Anaesthesieprobleme bei klinischer Nierentransplantation

Zusammenfassung

Bei 16 Empfängern von Nierentransplantaten wurde der gleiche Anaesthesietyp verwendet: Einleitung mit Thiopental, N₂O/O₂ und Halothan, Relaxation mit dem kurzwirkenden Curarepräparat Alloferin oder mit Succinylcholin. Die Patienten wurden mit dem Engström-Respirator beatmet und postoperativ gewöhnlicherweise solange am Respirator belassen, wie sie den Endotrachealtubus ertrugen. Bei einigen Patienten kam es einige Stunden nach dem Aufwachen zu Koma und Konvulsionen; 2 waren während dieser Zeit am Respirator, während 3 reintubiert werden mußten. Das Koma dauerte 32 Std bis mehrere Tage. ätiologisch spielten neben dem „reverse urea Syndrome” bei zwei Patienten die durch Oligurie bedingte Akkumulation von Narkosemitteln und Relaxantien eine Rolle.

Summary

In all 16 cases of renal transplantation desribed, the same type of anaesthesia was given: induction with thiopental, N₂O/O₂, and halothane, and muscle relaxation with the short-acting curare drug alloferine (N,N′-diallyl-bis-nor-toxiferine) or succinylcholine. Both alloferine and the metabolites of succinylcholine have to be excreted via the kidney, and both can give rise to prolonged neuromuscular block in renal failure. The patients were ventilated with an Engström ventilator during anaesthesia and were usually left on the ventilator postoperatively for as long as they could tolerate the endotracheal tube and artificial ventilation.

In some of the patients coma and convulsions occurred a few hours postoperatively after awakening. This happened three times after transplantation, once after bilateral nephrectomy, and once after a reoperation for bleeding. In three cases the patient had to be intubated again and put on a ventilator, and the other two were still under ventilation when coma and convulsions developed. The coma lasted from 32 hours to several days. The etiology of this syndrome is not clear. It may be related to the phenomenon that has been described as ‘reverse urea syndrome’ [2, 3] in the presence of osmotic gradients between brain and serum with cerebral oedema. In two of the patients, however, who suffered from oliguria after transplantation, the accumulation of anaesthetics and muscle relaxants was a contributory cause. These two patients died 80 and 120 hours respectively after transplantation.