Scholarly article on topic 'Influence of the Anesthetic Technique on the Hemodynamic Changes in Renal Transplantation. A Retrospective Study'

Influence of the Anesthetic Technique on the Hemodynamic Changes in Renal Transplantation. A Retrospective Study Academic research paper on "Health sciences"

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Brazilian Journal of Anesthesiology
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{"COMPLICATIONS: hemodynamic / immediate graft function / diuresis" / "SURGERY / Urologic: renal transplantation" / "CIRURGIA / Urológica: transplante renal" / "COMPLICAÇÕES: hemodinâmicas / função imediata do enxerto / diurese"}

Abstract of research paper on Health sciences, author of scientific article — Eunice Sizue Hirata, Maria Fernanda Baghin, Rosa Inês Costa Pereira, Gentil Alves Filho, Artur Udelsmann

Summary Background and objectives The success of renal transplantation (Tx) depends on the type of donor, length of cold ischemia, and hemodynamic parameters on reperfusion. The objective of this study was to analyze the anesthetic technique, the incidence of cardiovascular changes, and the presence of postoperative diuresis of Tx performed at UNICAMP. Methods Renal transplantation of adults performed from January 2005 and April 2006 were evaluated retrospectively. Demographic data, preoperative laboratorial exams, anesthetic techniques and agents, hydration, hemodynamic parameters, use of vasoactive amines, presence of a diuresis, and intraoperative complications were evaluated, and comparative analysis between the subgroups, formed according to the anesthetic technique, was undertaken. The Student t test (parametric), Mann-Whitney test (non-parametric), Chi-square test and Fisher Exact test for comparison of proportions and multivariate analysis were used. Results Ninety-two patients were evaluated; 59 underwent general anesthesia (GA) and 33 underwent general anesthesia associated with epidural block (GA + Epi); 42 patients received livedonor transplants and 50 from dead donors. Most preoperative parameters analyzed did not show statistically significant differences (p>0.05), except for the origin of the graft (82% of GA + Epi received dead donor kidneys). Hypotension (30% GA and 48% GA + Epi, p<0.05) was the most frequent cardiovascular change. The hydration regimen did not differ between both groups (86.7± 30.2 mL.kg-1 GA and 94.8±21.8 mL.kg−1 GA+Epi, p=0.38). Dead donor grafts were more commonly associated with hemodynamic instability and worse prognosis for the immediate function of the graft, p<0.01 and 0.01, respectively. Hydration of 80 mL.kg-1 was associated with the presence of diuresis (OR=2.94, CI 95% 1.00-8.32). Conclusions General anesthesia associated or not with epidural block was the anesthetic technique used. Hypotension was the most common hemodynamic change. Live-donor graft and volume of hydration of 80 mL.kg-1 of NS favored diuresis.

Academic research paper on topic "Influence of the Anesthetic Technique on the Hemodynamic Changes in Renal Transplantation. A Retrospective Study"

Rev Bras Anestesio! 2009; 59: 2: 166-176

ARTIGO CIENTÍFICO SCIENTIFIC ARTICLE

Influência da Técnica Anestésica nas Alteraçôes Hemodinâmicas no Transplante Renal. Estudo Retrospectivo*

Influence of the Anesthetic Technique on the Hemodynamic Changes in Renal Transplantation. A Retrospective Study

Eunice Sizue Hirata, TSA1, Maria Fernanda Baghin2, Rosa Inês Costa Pereira, TSA1, Gentil Alves Filho3, Artur Udelsmann, TSA4

RESUMO

Hirata ES, Baghin MF, Pereira RIC, Alves Filho G, Udelsmann A — Influencia da Técnica Anestésica nas Alterapóes Hemodinámicas no Transplante Renal. Estudo Retrospectivo.

JUSTIFICATIVA E OBJETIVOS: Sucesso no transplante renal (Tx) depende do tipo de doador, da durapáo da isquemia fria e de parámetros hemodinámicos na reperfusáo. O objetivo desta pesquisa foi analisar a técnica anestésica, a incidencia de alterapóes cardiovasculares e a ocorrencia de diurese no período periope-ratório dos Tx realizados na UNICAMP.

MÉTODO: Avaliou-se retrospectivamente Tx de adultos realizados entre janeiro de 2005 e abril de 2006. Consideraram-se dados demográficos, exames laboratoriais pré-operatórios, técnicas e agentes anestésicos, hidratapáo, parámetros hemodinámicos, em-prego de aminas vasoativas, presenpa de diurese e complicapóes intra-operatórias, com análise comparativa entre os subgrupos formados conforme a técnica anestésica empregada. Foram usados na análise estatística o teste t de Student (paramétricos), MannWhitney (náo paramétricos), teste do Qui-quadrado e Exato de Fisher para comparapáo de proporpóes e análise multivariada.

RESULTADOS: Estudaram-se 92 pacientes, 59 com anestesia geral (AG) e 33 anestesia geral associada á peridural (AG + Peri), 42 receberam rim de doadores vivos e 50 de falecidos. Náo houve di-ferenpa (p > 0,05) na maioria dos parámetros pré-operatórios es-tudados, excepáo feita á origem do enxerto (82% AG + Peri receberam rins de doador falecido). A alterapáo cardiovascular mais frequente foi hipotensáo arterial (30% AG e 48% AG + Peri, p < 0,05). Regime de hidratapáo náo diferiu entre os grupos (86,7 ± 30,2 mL.kg-1 AG e 94,8 ± 21,8 mL.kg-1 AG+Peri, p = 0,38). Enxerto de doador falecido correlacionou-se a maior instabilidade hemodinámica e pior prognóstico para funpáo imediata do enxerto, p < 0,01 e 0,01, respectivamente. Volume de hidratapáo de 80 mL.kg-1 associou-se á diurese (OR = 2,94, IC95% 1,00-8,32).

