Anestesia para hipertermia maligna no contexto do transplante renal: avaliando a transferência de halogenados pelo órgão transplantado
Data
2022-10-24
Autores
Neder Neto, Calim 
Orientadores
Silva, Helga Cristina Almeida da
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: hipertermia maligna (HM) é uma doença farmacogenética rara que ocorre em indivíduos geneticamente suscetíveis em resposta à exposição a anestésicos inalatórios halogenados ou succinilcolina. O quadro típico de hipermetabolismo e rabdomiólise pode ser mascarado no paciente submetido a transplante, principalmente renal, tornando o diagnóstico difícil. Além disso, mesmo que o paciente suscetível à HM não use halogenados, questiona-se a possibilidade dos agentes desencadeantes halogenados serem carreados com o tecido transplantado. Objetivo: verificar a possibilidade de anestésicos halogenados serem carreados do doador para o receptor de transplante renal e determinar fatores que influenciam esse processo. Métodos: o estudo foi do tipo observacional transversal controlado. A fração expirada de anestésicos inalatórios halogenados foi quantificada em pacientes receptores submetidos à anestesia geral do tipo venosa total para transplante renal, cujos respectivos doadores foram submetidos à anestesia geral do tipo balanceada com anestésicos inalatórios halogenados. Os pacientes receptores e doadores vivos de rim foram divididos da seguinte forma: 10 pacientes (5 duplas receptor/doador) para o grupo sevoflurano e 10 pacientes (5 duplas receptor/doador) para o grupo desflurano. A medição da fração expirada de anestésico halogenado no receptor foi feita por analisador de gases Vamos®. Resultados: os pacientes doadores que foram submetidos à anestesia combinada peridural e geral balanceada com desflurano eram em sua maioria pacientes do sexo feminino (4, 80%), apresentavam uma média de idade de 41,8 ± 7,79 anos (intervalo 32-51 anos), eram em sua maioria eutróficos (4 eutróficos e 1 sobrepeso) com média de IMC de 22,1 ± 2,14 kg/m2, avaliados em sua maioria como ASA I (4, 80%) e apenas um como ASA II (20%). O tempo médio de exposição dos rins dos pacientes doadores ao desflurano foi de 37,4 ± 5,50 minutos (intervalo 30-45 minutos). O tempo médio de duração total do procedimento dos pacientes doadores do grupo desflurano foi de 125,0 ± 16,95 minutos (intervalo 105-145 minutos). Nenhum receptor do grupo desflurano exalou halogenado após reperfusão renal. Os pacientes doadores que foram submetidos à anestesia combinada peridural e geral balanceada com sevoflurano eram em sua maioria pacientes do sexo feminino (4, 80%), apresentavam uma média de idade de 42,2 ± 9,09 anos (intervalo 29-54 anos), em sua maioria com sobrepeso (2 eutróficos e 3 sobrepesos) com média de IMC de 28,9 ± 4,20 kg/m2, avaliados em sua maioria como ASA I (3, 60%) e dois como ASA II (40%). O tempo médio de exposição dos rins dos pacientes doadores ao sevoflurano foi de 49,6 ± 14,77 minutos (intervalo 29-68 minutos). O tempo médio de duração total do procedimento dos pacientes doadores do grupo sevoflurano foi de 145,0 ± 30,62 minutos (intervalo 120-145 minutos). Em dois receptores do grupo sevoflurano foram identificadas leitura de halogenado após a reperfusão do órgão transplantado (valor de 0,1%). Conclusões: no presente estudo, foi possível mostrar que, possivelmente, o órgão sólido transplantado armazenou e transportou anestésico inalatório halogenado que foi liberado na corrente sanguínea do receptor após sua reperfusão. Esse transporte pode ser influenciado por fatores como massa corpórea e tipo e duração da exposição ao halogenado. Esses fatos devem ser levados em consideração em pacientes considerados suscetíveis que serão submetidos a transplante renal de doador vivo, de forma a não empregar agentes desencadeantes.
