the study group was composed of 10 patients aged 24.75  14.56 years ( adult male ) with american society of anaesthesiologists ( asa ii - iii ) who underwent elective laparoscopic retroperitoneal bilateral simultaneous nephrectomy for different indications over a 3-year period from 2006 to 2010 . they were advised to take morning dose of regular treatment for hypertension and anticonvulsant . in operating room , after securing intravenous cannula and protection of arteriovenous fistula all patients were given general anaesthesia . they were premeditated with intravenous glycopyrolate 0.004 mg and 3 g / kg fentanyl citrate . injection thiopental sodium 3 - 4 mg / kg was used for induction and endotracheal intubation was facilitated with injection suxamethinium 1 - 1.5 mg / kg and maintained with gas , oxygen and isoflurane . they were monitored with ecg , non - invasive blood pressure ( nibp ) , saturation of peripheral oxygen ( spo2 ) , end - tidal carbon dioxide ( etco2 ) and temperature probe . pulse rate , systolic blood pressure , diastolic blood pressure and etco2 were recorded after creation of pneumoperitoneum then after 15 , 30 , 45 minutes and after exsuffflation . normal saline was given as intravenous fluid and blood loss was replaced with pcv followed by injection calcium gluconate . injection tramadol 2 mg / kg was given for postoperative analgesia along with inj ondansetron 2 mg . at the completion of surgery , all patients were reversed from neuromuscular blockade and shifted to intensive care unit . data are expressed as mean  sd ( standard deviation ) for continuous variables and no ( % ) for categorical variables . continuous variables were compared using independent t - test and mann - whitney u - test . also related variables were compared using paired sample t - test and wilcoxon signed ranks test . data are expressed as mean  sd ( standard deviation ) for continuous variables and no ( % ) for categorical variables . continuous variables were compared using independent t - test and mann - whitney u - test . also related variables were compared using paired sample t - test and wilcoxon signed ranks test . among 10 patients , six patients were on antihypertensive drugs , one on anticoagulant , one on digoxin and one was diabetic on insulin . ecg , 2d echo and x - ray chest finding were presented in table 2 . pulse rate mean blood pressure and etco2 were recorded after creation of pneumoperitoneum and at 15 , 30 , 45 and after exsufflation of pneumoperitoneum . after pneumoperitoneum , there was increase in pulse rate from 91.3  18.7/min to 97.7  20.9/min ( p < 0.506 ) , systolic blood pressure from 142.3  19.1 mmhg to 157  35.6 mmhg ( p < 0.838 ) , diastolic blood pressure from 90.1  1 mmhg to 98  9.19 mmhg ( p < 0.143 ) and etco2 from 28.6  2.91 to 31.8  3.68 ( p < 0.475 ) , [ table 3 ] . only one patient required pcv transfusion and total intravenous fluid was 1  0.5 l. at the time of exsufflation , there was decrease in pulse rate , systolic and diastolic blood pressure and etco2 . all patients were ventilated with tidal volume of 7 - 10 ml / kg and respiratory rate of 12 - 14/min which was adjusted to keep the etco2 between 35 mmhg and 40 mmhg . three patients had mild - moderate pulmonary hypertension . demographic data and investigations ecg , x - ray & 2d echocardiography findings in patients comparison between right and left nephrectomy ( % increase in values of all variables with baseline ) anaesthesia for bilateral simultaneous nephrectomy represents a significant challenge and successful management of these patients requires systemic approach to preoperative evaluation and careful selection of anaesthetic agents . end stage renal disease is a multisystem disorder and is associated with increased risk of cardiovascular co morbidity and increased severity of cardiovascular disease . apart from the impact of surgery and co morbidity , the main perioperative care issues to be considered in this patient population are impact of haemodialysis and anephric state . the problems associated with haemodialysis are increased bleeding complications , arrthymias , and poor blood pressure control including hypertension and hypotension which may be aggravated by laparoscopic surgery . we have observed same hemodynamic and etco2 changes after creation of pneumoperitoneum as in healthy population . in our study , four patients required injection nitroglycerine for control of hypertension , this might be due to pneumoperitonium . the most common cardiovascular issues in