*Recebido do (Received from) Hospital de Clínicas da Faculdade de Ciénci-as Médicas da Universidade Estadual de Campinas (FCM/UNICAMP), SP

1. Professora Doutora do Departamento de Anestesiología da FCM/UNICAMP

2. ME3 do CET/SBA do Departamento de Anestesiologia da FCM/UNICAMP

3. Professor Doutor da Disciplina de Nefrologia do Departamento de Clínica Médica da FCM/UNICAMP

4. Professor Livre-Docente pela UNICAMP; Professor Associado do Departamento de Anestesiologia da FCM/UNICAMP

Apresentado (Submitted) em 30 de janeiro de 2008 Aceito (Accepted) para publicagao em 3 de dezembro de 2008

Enderego para correspondéncia (Correspondence to):

Dra. Eunice Sizue Hirata

Rua Dona Presciliana Soares, 195/71

13025-080 Campinas, SP

E-mail: eshirata@hotmail.com

© Sociedade Brasileira de Anestesiologia, 2009

CONCLUSÖES: A técnica anestésica empregada foi anestesia geral, associada ou náo á peridural. Alterapáo hemodinámica mais comum foi hipotensáo arterial. Mostraram-se benéfícos em relapáo á diurese ser receptor de doador vivo e receber hidratapáo de 80 mL.kg1 de solupáo físiológica a 0,9%.

Unitermos: CIRURGIA, Urológica: transplante renal; COMPLICA-QÖES: hemodinámicas, funpáo imediata do enxerto, diurese.

SUMMARY

Hirata ES, Baghin MF, Pereira RIC, Alves Filho G, Udelsmann A — Influence of the Anesthetic Technique on the Hemodynamic Changes of Renal Transplantation. A Retrospective Study.

BACKGROUND AND OBJECTIVES: The success of renal transplantation (Tx) depends on the type of donor, length of cold ischemia, and hemodynamic parameters on reperfusion. The objective of this study was to analyze the anesthetic technique, the incidence of cardiovascular changes, and the presence of postoperative diuresis of Tx performed at UNICAMP.

METHODS: Renal transplantation of adults performed from January 2005 and April 2006 were evaluated retrospectively Demographic data, preoperative laboratorial exams, anesthetic techniques and agents, hydration, hemodynamic parameters, use of vasoactive amines, presence of a diuresis, and intraoperative complications were evaluated, and comparative analysis between the subgroups, formed according to the anesthetic technique, was undertaken. The Student t test (parametric), Mann-Whitney test (non-parametric), Chi-square test and Fisher Exact test for comparison of proportions and multivariate analysis were used.

RESULTS: Ninety-two patients were evaluated; 59 underwent general anesthesia (GA) and 33 underwent general anesthesia associated with epidural block (GA + Epi); 42 patients received live-donor transplants and 50 from dead donors. Most preoperative parameters analyzed did not show statistically significant differences (p > 0.05), except for the origin of the graft (82% of GA + Epi received dead donor kidneys). Hypotension (30% GA and 48% GA + Epi, p < 0.05) was the most frequent cardiovascular change. The hydration regimen did not differ between both groups (86.7± 30.2 mL.kg-1 GA and 94.8 ± 21.8 mL.kg-1 GA+Epi, p = 0.38). Dead donor grafts were more commonly associated with hemodyna-mic instability and worse prognosis for the immediate function of the graft, p < 0.01 and 0.01, respectively Hydration of 80 mL.kg-1 was associated with the presence of diuresis (OR = 2.94, CI 95% 1.00-8.32).

CONCLUSIONS: General anesthesia associated or not with epidural block was the anesthetic technique used. Hypotension was the most common hemodynamic change. Live-donor graft and volume of hydration of 80 mL.kg-1 of NS favored diuresis.

Key Words: COMPLICATIONS: hemodynamic, immediate graft function, diuresis; SURGERY, Urologic: renal transplantation.

INTRODUQAO

Transplantes renais (Tx) sao realizados desde 1906; no en-tanto, apenas após 1960, com o desenvolvimiento de novos imunossupressores 1, em especial os inibidores de calci-neurinas, o reconhecimento do conceito de morte encefálica e a selegao adequada do binomio doador-receptor 2, os Tx se tornaram o tratamento de escolha para os pacientes com insuficiéncia renal crónica terminal 3. O Tx está associado a melhor qualidade de vida, melhor relagao custo/benefício e, possivelmente, maior sobrevida dos pacientes 3. Nas changas, o transplante realizado precoce-mente promove melhor crescimento e desenvolvimento 4. Os primeiros transplantes foram realizados com anestesia espinal, tendo em vista as poucas opgoes de fármacos dis-poníveis a época para a realizagao de anestesia geral. Com o advento de bloqueadores neuromusculares com baixa excregao renal 5 e anestésicos voláteis com baixa percen-tagem de biotransformagao 6, a anestesia geral tornou-se a melhor opgao para esses pacientes. Dentre as vantagens da anestesia geral pode-se citar imobilidade absoluta no momento das anastomoses vasculares e controle adequa-do da ventilagao e da perfusao em pacientes com estado geral normalmente comprometido pela uremia 7. Já o éxito no transplante renal depende de outros fatores: tipo de doa-dor, duragao da isquemia fria e possibilidade de manutengao de parámetros hemodinámicos adequados no momento da reperfusáo. Tem sido observado que o bom desempenho cardiovascular relacionado á administragao de grandes volumes de solugoes cristalóides está associado á fungao precoce do enxerto 8 e á menor incidéncia de necrose tubular aguda 9.

O objetivo foi estudar, de modo retrospectivo, a técnica e os agentes anestésicos utilizados na anestesia para Tx realizados no Hospital de Clínicas da UNICAMP, em individuos adultos, com foco principalmente nas alteragoes hemodiná-micas e na diurese.

