We present a case of a 44-year-old man with chronic renal failure listed for renal transplant surgery. Other co-morbidities included hypertension, diabetes, and diabetic retinopathy. He gave a history of breathlessness relieved by pleural tapping. High-resolution computed tomography chest showed moderate pleural effusion and generalized ground glass opacities. 2D echocardiography reported a left ventricular ejection fraction of 50%, a DD grade III, a pulmonary artery (PA) pressure of 50 mmHg, a dilated left atrium (4.6 × 5.4 cm), and a thin rim of pericardial effusion. His hemoglobin was 7.3 g/dl, serum creatinine 5.40 mg/dl, and serum potassium 4.31 mmol/dl. Other laboratory investigations were within normal limits. Pleural tapping and dialysis were done a day prior to surgery. Intraoperatively, oxygen saturation (SpO2), electrocardiogram (ECG), heart rate, invasive blood pressure (IBP), central venous pressure (CVP), pulse pressure variation (PPV), and bi-spectral index (BIS) were monitored. Anesthetic medications included midazolam, fentanyl, propofol, atracurium, and sevoflurane in air/oxygen mixture. Vital signs on induction included a blood pressure of 160/80 mmHg and a heart rate of 84 beats per minute. The patient stayed hemodynamically stable throughout the 5-h procedure. 0.9% sodium chloride was used as intravenous fluid; 350 ml of blood was also transfused. Fluid infusion was guided by CVP and PPV. At the time of declamping, CVP was maintained between 10 and 12 mmHg. The transplanted kidney functioned well immediately. Nitrogycerine and milrinone infusions were prepared but were not required intraoperatively. Extubation was attempted at the end of surgery, and the patient’s vital parameters were within normal range; hence, the patient was extubated at the end of surgery. Intravenous infusions of frusemide and renal dose of dopamine were started and also fentanyl infusion for pain relief. The patient was comfortable after extubation and was shifted to the intensive care unit (ICU).

A 58-year-old man with chronic renal failure was posted for renal transplant surgery. Other co-morbidities included hypertension, diabetes, chronic liver disease, and pulmonary Koch’s for which anti-tubercular treatment was taken. He gave a history of cough relieved by pleural tapping. Ultrasound of the chest showed moderate right-sided pleural effusion with basal atelectasis. The patient expressed symptomatic relief after pleural tapping. The spirometry test suggested a mild restrictive defect with diminished flow in small airways and no post-bronchodilator reversibility. Mild ascites were noted on the ultrasound abdomen. The 2D echocardiography reported a DD grade III, a dilated left atrium (4.2 × 4.7 cm), a pulmonary artery (PA) pressure of 68 mmHg, and a left ventricular ejection fraction of 55%. Pleural tapping and dialysis were done a day prior to surgery. His hemoglobin was 9.8 g/dl, serum creatinine 4.64 mg/dl, serum potassium 4.03 mmol/ dl, aspartate aminotransferase 14.1, alanine aminotransferase 10.2, and gamma-glutamyl transferase 89.9. In the operation theater standard monitors including NIBP, SpO2 and five lead ECG were attached. An arterial line (radial) and central line (right internal jugular) were established for IBP and CVP monitoring.

Anesthetic medications included midazolam, fentanyl, propofol, atracurium, and sevoflurane in air/oxygen mixture. Intraoperatively, electrocardiogram, heart rate, IBP, CVP, PPV, and BIS were monitored continuously. Vital signs on induction included a blood pressure of 140/80 mmHg and a heart rate of 68 beats per minute. The patient stayed hemodynamically stable throughout the 4-h procedure. 0.9% sodium chloride was used as intravenous fluid. Fresh frozen plasma was transfused in view of his hepatic status. Fluid infusion was guided by CVP and PPV. At the time of declamping, CVP was maintained between 10 and 12 mmHg. The transplanted kidney functioned well immediately. At the end of surgery, arterial blood gas analysis reported all parameters within the normal range. Extubation was attempted at the end of surgery, the patient’s vital parameters were within the normal range; hence, the patient was extubated. Nitrogycerine and milrinone infusions were prepared but were not required intraoperatively. The patient was comfortable after extubation and was shifted to the ICU. Intravenous insulin and dopamine infusions and fentanyl infusion for pain relief were ongoing when the patient was shifted to the ICU.