Preinduction hemodynamic fluctuations in renal transplant recipients--comparison of two combined anesthesia regimens

An ideal anesthetic technique for a renal allograft recipient must ensure hemodynamic stability, enhance graft reperfusion,and provide good postoperative pain relief. Hence,a combined general and epidural anesthesia is preferred. In our clinical practice,it has been observed that in chronically ill end-stage renal disease (ESRD) patients,a bolus injection of epidural local anesthetics invariably necessitated the use of vasopressor agents. Such hemodynamic fluctuations may not be favorable for the graft. A prospective,randomized,double-blind study was conducted on 50 ESRD adults, 18-55 years,scheduled for elective live related kidney transplantation. The patients randomly received either epidural fentanyl (50 μg) and normal saline (10 mL) or epidural fentanyl (50 μg) and bupivacaine (0.5%; 10 mL) followed by standardized general anesthesia. Perioperative hemodynamics and vasopressor requirements were compared with both regimens. Early graft function was assessed by the onset of diuresis after declamping,serial creatinine values,glomerular filtration rate,and 24-hour urine output estimation. In the preoperative period,statistically significant reduction in the mean arterial pressure and the cardiac index occurred in 60% of the patients receiving epidural bupivacaine boluses. These hypotensive episodes required a therapeutic intervention prior to general anesthesia,that is,intravenous mephenteramine (3-6 mg; 9.60±2.32 mg) and crystalloid infusion (189.28±21.29 mL). Intraoperative hemodynamic parameters,surgical blood loss,and transplanted kidney function were comparable between the groups. We concluded that the use of regional anesthetics needed to administered cautiously in renal transplant recipients to maintain hemodynamic parameters.