MÉTODO

Foram estudados todos os transplantes renais, de doado-res vivos e de falecidos, realizados no período de janeiro de 2005 a abril de 2006, no Hospital de Clínicas da UNICAMP. Das fichas de avaliagao pré-operatória foram obtidos a idade, o sexo, o peso, a altura, a classificagao de estado físico segundo a Sociedade Americana de Anestesiologistas (ASA), os valores de hemoglobina, de hematócrito, de potássio, da uréia e da creatinina plasmáticos. Os demais parámetros foram extraídos da ficha de anestesia, inclusive aqueles relacionados á monitorizagao intraoperatória. Quando neces-sário, foram utilizados dados do prontuário médico. Foram considerados, além dos parámetros hemodinámi-cos, os agentes anestésicos utilizados, a hidratagao e as complicagoes apresentadas durante a anestesia. Foi considerada hipotensao arterial ou hipertensao arterial, varia-

goes da pressao arterial sistólica ou pressao arterial média inferiores ou superiores a 30% em relagao á inicial, mantida por período igual ou superior a 15 minutos e/ou administragao de fármacos vasoativos com a finalidade de aumentar ou diminuir a pressao arterial, respectivamente. Foi considerada bradicardia a frequéncia cardíaca inferior a 50 batimentos por minuto, e taquicardia a frequéncia superior a 120 batimentos por minuto. A pressao venosa central (PVC) foi considerada normal para valores entre 2 e 12 cmH2O. As variáveis categóricas foram descritas por meio de sua distribuigao percentual e as contínuas pela média e desvio-padrao. A análise estatística foi realizada utilizando-se o teste Exato de Fisher e o de Qui-quadrado (x2) para compa-ragao de variáveis categóricas, o teste t de Student e de Mann-Whitney para comparagao de médias. O tamanho da amostra foi determinado pelo número de sujeitos encontrados no período de estudo, sendo o poder do teste avaliado após a coleta de dados, considerando-se um erro tipo I de 5%. Para estudar a magnitude do risco dos fatores estudados e sua inter-relagao, realizou-se regressao logística múltipla; considerando-se a diurese como variável dependente. O nível de significáncia foi de 5% e o software utilizado para análise foi o SAS versao 8,2.

RESULTADO

Foram submetidos ao transplante renal, no período considerado, 98 pacientes. Dois pacientes foram excluídos do estudo por informagoes incompletas e quatro por terem menos de 14 anos. Em quatro pacientes houve necessida-de de consulta ao prontuário médico para completar as in-formagoes. Dos 92 pacientes estudados, 59 receberam anestesia geral (AG) e 33 anestesia geral associada á peridural (AG+Peri). Quanto á origem do enxerto, 42 receberam rim de doadores vivos relacionados e 50 de doadores falecidos. Os pacientes foram subdivididos em dois grupos, segundo a técnica anestésica empregada. As características dos pacientes segundo idade, sexo, peso e altura, além de exames pré-operatórios mostraram-se semelhantes nos dois grupos (p > 0,05), exceto em relagao á origem do enxerto, pela predomináncia de implante de rins de doadores falecidos (82%) no grupo AG+Peri (p < 0.01) (Tabela I). Os grupos AG e AG+Peri também foram comparáveis quanto á presenga de doengas associadas, sendo as mais frequentes a hipertensao arterial (p = 0,36), a acidose metabólica (p = 0,13) e a anemia (p = 0,24).

A monitorizagao intraoperatória consistiu em: cardioscopia, oximetria de pulso, pressao venosa central, pressao arterial sistólica pelo método de palpagao de pulso ou pressao arterial média por pungao da artéria radial e cateterizagao vesical.

A técnica anestésica empregada foi anestesia geral balanceada, venosa e inalatória, com ventilagao controlada mecánica em sistema com reabsorgao de CO2 nos dois grupos e associada á peridural única, no grupo AG+Peri. O agente

inalatório utilizado foi o isoflurano 0,5 a 1,0%, vaporizado em uma mistura de oxigênio e óxido nitroso a 50%. Os anestésicos venosos mais empregados foram o fentanil, sufentanil, propofol e atracúrio. O consumo médio e seu respectivo desvio-padrâo, nas duas técnicas anestésicas podem ser vistos na tabela II, sem diferença significativa entre os grupos. A hidrataçâo foi mantida com soluçâo fisiológica a 0,9% em infusâo média de 86,7 ± 30,2 mL.kg-1 no grupo AG e 94,8 ± 21,8 mL.kg-1 no grupo AG+Peri (p = 0,38). A transfusâo de hemoderivados foi realizada quando os valores de hemoglobina eram inferiores a 8 g.dL-1 e nâo diferiu nos grupos estudados.

Todos os pacientes receberam furosemida, 0,5 a 1,0 mg.kg-1 durante a realizaçâo das anastomoses vasculares e todos, exceto três, receberam doses habituais de atropina e neostigmina e foram extubados ao final da operaçâo. A analgesia pós-operatória, no grupo submetido à anestesia peridural, foi realizada com a associaçâo de bupivacaína a

0,25% (32,5 a 50 mg) e morfina 0,03 mg.kg-1. Nos 59 pacientes do grupo da anestesia geral, a analgesia foi realizada com morfina subcutánea, 0,1 mg.kg-1 , associada á infiltragao da ferida cirúrgica com 100 mg de bupivacaína a 0,5%. Todos os pacientes foram encaminhados á unidade de terapia intensiva (UTI) no pós-operatório imediato. Quanto ás alteragoes cardiovasculares encontradas no período perioperatório, objeto desse estudo, verificou-se que a hipotensáo arterial ocorreu em 34 pacientes, 17 (29%) do grupo AG e 17 (51%) do grupo AG+Peri (p = 0,03) e PVC > 12 cmH2O ocorreu em 60 pacientes, 42 (71%) do grupo AG e 18 (54%) do grupo AG+Peri, (p = 0,11). Sessenta e sete pacientes apresentavam diurese no final da operagáo, 44 (74,57%) do grupo AG e 23 (69,69%) do grupo AG + Peri, conforme Tabela III. O emprego de fármaco vasoativo ocorreu de forma idéntica á hipotensáo arterial. Nenhum paciente apresentou hipertensáo arterial, dois revelaram taquicardia e um bradicardia.