these patients are arteriosclerosis mediated hypertension , ischemic heart disease , impaired systolic and/or diastolic ventricular function and arrhythmogenic sudden cardiac death . our three patients had left ventricular hypertrophy ( lvh ) , two had low ejection fraction and global left ventricular dysfunction . the presence of severe pulmonary hypertension should be determined preoperatively as it will have a significant impact on the anaesthetic management of the patient . management goals should centre on the avoidance of hypoxia , hypercapnia , acidosis and hypotension as each of these factors will increase pulmonary vascular resistance . if the patient is above their dry weight preoperatively , they risk for pulmonary oedema and poorly controlled hypertension perioperatively and poor tissue healing postoperatively . if under their dry weight , they may become profoundly hypotensive during surgery which will be exacerbated by blood loss and anaesthetic agents . careful consideration should be given to the type and quantity of fluid to be administered during surgery . this will be determined by the preoperative hydration status of the patient , duration of surgery and the estimated fluid losses during surgery . we had infused normal saline to maintain hydration and surgical loss . in anephric patients , there is failure to normally excrete and/or metabolise anaesthetics and analgesics leading to toxic levels of these agents and difficulty in adjusting fluid and electrolytes in the perioperative period . potential alterations in volume of distribution , protein binding , drug metabolism and excretion must be considered carefully before deciding upon a particular anaesthetic technique . we have used fentanyl as premedication as it is safe in renal failure . a significant hyperkalemic response to suxamethonium is not observed in chronic renal failure provided the preoperative serum potassium level is within normal limit . in our all patients serum potassium level was normal so we had used suxamethonium to facilitate endotracheal intubation and we did not observed hyperkalemic response . , sevoflurance has been used in renal disease and it appears safe from serum inorganic fluoride levels and elimination rate than the healthy control . pharmacodynamic measurements show almost identical times for duration and recovery from neuromuscular blockade in normal and anephric patients under isoflurane anaesthesia . vecuronium and rocuronium are significantly prolonged in renal failure because of reduced clearance . intravenous access and blood pressure monitoring should be avoided in the arteriovenous fistula arm . crystalloid / colloid can be used for maintenance or replacement fluid . in this patient population , maintenance fluid must be o restricted , however , ongoing sequestration or overt losses should be replaced with either crystalloid , colloid or blood products . we have used 0.9 normal saline but we can used ringer 's lactate if serum potassium is low . because of advancement in anaesthetic agents and muscle relaxant , there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy .
study objective : to assess outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy.design:retrospective study.measurements:preoperative hb% , serum potassium , coagulation profile electrocardiography ( ecg ) changes , 2d echography , x - ray chest , haemodynamic changes , end - tidal carbon dioxide ( etco2 ) , fluid management and postoperative analgesia.results:the mean age was 24.75  14.35 years . 
 the mean duration of surgery was 120  80 minutes . 
 the hb% , serum creatinine and serum potassium were 9.4  1.04% , 6.79 
 4.91 meq / l and 3.61  0.51 meq / l , respectively . 
 pulse rate mean blood pressure and etco2 were recorded after creation of pneumoperitoneum and at 15 , 30 , 45 and after exsufflation of pneumoperitoneum . 
 after pneumoperitoneum , there was increase in pulse rate , systolic blood pressure , diastolic blood pressure and etco2 . 
 after 30 minutes and throughout the surgery , these variables remained stable . 
 four patients required nitroglycerine infusion for intraoperative hypertention . 
 only one patient required packed cell volume ( pcv ) transfusion and total intravenous fluid was 1  0.5 l. at the time of exsufflation , there was decrease in pulse rate , systolic and diastolic blood pressure and etco2.conclusion:because of advancement in anaesthetic agents and muscle relaxant , there is safe outcome from anaesthesia during laparoscopic bilateral simultaneous nephrectomy .