Difference between revisions of "Pancreas transplant"

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| lines_access = 2-3 PIV, 16-18 G, Arterial Line
| lines_access = 2-3 PIV, 16-18 G, Arterial Line
| monitors = Standard, 5 lead ECG
| monitors = Standard, 5 lead ECG
| considerations_preoperative =  
| considerations_preoperative = Glucose and Hemoglobin
| considerations_intraoperative = Labile Glycemia -insulin and glucose may be needed in the same patient. Heparin should be prepared and may be sued before clamping of the iliac A or V before pancreatic anastomosis.  Intraop immunosuppression should be running before Thymoglobulin or Simulect and prior to reperfusion.
| considerations_intraoperative = Labile Glycemia -insulin and glucose may be needed in the same patient. Heparin should be prepared and may be sued before clamping of the iliac A or V before pancreatic anastomosis.  Intraop immunosuppression should be running before Thymoglobulin or Simulect and prior to reperfusion.
| considerations_postoperative =  
| considerations_postoperative =  
Line 53: Line 53:
* Prepare arterial line
* Prepare arterial line
* Have heparin in the room
* Have heparin in the room
* May need steroid and/or anti-thymocyte globulin prepared
* May need steroid and anti-thymocyte globulin and/or Basiliximab prepared
*Discuss Abx with surgical team: Cefazolin 2 grams and Flagyl 500 mg IV, or Clindamycin IV 600 mg and Ciprofloxacin 400 mg IV (if penicillin allergy)


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication ===


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
* Consider midazolam and Tylenol
 
=== Regional and neuraxial techniques ===
 
* Epidural or CSE may be used for postop pain management


== Intraoperative management ==
== Intraoperative management ==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access ===
 
* Arterial line for blood pressure monitoring and frequent lab draws
* Many patients also have ESRD - IVs and arterial lines should avoid the side of AV fistula if present
* Nasogastric tube should be placed, secured, and position confirmed, prior to emergence


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Positioning ===


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Supine-the operative approach is intra-abdominal via a midline laparotomy


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations ===


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
* Normal blood pressure is important for pancreas reperfusion and additional fluid and/or vasopressors may be needed at the time of organ reperfusion
* Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).
* At case conclusion, the surgical team may request a low dose heparin infusion (300-400 units/hr) for vascular patency of the graft, provided hemostasis is adequate.
* Glucose management may vary from an insulin infusion to glucose infusion in the same patient
 
=== Emergence ===
 
* A Nasogastric tube should be placed, secured, and position confirmed, prior to emergence
* Most patients are candidates for extubation


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition ===
 
* A surgical ICU bed postoperatively is typically required


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications ===
 
* Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).  
* hypoglycemia


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Latest revision as of 21:24, 5 January 2023

Pancreas transplant
Anesthesia type

General

Airway

ETT

Lines and access

2-3 PIV, 16-18 G, Arterial Line

Monitors

Standard, 5 lead ECG

Primary anesthetic considerations
Preoperative

Glucose and Hemoglobin

Intraoperative

Labile Glycemia -insulin and glucose may be needed in the same patient. Heparin should be prepared and may be sued before clamping of the iliac A or V before pancreatic anastomosis. Intraop immunosuppression should be running before Thymoglobulin or Simulect and prior to reperfusion.

Postoperative
Article quality
Editor rating
Unrated
User likes
0

Pancreas transplantation is performed in one of the following three settings (in decreasing order of frequency): Simultaneous pancreas and kidney transplant (SPK) Pancreas after kidney transplant (PAK) Pancreas transplant alone (PTA).

Overview

Preoperative management

Patient evaluation

The recipients are patients with longstanding type 1 diabetes(juvenile onset) and therefore have issues related to long term glucose intolerance.

System Considerations
Airway Incidence of difficult intubation is somewhat increased in this patient population due to limited mobility of the cervical spine or temporomandibular joint.
Neurologic autonomic nervous system dysfunction, systemic and peripheral neuropathy
Cardiovascular CAD is common in this population
Gastrointestinal gastroparesis
Renal Renal insufficiency
Endocrine Insulin dependence is likely in this population. Favorable peri-operative glycemic control and pre-operative glucose assessment is necessary. Pre-operative NPO status requires insulin adjustments.
Other

Labs and studies

  • CBC
  • CMP

Operating room setup

  • Prepare arterial line
  • Have heparin in the room
  • May need steroid and anti-thymocyte globulin and/or Basiliximab prepared
  • Discuss Abx with surgical team: Cefazolin 2 grams and Flagyl 500 mg IV, or Clindamycin IV 600 mg and Ciprofloxacin 400 mg IV (if penicillin allergy)

Patient preparation and premedication

  • Consider midazolam and Tylenol

Regional and neuraxial techniques

  • Epidural or CSE may be used for postop pain management

Intraoperative management

Monitoring and access

  • Arterial line for blood pressure monitoring and frequent lab draws
  • Many patients also have ESRD - IVs and arterial lines should avoid the side of AV fistula if present
  • Nasogastric tube should be placed, secured, and position confirmed, prior to emergence

Positioning

  • Supine-the operative approach is intra-abdominal via a midline laparotomy

Maintenance and surgical considerations

  • Normal blood pressure is important for pancreas reperfusion and additional fluid and/or vasopressors may be needed at the time of organ reperfusion
  • Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).
  • At case conclusion, the surgical team may request a low dose heparin infusion (300-400 units/hr) for vascular patency of the graft, provided hemostasis is adequate.
  • Glucose management may vary from an insulin infusion to glucose infusion in the same patient

Emergence

  • A Nasogastric tube should be placed, secured, and position confirmed, prior to emergence
  • Most patients are candidates for extubation

Postoperative management

Disposition

  • A surgical ICU bed postoperatively is typically required

Pain management

Potential complications

  • Significant bleeding from the pancreas graft may occur following reperfusion-It is not uncommon for patients to require transfusion with blood products (generally not more than 2 units).
  • hypoglycemia

Procedure variants

Variant 1 Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Tony Wang and Imelda Muller

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