Tabela I - Características Gerais dos Grupos, e Valores Médios dos Exames Pré-Operatórios, Segundo a Técnica Anestésica

Técnica Anestésica AG (n = 59) AG + Peri (n = 33) p

Idade (anos)* 36,1 ±13,2 40,6 ± 11,1 0,10"

Peso (kg)* 62,4 ± 13,9 63,5 ± 13,5 0,72"

Altura (cm)* 164,6 ± 10,4 163,4 ± 9,1 0,63"

IMC (kg.m-2)* 23,5 ± 4,4 23,1 ± 4,5 0,72"

Sexo (M / F) 37 / 22 21 / 12 0,93°

Estado físico (ASA III / IV) 56 / 3 29 / 4 0,25°°

Doador vivo / Doador cadáver 36 / 23 6 / 27 < 0,01°

Exames laboratoriais

Creatinina (mg%)* 12,0 ± 9,9 9,0 ± 3,0 0,05»

Potássio (mEq)* 4,7 ± 0,9 4,5 ± 0,7 0,27"

Hemoglobina (mg%)* 12,0 ± 2,0 12,3 ± 2,5 0,44»

* Valores expressos em Média ± "Teste de x2 ; °° Exato de Fisher; IMC — índice de massa corporal DP. # t de Student; ## Mann-Whitney.

Tabela II - Consumo de Anestésicos nos Diferentes Grupos Estudados

AG (n = 59) AG + Peri (n = 33) p

Fentanil (ig.kg-1) 9,0 ± 6,3 12,9 ± 8,2 0,27"

Sufentanil (ig.kg-1) 3,0 ± 2,9 1,4 ± 0,7 0,05

Propofol (mg.kg-1) 4,4 ± 0,5 1,8 ± 2,2 0,81"

Atracúrio(mg.kg-1) 1,3 ± 0,7 1,1 ± 0,3 0,52"

SF 0,9% (mL.kg-1) 86,7 ± 30,2 94,8 ± 21,8 0,38

Valores expressos em Média ± DP.

SF - soluçâo fisiológica a 0,9%.

Teste de t de Student; "Teste de Mann-Whitney.

INFLUÉNCIA DA TÉCNICA ANESTÉSICA NAS ALTERAQÓES HEMODINÁMICAS NO TRANSPLANTE RENAL. ESTUDO RETROSPECTIVO Tabela III - Parámetros Hemodinámicos e Diurese, Segundo Técnica Anestésica

AG (n = 59)

AG + Peri (n = 33)

Doador vivo / Doador cadáver 36 / 23 6 / 27 92 < 0,001

Hipotensâo arterial 17 17 34 0,03

PVC > 12 cmH2O 42 18 60 0,11

Diurese (+) 44 23 67 0,62

Teste de %2.

Tabela IV - Parámetros Hemodinámicos, Técnica Anestésica e Diurese, Segundo a Origem do Enxerto

Doador Vivo (n = 42) Doador Cadáver (n = 50) n p

AG / AG+Peri 36 / 6 23 / 27 92 < 0,001

Hipotensâo arterial 9 25 34 < 0,01

PVC > 12 cmH2O 32 28 60 0,04

Diurese (+) 36 31 67 0,01

Teste de %2.

A origem do enxerto esteve correlacionada a maior instabi-lidade hemodinámica e pior prognóstico para fungáo ime-diata do enxerto. O estudo das associagoes entre as variáveis: técnica anestésica, hipotensao arterial, PVC e pre-senga de diurese segundo tipo de doador, demonstrou que os pacientes que receberam rim de cadáver apresentaram com maior frequéncia hipotensao arterial (p < 0,01) e PVC

mais baixa que os pacientes que receberam rim de doador vivo. A diurese foi mais frequente entre pacientes que receberam rim de doador vivo relacionado (p = 0,01) (Tabela IV). A regressâo logística múltipla, considerando as variáveis estudadas e a ocorrência de diurese apontou como fatores significativos a origem do enxerto e o volume de hidrataçâo recebido (Figura 1). O poder do teste foi avaliado nas tabe-

PVC > 12 cm/H2O

Hidrataçâo > 80mL.kg-1

Hipotensâo arterial

Doador vivo

AG + Peri

(OR e IC 95%) I- 1,18 (0,41-3,42)

2,94 (1,00-8,32)

0,69 (0,24-1,95)

4,39 (1,31-14,72)

1,95 (0,59-6,40)

Figura 1 - Fatores Associados à Diurese no Final do Procedimento

las III e IV, sendo de aproximadamente 60% e 80% respectivamente, exceto para PVC > 12, que apresentou um poder de 37% na associagao com o tipo de técnica anestésica e de 55% com o tipo de doador. A diurese apresentou o poder mais baixo (10%) na associagao com a técnica anestésica. Outras complicagoes frequentes durante o período periope-ratório foram acidose metabólica, anemia e hiperpotasse-mia. Nao houve diferenga significativa entre os grupos estudados. Os pacientes que apresentaram acidose metabólica receberam infusao de bicarbonato de sódio. A hiper-potassemia foi corrigida com a administragao de solugao polarizada e ou cloreto de cálcio. Dez pacientes receberam transfusao de concentrado de hemáceas no intraoperatório. Trés pacientes foram encaminhados intubados a UTI: dois por broncoespasmo e um por instabilidade hemodinámica. Outras complicagoes menos frequentes foram disturbios de coagulagao e rash cutáneo.

DISCUSSAO

A anestesia geral venosa e inalatória com ventilagao controlada mecánica é a técnica mais empregada no Tx 710. Existe também consenso quanto aos agentes anestésicos utilizados: o tiopental sódico e mais recentemente o propofol associado ao fentanil. A intubagao é facilitada pela administragao de atracúrio e a manutengao feita com isoflurano associada ou nao ao óxido nitroso10. Quanto a dor pós-ope-ratória, tem sido tratada mais comumente com analgesia controlada pelo paciente (PCA) com opioide 11, fentanil ou morfina, apesar da possibilidade de acúmulo de metabó-litos ativos com a morfina 12.

A presente casuística é concorde com a literatura com rela-gao a técnica e agentes anestésicos empregados. Todos os pacientes receberam anestesia geral balanceada. A indugao foi realizada com propofol em 97,83% dos pacientes e atracúrio em 96,74%. A manutengao foi feita com isoflurano, vaporizado em uma mistura de O2 e NO2 a 1:1 em 100% dos casos estudados e o opioide empregado foi o fentanil (53,26%) e o sufentanil (46,74%), sem diferenga entre os grupos. O consumo de anestésicos foi igual nos dois grupos estudados, apesar da associagao da peridural em 35,87% dos pacientes.