Introduction: malignant hyperthermia (MH) is a rare pharmacogenetic disease that occurs in genetically susceptible individuals after exposure to volatile halogenated anesthetics or succinylcholine. Diagnosis can be challenging in specific situations such as renal transplantation since the typical clinical presentation of hypermetabolism and rhabdomyolysis can be masked in this population. A transplantation receptor susceptible to MH requires a careful anesthesia management for both donor and receptor due to a potential risk of halogenated triggering agents being carried with the transplanted tissue. Aim: to verify the possibility of volatile halogenated anesthetics being transported from the donor to the recipient throughout the transplanted kidney and to determine factors that influence this process. Methods: the study was an observational cross-sectional controlled study. We quantified the expired fraction of volatile halogenated anesthetics in recipient patients undergoing total venous general anesthesia for kidney transplantation, whose respective donors underwent balanced general anesthesia with volatile halogenated anesthetics. Recipient patients and living kidney donors were divided as follows: 10 patients (5 recipient/donor pairs) for the sevoflurane group and 10 patients (5 recipient/donor pairs) for the desflurane group. The measurement of the expired fraction of volatile halogenated anesthetic in the receiver was performed by a Vamos gas analyzer. Results: donor patients who underwent combined epidural and general balanced anesthesia with desflurane were mostly female patients (4, 80%), they had a mean age of 41.8 ± 7.79 years (range 32-51 years), they were mostly eutrophic (4 eutrophic and 1 overweight) with a mean BMI of 22.1 ± 2.14 kg/m2, evaluated mostly as ASA I (4, 80%) and only one as ASA II (20%). The mean exposure time of the kidneys of donor patients to desflurane was 37.4 ± 5.50 minutes (range 30-45 minutes). The mean total duration of the procedure for donor patients in the desflurane group was 125.0 ± 16.95 minutes (range 105-145 minutes). None of the desflurane group recipients exhaled volatile halogenated anesthetic after renal reperfusion. Donor patients who underwent combined epidural and balanced general anesthesia with sevoflurane were mostly female patients (4, 80%), they had a mean age of 42.2 ± 9.09 years (range 29-54 years), mostly overweight (2 eutrophic and 3 overweight) with a mean BMI of 28.9 ± 4.20 kg/m2, evaluated mostly as ASA I (3, 60%) and two as ASA II (40 %). The mean exposure time of the kidneys of donor patients to sevoflurane was 49.6 ± 14.77 minutes (range 29-68 minutes). The mean total duration of the procedure for donor patients in the sevoflurane group was 145.0 ± 30.62 minutes (range 120-145 minutes). In two recipients of the sevoflurane group, volatile halogenated anesthetic readings were identified after reperfusion of the transplanted organ (0.1% value). Conclusions: in our study, it was possible to show that, possibly, the transplanted solid organ stored and transported volatile halogenated anesthetic that was released into the recipient's bloodstream after its reperfusion. This transport can be influenced by factors such as body mass and type and duration of exposure to the volatile halogenated anesthetic. These facts should be taken into account in patients considered susceptible who will undergo living donor kidney transplantation, in order to avoiding triggering agents.
Introduction: malignant hyperthermia (MH) is a rare pharmacogenetic disease that occurs in genetically susceptible individuals after exposure to volatile halogenated anesthetics or succinylcholine. Diagnosis can be challenging in specific situations such as renal transplantation since the typical clinical presentation of hypermetabolism and rhabdomyolysis can be masked in this population. A transplantation receptor susceptible to MH requires a careful anesthesia management for both donor and receptor due to a potential risk of halogenated triggering agents being carried with the transplanted tissue. Aim: to verify the possibility of volatile halogenated anesthetics being transported from the donor to the recipient throughout the transplanted kidney and to determine factors that influence this process. Methods: the study was an observational cross-sectional controlled study. We quantified the expired fraction of volatile halogenated anesthetics in recipient patients undergoing total venous general anesthesia for kidney transplantation, whose respective donors underwent balanced general anesthesia with volatile halogenated anesthetics. Recipient patients and living kidney donors were divided as follows: 10 patients (5 recipient/donor pairs) for the sevoflurane group and 10 patients (5 recipient/donor pairs) for the desflurane group. The measurement of the expired fraction of volatile halogenated anesthetic in the receiver was performed by a Vamos gas analyzer. Results: donor patients who underwent combined epidural and general balanced anesthesia with desflurane were mostly female patients (4, 80%), they had a mean age of 41.8 ± 7.79 years (range 32-51 years), they were mostly eutrophic (4 eutrophic and 1 overweight) with a mean BMI of 22.1 ± 2.14 kg/m2, evaluated mostly as ASA I (4, 80%) and only one as ASA II (20%). The mean exposure time of the kidneys of donor patients to desflurane was 37.4 ± 5.50 minutes (range 30-45 minutes). The mean total duration of the procedure for donor patients in the desflurane group was 125.0 ± 16.95 minutes (range 105-145 minutes). None of the desflurane group recipients exhaled volatile halogenated anesthetic after renal reperfusion. Donor patients who underwent combined epidural and balanced general anesthesia with sevoflurane were mostly female patients (4, 80%), they had a mean age of 42.2 ± 9.09 years (range 29-54 years), mostly overweight (2 eutrophic and 3 overweight) with a mean BMI of 28.9 ± 4.20 kg/m2, evaluated mostly as ASA I (3, 60%) and two as ASA II (40 %). The mean exposure time of the kidneys of donor patients to sevoflurane was 49.6 ± 14.77 minutes (range 29-68 minutes). The mean total duration of the procedure for donor patients in the sevoflurane group was 145.0 ± 30.62 minutes (range 120-145 minutes). In two recipients of the sevoflurane group, volatile halogenated anesthetic readings were identified after reperfusion of the transplanted organ (0.1% value). Conclusions: in our study, it was possible to show that, possibly, the transplanted solid organ stored and transported volatile halogenated anesthetic that was released into the recipient's bloodstream after its reperfusion. This transport can be influenced by factors such as body mass and type and duration of exposure to the volatile halogenated anesthetic. These facts should be taken into account in patients considered susceptible who will undergo living donor kidney transplantation, in order to avoiding triggering agents.