Resuscitation Guided by Cardiac Output using Transesophageal Echocardiography in Kidney Transplantation: Case Report

ABSTRACT


I. INTRODUCTION
Accurate assessment of hemodynamic status is essential for optimal fluid management in critically ill patients.Optimizing intravascular volume can improve tissue perfusion and therefore morbidity and mortality associated with various medical conditions.Transesophageal echocardiography allows a direct and detailed view of cardiac anatomy and function, making it an invaluable tool for evaluating hemodynamic status and guiding fluid management.By providing real-time images of the heart and adjacent structures from a close-up position, TEE allows accurate assessment of ventricular function, filling capacity, and pressure in the cardiac chambers.Written consent was obtained from the patient for the publication of this clinical case as well as approval and exemption from the consent requirement of the Research Ethics Committee.

CASE DESCRIPTION
28-year-old female patient (64 kg, 1.65 m) with a history of undetermined chronic kidney disease without comorbidities and with renal function replacement treatment through intermittent hemodialysis (3 times a week); 24 hours before surgery, hemodialysis was performed with 3500 ml UF.The preoperative cardiovascular evaluation included a Corresponding Author: Alfonso de Jesus Flores Rodriguez transthoracic echocardiogram with LVEF of 56% and adequate left cavities filling with jugular regurgitation of 1 cm/s, mild due to tricuspid insufficiency with right diastolic dysfunction type I with E/e 14 without left diastolic dysfunction E/A 0.8.Anesthetic Procedure Through a standardized anesthetic procedure at the Hospital Juarez of Mexico, balanced general anesthesia was administered with IV Fentanyl at a dose of 2 mcg/kg, Propofol at 2 mg/kg and Rocuronium at 0.60 mg/kg with a latency of 4 minutes and intermittent manual positive pressure ventilation with FIO2.100%; Atraumatic laryngoscopy was performed with a 7.5 DI endotracheal tube + 4ml of pneumotamponade and <10% leak.It is connected to an anesthetic circuit with mechanical ventilation in PCV-VG mode, VTE 6-8 ml/kg, RR 10-17 rpm, I:E 1:2.5, PEEP 6-8 according to PEEP/ARDSnet.For anesthetic maintenance, Desflurane 0.8-1.2MAC with Sedline 30-50 PSI is used.The right jugular vein was cannulated with a 7FR central catheter and a 20G right radial arterial line.At induction, three boluses of 100 ml/hr are administered to dilute medications (antibiotic therapy, steroids, and antihistamines).The immunosuppressive medication is administered diluted in SF0.9% 250 ml for 6 hours at a rate of 41.6 ml/hr.An infusion of Sol Hartman at 10 ml/kg was administered for fluid maintenance and boluses of Sol Hartman at 250 ml were administered to maintain a normalized Cardiac Output of 6-8 Lt/min.In case of hypotension, a bolus of ephedrine 5 mg IV is administered every 3-5 minutes until the episode resolves.During kidney transplant, Type I Monitoring (GE Monitor) is performed: Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), pulse variation index (PVI); Type II monitoring (Hemosphere/Edwards): Central venous pressure (CVP), mean systemic filling pressure (MSFP), systemic vascular resistance (SVR), stroke volume (SV), cardiac output (CO), stroke volume variability (SVV ); Type III monitoring with transesophageal echocardiography (TEE/TE7): Cardiac Output (CO), tricuspid regurgitation jet (TR), inferior vena cava diameter (IVCD), estimated right atrial pressure (RAP), estimated arterial pressure pulmonary volume (PSAP), endsystolic volume (ESV), end-diastolic volume (EDV) and ejection fraction (LVEF).Echocardiographic Monitoring (TEE) The transesophageal probe is introduced orally in a neutral position to the mid-esophageal plane where with a bicaval view (115°) with visibility of the inferior vena cava.In a fourchamber plane (0°) by means of the Simpson method and continuous integral of the left ventricular outflow tract (LVOT), images and 30-second video were obtained for endsystolic (ESV) and end-diastolic (EDV) measurements in each period: 1) Beginning Anesthesia, 2) Warm Ischemia (donor), 3) Cold Ischemia, 4) Renal Vein Anastomosis, 5) Renal Artery Anastomosis, 6) Before Reperfusion (1min), 7) At Reperfusion(1min), 8) to Reperfusion(5min), 9) to Reperfusion(10min), 10) End of Anesthesia (aponeurosis closure).All measurements were performed by trained personnel with a master's degree in Transesophageal Echocardiography from the Spanish Society of Clinical Echocardiography.
(increase in RAP); Portal Vein pulsatility of 30% and Renal Vein of the graft with continuous monophasic doppler wave.LUSS Score with all the PLAPS with "A" Pattern.The presurgical proBNP clearance was 4250 ng/L while the postsurgical value of 1058 ng/L.The pre-surgical serum creatinine clearance was 11.7 mg/dL while the post-surgical value on the first day was 2.55 mg/dL, second day was 1.38 mg/dL and at discharge 0.98 mg/dL.The patient was discharged without renal function replacement treatment 5 days after the surgical procedure.

Figure 1 .
Figure 1.Transesophageal echocardiographic values obtained at reperfusion in kidney transplantation.

Figure
Figure 2. Transesophageal echocardiographic values obtained 5 min after reperfusion in kidney transplantation.

Figure 4 .
Figure 4. Combination of the Frank-Starling relationship with Diamond-Forrester profiles.In a contemporary ultrasound-based interpretation, the venous excess according to mean systemic filling pressure (MSFP <15 mm Hg) dichotomizes cardiac filling on the x-axis and cardiac output (CO <4 Lt/min), dichotomizes the filling volume on the yaxis.On the left is shown the escalation period of the patient undergoing kidney transplant from the beginning of