Mesmo que os trabalhos da literatura apontem a anestesia geral como técnica de escolha para o Tx, existem vários estudos mostrando que a anestesia regional pode ser empre-gada com éxito nessas operagoes. Segundo Akpek e col. 13 e Hadimiaglee col. 14, a anestesia peridural continua e o blo-queio combinado raquiperidural sao tao eficazes quanto a anestesia geral nos quesitos estabilidade cardiovascular e complicagoes, com a vantagem de proporcionar boa analgesia pós-operatória.

Ocorre, no entanto, que os pacientes urémicos sao particularmente susceptíveis a algumas complicagoes decorrentes da pungao espinal. Trabalhos publicados relatam inclusive

lesao neurológica por hematoma peridural 15. Causas para tanto nao faltam: efeito residual da heparina, utilizada na diálise, plaquetopenia e disfungao plaquetária sao comuns na insuficiéncia renal crónica terminal. Mesmo a normalida-de de exames como o RNI e o R nao exclui a alteragao mais comumente encontrada, que é a disfungao plaquetária 16. Apesar da pequena casuística, nao foram observadas com-plicagoes dessa natureza.

Além destas complicagoes, os bloqueios espinais induzem hipotensao arterial e diminuigao da pressao venosa central (PVC), por diminuigao do retorno venoso ao coragao. Também causam bradicardia que, dependendo da intensidade, pode levar a diminuigao do débito cardíaco e da pressao arterial. Em determinadas circunstáncias, pode levar a bradiarritmias graves como o bloqueio átrio ventricular 17. Todos esses efeitos sao considerados deletérios, pois ca-minham em sentido oposto as recomendagoes de Carlie e col. 8 e Luciani e col. 9. Esses autores mostraram a impor-táncia da hidratagao máxima e de parámetros hemodiná-micos adequados, no momento da reperfusao, para a obtengao de diurese precoce e profilaxia de necrose tubular aguda no pós-operatório imediato 18. A hipotensao arterial é uma complicagao relativamente frequente em urémicos. Sao várias as justificativas para essa ocorréncia: pacientes muito desidratados por diálise recente, doses excessivas de agentes anestésicos e ou tratamento de longa duragao com inibidores da enzima conversora 19. No presente estudo, a incidéncia de hipotensao arterial foi significativamente mais elevada entre pacientes receptores de rim de doador faleci-do. Dois fatores poderiam explicar essa complicagao nesse grupo específico de pacientes: preparo inadequado dado a urgéncia relativa desse tipo de intervengao cirúrgica e o pre-domínio de Tx de doador falecido realizado sob anestesia geral associada a peridural (81,82%). O bloqueio simpático poderia explicar também a utilizagao significativamente maior de vasopressores, observada no grupo da associa-gao anestesia geral e peridural. Embora a dopamina seja o vasopressor mais indicado no tratamento da hipotensao arterial, e foi o mais utilizado nessa casuística, seu uso deve ser visto com parcimónia, pois, além de ser desprovida de efeito benéfico no rim, a dopamina está associada a complicagoes como taquiarritmias 20.

A diurese precoce é importante nos Tx, como fator de bom prognóstico. Ela está relacionada a maior sobrevida do en-xerto e menor mortalidade 21. Diurese precoce é uma obser-vagao comum entre doadores vivos e foi constatada nessa casuística. No caso de doadores falecidos, a diurese é menos frequente porque os rins ficam isquémicos por períodos variáveis e sao armazenados em solugoes eletrolíticas a baixas temperaturas, até o momento de serem implantados 22. Algumas medidas como a administragao de grandes volumes de líquidos e manitol tém sido preconizadas com a finalidade de se obter diurese ao final da operagao 23, desestimulando-se o uso sistemático de dopamina e de altas doses de furosemida 24.

Outra medida que encontra amparo na literatura é a manu-tengáo da PVC elevada no momento da reperfusáo do enxer-to. Valores variando de 10 até 15 cm de H2O sáo descritos como adequados 25. Na atual casuística, procurou-se man-ter a PVC acima de 12 cm de água, á custa de hidratagáo com solugáo fisiológica a 0,9% em volumes elevados, 86,7 a 94,8 mL.kg-1. Estes volumes podem estar associados a complicagoes e a recomendagáo é o acompanhamento clínico por meio de agoes simples como medida da pressáo arterial e da PVC e controle de aparecimento de edemas 24. A necessidade de adequada manutengáo do volume intravascular pode ser comprovada pela análise multivariada dos parámetros com diferenga estatística significativa na análise bivariada. Elegendo-se um regime de hidratagáo in-termediário entre os valores recomendados na literatura (70 a 90 mL.kg-1), pode-se observar aumento na probabilidade de ocorréncia de diurese precoce 2627. Este resultado, porém, deve ser interpretado com cautela, uma vez que a diurese apresentou um baixo poder estatístico, evidenciado pelos grandes intervalos de confianga.

A técnica anestésica utilizada na anestesia para transplante renal, no período considerado, foi geral venosa e inalatória, associada em 33 (35,86%) pacientes á anestesia peridural simples.

A alteragáo hemodinámica mais frequente nessa casuística foi hipotensáo arterial, maior entre os pacientes que rece-beram rim de cadáver, independentemente da técnica anestésica empregada.

Dois fatores podem ser considerados de bom prognóstico em relagáo á fungáo renal imediata do enxerto: ser receptor de doador vivo relacionado e receber hidratagáo de pelo menos 80 mL.kg-1 de solugáo eletrolítica.

Influence of the Anesthetic Technique on the Hemodynamic Changes in Renal Transplantation. A Retrospective Study

Eunice Sizue Hirata, TSA, M.D.; Maria Fernanda Baghin, M.D.; Rosa Inês Costa Pereira, TSA, M.D.; Gentil Alves Filho, M.D.; Artur Udelsmann, TSA, M.D.

INTRODUCTION

Renal transplantations (Tx) have been performed since 1906; however, only after 1960, with the development of new immunosuppressive agents 1, especially calcineurin inhibitors, recognition of brain death, and adequate selection of the binomium donor-receptor 2, Tx became the treatment of choice for patients with end-stage renal disease 3. Renal transplantations are associated with better quality of life, better cost/benefit ratio, and possibly longer survival 3.

In children, early transplantation promotes better growth and development 4.

The first transplantations were done under spinal block, since very few agents were available for general anesthesia at the time. With the advent of neuromuscular blockers with low urinary excretion 5 and volatile anesthetics with a low percentage of biotransformation 6, general anesthesia became a better option for those patients. Among the advantages of general anesthesia, one should mention the absolute immobility at the time of vascular anastomosis and adequate control of ventilation and perfusion in patients debilitated by uremia 7. However, the success of renal transplantations depends on other factors: type of donor, length of cold ischemia, and maintenance of adequate hemodynamic parameters at the time of reperfusion. It has been observed that good cardiovascular performance, related with the administration of large volumes of crystalloids, is associated with early graft function 8 and lower incidence of acute tubular necrosis 9. Our objective was to study retrospectively the technique and anesthetic agents used in anesthesia for Tx in adults at the Hospital das Clínicas da UNICAMP, focusing mainly on hemodynamic changes and diuresis.

METHODS

All live and dead donor renal transplantations performed from January 2005 and April 2006 at the Hospital das Clínicas da UNICAMP were analyzed.

Age, gender, weight, height, physical status (ASA), hemoglobin, hematocrit, and plasma potassium, urea, and creatinine were obtained from the pre-anesthetic evaluation records. All other parameters were obtained from the anesthesia chart, including those related with the intraoperative monitoring. Data from the medical charts were used whenever necessary. Besides hemodynamic parameters, the anesthetic agents, hydration, and complications during anesthesia were also analyzed. Hypotension or hypertension was defined as changes in systolic or mean arterial pressure greater than 30% of baseline levels for 15 minutes or more and/or administration of vasoactive drugs to increase or reduce the blood pressure, respectively. Bradycardia was defined as heart rate below 50 bpm, and tachycardia was defined as a heart rate greater than 120 bpm. Central venous pressure (CVP) between 2 and 12 cmH2O was considered normal. Categorical parameters were reported as the percentage distribution, while continuous parameters as mean and standard deviation. Fisher Exact test and Chi-square test (X2) were used to compare categorical parameters, and the Student t test and Mann-Whitney test were used to compare means. The size of the study population was determined by the number of subjects found during the study time, and the power of the test was evaluated after data collection, considering a type I error of 5%. Multiple logistic regression was used to study the magnitude of the risk factors studied and their relationship; diuresis was considered a de-

pendent parameter. It was determined a level of significance of 5%; the software SAS version 8.2 was used for the analysis.

RESULTS

During the study period, 98 patients underwent renal transplantation. Two patients were excluded from the study because their information was incomplete, and four were excluded due to their age (14 years). In four patients, the medical chart had to be consulted to complete the information. Out of 92 patients, 59 underwent general anesthesia (GA) and 33 underwent general anesthesia associated with epidural block (GA+Epi). As for the origin of the graft, 42 patients received live donor grafts and 50 received dead donor grafts. Patients were subdivided in two groups according to the anesthetic technique. Age, gender, weight, and height, as well as preoperative exams, were similar in both groups (p > 0.05), but the same does not apply to the

origin of the graft, since a predominance of dead donor grafts was seen in the GA+Epi (82%) (p < 0.01) (Table I). The general anesthesia and GA+Epi groups were also compatible regarding the presence of associated diseases and, among them, hypertension (p = 0.36), metabolic acidosis (p = 0.13), and anemia (p = 0.24) were the most frequent. Intraoperative monitoring consisted of: cardioscope, pulse oximetry, central venous pressure, non-invasive systolic blood pressure or mean arterial pressure by catheterizing the radial artery, and urinary catheter.

All patients underwent balanced, intravenous and inhalatio-nal, general anesthesia with mechanical ventilation with CO2 reabsorbtion system in both groups, and in the GA+Epi group, it was associated with epidural block. The inhalatio-nal agent used, 0.5 to 1.0% isoflurane, was vaporized in a mixture with oxygen and nitrous oxide at 50%. Intravenous anesthetics used more often were fentanyl, sufentanil, pro-pofol, and atracurium. Table II shows the mean anesthetic consumption with the standard deviation for both techni-

Table I - General Characteristics of the Groups and Mean Exams Values According to the Anesthetic Technique.

Anesthetic Technique GA (n = 59) GA + Epi (n = 33) P

Age (years) * 36.1 ±13.2 40.6 ± 11.1 0.10#

Weight (kg) * 62.4 ± 13.9 63.5 ± 13.5 0.72#

Height (cm) * 164.6 ± 10.4 163.4 ± 9.1 0.63#

BMI (kg.m-2) * 23.5 ± 4.4 23.1 ± 4.5 0.72#

Gender (M / F) 37 / 22 21 / 12 0.93°

Physical status (ASA III / IV) 56 / 3 29 / 4 0.25°°

Live Donor/Dead Donor 36 / 23 6 / 27 < 0.01°

Laboratory exams

Creatinine (mg%) * 12.0 ± 9.9 9.0 ± 3.0 0.05»

Potassium (mEq) * 4.7 ± 0.9 4.5 ± 0.7 0.27#

Hemoglobin (mg%) * 12.0 ± 2.0 12.3 ± 2.5 0.44»

'Results expressed as Mean ± SD

° x2 test; °° Fisher Exact test; # Student t test; » Mann-Whitney test BMI — body mass index

Table II - Anesthetic Consumption in the Different Study Groups.

GA (n = 59) GA + Epi (n = 33) p

Fentanyl (ig.kg-1) 9.0 ± 6.3 12.9 ± 8.2 0.27#

Sufentanil (ig.kg-1) 3.0 ± 2.9 1.4 ± 0.7 0.05

Propofol (mg.kg-1) 4.4 ± 0.5 1.8 ± 2.2 0.81#

Atracurium (mg.kg-1) 1.3 ± 0.7 1.1 ± 0.3 0.52#

NS (mL.kg-1) 86.7 ± 30.2 94.8 ± 21.8 0.38

Results expressed as Mean ± SD.

