58 patients, 4 (7%) of the patients had bleeding requiring postoperative transfusion. Most of the patients underwent open nephrectomy 89% and only 11% laparoscopic. High level of vigilance and early detection of complications must be maintained.

The donors should also be informed about the possible risks associated with the procedure. As an anesthesiologist, our aim is to have a high index of suspicion for any unusual event occurring intra-operatively and living donor nephrectomies pose a unique challenge in this regard.

CONCLUSION

Vigilant monitoring and sound clinical acumen are powerful tools of anesthetist and proved to be lifesaving in our case. Timely detection and prompt intervention resulted in avoiding a potentially catastrophic event.

The incidence of complications in donor nephrectomy can be reduced by careful surgical technique, ensuring high vigilance and early detection of complications bearing in mind any kind of unfortunate intra-operative event. Thus, as observed in the above case scenario, accurate monitoring and timely intervention by the anesthetist is of paramount importance. Clinical assessment of the patient at all times, along with modern monitoring techniques are pearls in the hands of the anesthetist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest