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LETTER TO THE EDITOR
Year : 2020  |  Volume : 13  |  Issue : 4  |  Page : 417-420  

Ventricular arrythmias in a end-stage renal disease patient during cadaveric renal transplantation


Department of Anesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra, India

Date of Submission28-Jun-2019
Date of Decision11-Sep-2019
Date of Acceptance12-Sep-2019
Date of Web Publication20-Jul-2020

Correspondence Address:
Vidhu Bhatnagar
Department of Anaesthesiology and Critical Care, INHS Asvini, Near RC Church, Colaba, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_188_19

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How to cite this article:
Bhatnagar V, Kulkarni S N, Surse Y B, Kumar P. Ventricular arrythmias in a end-stage renal disease patient during cadaveric renal transplantation. Med J DY Patil Vidyapeeth 2020;13:417-20

How to cite this URL:
Bhatnagar V, Kulkarni S N, Surse Y B, Kumar P. Ventricular arrythmias in a end-stage renal disease patient during cadaveric renal transplantation. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Dec 1];13:417-20. Available from: https://www.mjdrdypv.org/text.asp?2020/13/4/417/290163



Dear Sir,

End-stage renal disease (ESRD) is the most severe progression of chronic kidney disease (CKD) that affects all body systems. Chronic glomerulonephritis is the most common cause accounting for > one-third of patients followed by diabetic nephropathy. In India, patients are generally younger (mean age 42 years) and <10% receive renal replacement therapy.[1] CKD begins without any specific symptoms and symptoms may appear only as the condition progresses to ESRD. The most common symptoms are hypertension, lethargy, malaise, bone pain, or fractures due to renal osteodystrophy and generalized edema. Cardiac arrhythmias, pulmonary edema, and encephalopathy occur as the disease worsens.[2] Renal transplantation (RT) is the definitive treatment for ESRD patients. However, RT recipients vis-a-vis general population have a fourfold higher risk of cardiovascular disease and a twofold higher risk of cardiovascular death. Complex ventricular arrhythmias have been demonstrated as one of the etiologies of sudden death, responsible for around 15% of mortality among kidney transplant recipients with functioning grafts.[3] Cardiovascular depression, arrhythmias, postoperative cardiac failure, and acute-on chronic renal failure are well-known complications of general anesthesia in these patients.[4] We present a case of ESRD scheduled for RT with cadaveric kidney who developed ST-segment abnormality and cardiac arrythmias intraoperatively, creating a dilemma as to the etiology of myocardial ischemic changes.

Our patient, 39-year-old, female, 46 kg, a case of ESRD on hemodialysis (past 6 years), presented for cadaveric RT. On preanesthetic checkup immediately prior to surgery, her vital parameters, systemic examination, and serum electrolytes post dialysis were within normal limits. Electrocardiogram (ECG) revealed giant T wave inversion in leads V3–V6 with strain pattern in lead I and aVL which was suggestive of hypertensive heart disease. A two-dimensional (2D) echocardiography demonstrated severe concentric left ventricular hypertrophy (LVH), left ventricular (LV) dilatation, mild left atrium dilatation, mild mitral regurgitation, normal aortic valve, and LV ejection fraction of 65%. She was classified as American Society of Anesthesiologists Grade III. Informed consent was taken.

She was taken up for RT and the monitoring inside operating room (OR), included heart rate, noninvasive blood pressure, ECG, pulse oximetry (SpO2), capnography (EtCO2), temperature monitoring, and bispectral index (BIS) (for depth of anesthesia monitoring). The right internal jugular vein was cannulated for central venous pressure (CVP) monitoring under local anesthesia and ultrasonography guidance. Cardiac drugs and defibrillator were kept standby. Anesthesia was induced with fentanyl 80 μg, propofol 60 mg, and atracurium 20 mg, and the trachea was intubated with a 7.0-mm cuffed endotracheal tube. General anesthesia was maintained with O2/air (50:50), isoflurane at minimum alveolar concentration (MAC) of 0.6–0.7 and atracurium. A BIS reading ranging between 60 and 70 was maintained. After 2 h of surgery, while the bed for kidney placement was being prepared, series of events took place intraoperatively As shown in [Table 1].
Table 1: Sequence of intra-operative events and their management