NS - normal saline.

Student t test; # Mann-Whitney test.

ques, which did not show statistically significant differences between both groups.

Patients were hydrated with NS at 86.7 ± 30.2 mL.kg-1 in the GA group, and 94.8 ± 21.8 mL.kg-1 in the GA+Epi group (p = 0.38). Blood products were transfused when hemoglobin levels were lower than 8 g.dL-1 and showed no differences between both groups.

All patients received furosemide 0.5 to 1.0 mg.kg-1 during vascular anastomosis, and all, except for three, received the usual doses of atropine and neostigmine and were extu-bated at the end of the surgery. Postoperative analgesia in the group that received epidural block consisted of the association of 0.25% bupivacaine (32.5 to 50 mg) and morphine 0.03 mg.kg-1. In the GA group (59 patients), analgesia consisted of subcutaneous morphine 0.1 mg.kg-1 associated with infiltration of the surgical wound with 100 mg of 0.5% bupivacaine. All patients were transferred to the intensive care unit (ICU) in the immediate postoperative period.

As for the perioperative cardiovascular changes, the objective of the present study, hypotension was seen in 34 patients, 17 (29%) in the GA group and 17 (51%) in the GA+Epi group (p = 0.03), and PVC > 12 cmH2O was seen in 60 patients, 42 (71%) in the GA group and 18 (54%) in the GA+Epi group (p = 0.11). Diuresis was seen in 67 patients at the end of the surgery, 44 (74.57%) in the GA group and 23 (69.69%) in the GA+Epi group, as shown in table III. The incidence of the use of vasoactive drugs was similar to that of hypotension. Patients did not develop hypertension, two developed tachycardia, and one had bradycardia.

The origin of the graft was associated with greater hemody-namic instability and worse prognosis for the immediate function of the organ. The study of the associations among the following parameters: anesthetic technique, hypotension, CVP, and presence of diuresis, according to the type of donor, demonstrated that patients who received dead donor grafts had a greater frequency of hypotension (p < 0.01) and lower CVP than patients who received live donor grafts. The presence of diuresis was more frequent in patients who received live donor grafts (p = 0.01) (Table IV). Logistic regression of the parameters studied and the presence of diuresis indicated that the origin of the graft and the volume of hydration were important factors (Figure 1). The power of the test, shown in tables III and IV, was approximately 60% and 80%, respectively, except for CVP > 12, which had a power of 37%, for the association with the anesthetic technique, and 55%, for the type of donor. Diuresis had the lowest power (10%) in its association with the anesthetic technique.

Other common perioperative complications included metabolic acidosis, anemia, and hyperkalemia. Significant differences between both groups were not observed. Patients who develop metabolic acidosis were treated with the infusion of sodium bicarbonate. Hyperkalemia was treated with the administration of polarized solution and/or calcium chloride. Ten patients received intraoperative blood transfusion. Three patients were intubated when they were transferred to the ICU: two for bronchospasm and one for hemodynamic instability. Less frequent complications included coagulation disorders and cutaneous rash.

Table III - Hemodynamic Parameters and Diuresis According to the Anesthetic Technique

GA (n = 59) GA + Epi (n = 33) n p

Live Donor/ Dead Donor 36 / 23 6 / 27 92 < 0.001

Hypotension 17 17 34 0.03

CVP > 12 cmH2O 42 18 60 0.11

Diuresis (+) 44 23 67 0.62

X2 test.

Table IV - Hemodynamic Parameters, Anesthetic Technique, and Diuresis According to Graft Origin

Live Donor (n = 42) Dead Donor (n = 50) n p

GA / GA+Epi 36 / 6 23 / 27 92 < 0.001

Hypotension 9 25 34 < 0.01

CVP > 12 cmH2O 32 28 60 0.04

Diuresis (+) 36 31 67 0.01

X2 test.

(OR and CI 95%)

Hydration > 80mL.kg-1

Hypotension

Live donor

GA + Epi

1,18 (0,41-3,42)

2,94 (1,00-8,32)

0,69 (0,24-1,95)

4,39 (1,31-14,72)

1,95 (0,59-6,40)

CVP > 12 cm/H2O

Figure 1 - Factors Associated with Diuresis at the End of the Procedure

DISCUSSION

General anesthesia, with intravenous and inhalational agents, associated with mechanical ventilation is the most common technique used in renal transplantations 710. A consensus on the anesthetic agents used, sodium thiopental and more recently propofol associated with fentanyl exists. Intubation is facilitated by the administration of atra-curium, and maintenance is accomplished with isoflurane associated or not with nitrous oxide 10. Postoperative pain has been treated, more often, with patient-controlled analgesia (PCA) with opioids 11, fentanyl, or morphine, despite the accumulation of active metabolites seen with morphine 12. The results of the present study regarding anesthetic techniques and agents are similar to those found in the literature. All patients received balanced general anesthesia. Propofol in 97.83% of the patients, and atracurium in 96.74% were used for induction. Isoflurane, vaporized in a mixture of O2 and NO2 at 1:1, was used for maintenance in all patients; fentanyl (53.26%) and sufentanil (46.74%) were the opioids of choice; no differences were seen between both groups. The consumption of anesthetics was similar in both study groups, despite the association of epidural block in 35.87% of the patients.

Although the studies in literature indicate general anesthesia as the technique of choice in Tx, several studies demonstrate that regional blocks can be successfully used in this type of surgery. According to Akpek et al. 13 and Hadimiaglee et al. 14, continuous epidural block and combined spinal-

epidural block are as effective as general anesthesia regarding cardiovascular stability and complications, with the advantage of providing good postoperative analgesia. However, uremic patients are especially susceptible to some complications secondary to spinal block. Studies have even reported epidural hematoma leading to neurological lesion 15. There are several reasons for this: residual effects of heparin used in dialysis; and thrombocytopenia and platelet dysfunction are common in end-stage renal disease. Even the presence of normal exams, such as INR and R, do not exclude the most common change seen in those patients, platelet dysfunction 16. Despite the small number of patients in the present study, this type of complication was not observed.

Besides those complications, spinal blocks also induce hypotension and a reduction in central venous pressure (CVP) by reducing venous return to the heart. They also cause bradycardia, which, depending on the severity, can lead to a reduction in cardiac output and blood pressure. In special circumstances, they can lead to severe bradyarrhythmias with AV block 17. All those effects are considered deleterious because they lead to the opposite of the recommendations of Carlie et al. 8 and Luciani et al 9.Those authors showed the importance of maximal hydration and adequate hemodynamic parameters at the time of reperfusion for the development of early diuresis and prophylaxis of acute tubular necrosis in the immediate postoperative period 18. Hypotension is a relatively common complication in uremic patients. The reasons for this include: severe dehydration due to

recent dialysis, excessive doses of anesthetic agents, and/ or long-term treatment with angiotensin-converting enzyme inhibitors 19. In the present study, the incidence of hypotension was significantly higher among patients receiving dead donor organ. Two factors could explain this complication in this group of patients: inadequate preparation, due to the relative urgency of this type of surgery, and predominance of transplantations of dead donor grafts under general anesthesia associated with epidural block (81.82%). The sympathetic blockade could also explain the significantly higher use of vasopressors observed in patients who underwent general anesthesia associated with epidural block. Although dopamine is the most indicated vasopressor for the treatment of hypotension, and it was indeed the vasopressor used more often in the present study, one should use it cautiously because, besides its lack of effects in the kidneys, its use is associated with complications, such as tachyarrhythmias 20.

Early diuresis is important in Tx as a good prognostic factor. It is associated with longer graft survival and lower mortality 21. Early diuresis is commonly observed in live donor grafts and it was present in this study. In dead donor grafts, diuresis is less frequent due to the variable period of kidney ischemia and their storage at low temperatures in electrolyte solutions until they are implanted 22. Some measures, such as the administration of large volumes of liquids and mannitol, have been advocated to obtain diuresis at the end of the surgery 23, discouraging the systematic use of dopamine and high doses of furosemide 24. Maintenance of an elevated CVP at the time of graft reperfusion is another measure supported by the literature. Levels ranging from 10 to 15 cmH2O have been described as adequate 25. In the present study, the goal was to maintain the CVP above 12 cmH2O by the administration of high volumes of NS, 86.7 to 94.8 mL.kg-1. Those volumes can be associated with complications, and clinical follow-up by simple measures, such as blood pressure, CVP, and the control of edema formation, are recommended 24. The need to maintain adequate intravascular volume can be shown by the multivariate analysis of the parameters, with statistically significant differences in the bivariate analysis. The hydration regimen chosen, which is intermediate of those recommended in the literature (70 to 90 mL.kg-1), was associated with an increase in the probability of early diuresis 26,27. However, this result should be interpreted with caution, since this parameter had low statistical power, demonstrated by the large confidence interval.

Intravenous and inhalational general anesthesia associated with epidural block in 33 patients (35.86%) was the anesthetic technique used for the renal transplantation during the study period.

Hypotension, more frequent in patients who received dead donor grafts, independent of the anesthetic technique used, was the most common hemodynamic change.

Two factors can be considered as indication of a good prognosis for the immediate function of the graft: to receive a live

donor graft and hydration of at least 80 mL.kg-1 of electrolytic

solution.

REFERENCIAS — REFERENCES

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14. Hadimioglu N, Ertug Z, Bigat Z et al. — A randomized study comparing combined spinal epidural or general anesthesia for renal transplantation surgery. Transplant Proc, 2005;37:2020-2022.

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RESUMEN

Hirata ES, Baghin MF, Pereira RIC, Alves Filho G, Udelsmann A — Influencia de la Técnica Anestésica en las Alteraciones Hemodi-námicas en el Transplante Renal. Estudio Retrospectivo.

JUSTIFICATIVA Y OBJETIVOS: El éxito en el transplante renal (Tx) depende del tipo de donador, de la duración de la isquemia fría y de los parámetros hemodinámicos en la reperfusión. El objetivo de esta investigación fue analizar la técnica anestésica, la incidencia

de alteraciones cardiovasculares y el aparecimiento de diuresis en el período perioperatorio de los Tx realizados en la UNICAMP.

MÉTODO: Se evaluó retrospectivamente Tx de adultos realizados entre enero de 2005 y abril de 2006. Se tuvieron en cuenta los datos demográficos, los exámenes laboratoriales preoperatorios, técnicas y agentes anestésicos, hidratación, parámetros hemodinámicos, el uso de aminas vasoactivas, la presencia de diuresis y complicaciones intraoperatorias, con análisis comparativo entre los subgrupos formados conforme a la técnica anestésica empleada. Se usaron en el análisis estadístico el test t de Student (paramé-tricos), Mann-Whitney (no paramétricos), test del Cui-cuadrado y Exacto de Fisher para la comparación de proporciones y análisis multivariada.

RESULTADOS: Se estudiaron 92 pacientes, 59 con anestesia general (AG) y 33 anestesia general asociada a la epidural (AG + Peri), 42 recibieron riñones de donantes vivos y 50 de fallecidos. No hubo diferencia (p < 0,05) en la mayoría de los parámetros preoperatorios estudiados, con excepción del origen del injerto (82% AG + Peri recibieron riñones de donante fallecido). La alteración cardiovascular más frecuente fue la hipotensión arterial (30% AG y 48% AG + Peri, p < 0,05). El régimen de hidratación no fue diferente entre los grupos (86,7 ± 30,2 mL.kg-1 AG y 94,8 ± 21,8 mL.kg-1 AG+Peri, p = 0,38). El injerto del donante fallecido se correlacionó con una mayor inestabilidad hemodinámica y con un peor pronóstico para la función inmediata del injerto, p < 0,01 y 0,01 respectivamente. Un volumen de hidratación de 80 mL.kg-1 se asoció a la diuresis (OR = 2,94, IC95% 1,00-8,32).

CONCLUSIONES: La técnica anestésica empleada fue anestesia general, asociada o no a la epidural. La alteración hemodinámica más común fue la hipotensión arterial. Se mostraron benéficos con relación a la diuresis por ser de un receptor de donante vivo y recibir una hidratación de 80 mL.kg-1 de solución fisiológica a 0,9%.