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Intraoperative CVP was maintained between 5 and 7 cmH2O. Urine output was 1000 ml. Perioperative pain relief was obtained with intravenous (IV) paracetamol 1 g, IV fentanyl 50 μg, and IV morphine 3 mg was administered when ST elevation (>1 mm) appeared. Surgery lasted for 5 h with a total blood loss of 600 ml. Myocardial ischemia as the etiology of cardiac arrythmias was ruled out by intraoperative echocardiography; thereafter, the patient was reversed and extubated. As the depth of anesthesia decreased from MAC 0.7 to 0.2, the ECG changes stabilized, NSR regained, and blood pressures improved. The phenylephrine infusion was tapered and switched off after extubation. The patient's recovery was smooth, complete, and uneventful, and she was shifted to renal care unit for postoperative monitoring with further cardiologic evaluation. Increased sympathetic nervous system activity in the form of tachycardia and hypertension is present in the vast majority of ESRD patients preoperatively which may play a role in a high rate of cardiovascular events.[5],[6] Although the simplest and most cost-effective method for myocardial ischemia detection is electrocardiography, it has its own limitations. ST-segment changes (horizontal or downsloping ST-segment depression or ST-segment elevation of at least 1 mm (0.1 mV) give an indication to the diagnosis of myocardial infarction; T wave inversions, R-wave changes, ventricular dysrhythmias (ventricular tachycardia) are also associated with myocardial ischemia and this diagnosis is to be considered in patients who are at risk of coronary artery disease. Signicant ST-segment change is difficult to determine when a baseline ST segment depression or LVH with strain is preexistent on ECG; however, treatment is begun, mostly when the ST-segment change reaches 1 mm in patients at high risk for the development of myocardial ischemia. Our patient had a ST elevation (>1 mm) and T wave changes (peaked T wave); thus, etiology of myocardial ischemia was considered. Pathophysiology of ventricular arrythmias in CKD patients is postulated to vulnerable ailing myocardium, myocardial fibrosis, hypertrophy, and electrolyte imbalance, leading to increased electric instability which trigger arrythmias and is well established[7] but early detection of perioperative myocardial ischemia can lead to favorable results; hence, the differential diagnosis of myocardial ischemia was also entertained till we confirmed nil regional wall motion abnormalities (RWMA) by 2D echocardiography post closure in OR. After confirmation by 2D echocardiography, we proceeded with extubation instead of taking the patient for cardiac catheterization. Transthoracic echocardiography, thus, provided a diagnosis of the unexpected events in this case.

Establishing development of new RWMA using transesophageal echocardiography (TEE) perioperatively has emerged as a new standard for intraoperative diagnosis of myocardial ischemia and TEE is a useful asset during cardiac surgery. The use of TEE is recommended in patients undergoing noncardiac surgery who develop intraoperative hemodynamic instability, ST changes, arrhythmias, and refractory hypotension.[8],[9] TEE is a viable option if a difficult diagnostic dilemma arises (like in our case) and it can be inserted quickly to confirm about wall motion abnormalities and direct treatment and is useful to rapidly assess patients undergoing noncardiac surgery.[10],[11] Use of TEE in noncardiac surgery identified the cause of the wall motion abnormalities and was also associated with etiology-directed management in 72.9% cases, leading to improved survival rates.[12] However, the use of TEE is usually limited due to unavailability of equipment and lack of TEE-trained physcians.

This article highlights the use of intraoperative transthoracic echocardiography and/or TEE as a valuable diagnostic tool in cardiac events during noncardiac surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baxi V, Jain A, Dasgupta D. Anaesthesia for renal transplantation: An update. Indian J Anaesth 2009;53:139-47.  Back to cited text no. 1
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2.
Schmid S, Jungwirth B. Anaesthesia for renal transplant surgery: An update. Eur J Anaesthesiol 2012;29:552-8.  Back to cited text no. 2
    
3.
Siedlecki A, Muslin AJ. Left ventricular hypertrophy in the setting of chronic kidney disease: Mechanisms and treatment. US Nephrol 2008;3:40-2.  Back to cited text no. 3
    
4.
Thiagarajah PH, Thiagarajah S, Frost EA. Anesthetic considerations in patients with cardiomyopathies – A review. Middle East J Anaesthesiol 2009;20:347-54.  Back to cited text no. 4
    
5.
Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, et al. Cardiac disease evaluation and management among kidney and liver transplantation candidates: A scientific statement from the American heart association and the American college of cardiology foundation. J Am Coll Cardiol 2012;60:434-80.  Back to cited text no. 5
    
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Herzog CA, Littrell K, Arko C, Frederick PD, Blaney M. Clinical characteristics of dialysis patients with acute myocardial infarction in the United States: A collaborative project of the United States renal data system and the national registry of myocardial infarction. Circulation 2007;116:1465-72.  Back to cited text no. 6
    
7.
Wang AY, Lam CW, Chan IH, Wang M, Lui SF, Sanderson JE, et al. Sudden cardiac death in end-stage renal disease patients: A 5-year prospective analysis. Hypertension 2010;56:210-6.  Back to cited text no. 7
    
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Reeves ST, Finley AC, Skubas NJ, Swaminathan M, Whitley WS, Glas KE, et al. Basic perioperative transesophageal echocardiography examination: A consensus statement of the American Society of echocardiography and the Society of cardiovascular anesthesiologists. J Am Soc Echocardiogr 2013;26:443-56.  Back to cited text no. 8
    
9.
Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: Recommendations from the American Society of echocardiography and the Society of cardiovascular anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.  Back to cited text no. 9
    
10.
Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: A review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005;173:627-34.  Back to cited text no. 10
    
11.
Goldhaber-Fiebert SN, Pollock J, Howard SK, Bereknyei Merrell S. Emergency manual uses during actual critical events and changes in safety culture from the perspective of anesthesia residents: A pilot study. Anesth Analg 2016;123:641-9.  Back to cited text no. 11
    
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Shillcutt SK, Markin NW, Montzingo CR, Brakke TR. Use of rapid “rescue” perioperative echocardiography to improve outcomes after hemodynamic instability in noncardiac surgical patients. J Cardiothorac Vasc Anesth 2012;26:362-70.  Back to cited text no. 12
    



 
 
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