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 | * 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 | === Patient preparation and premedication === | ||
=== Regional and neuraxial techniques | * 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 | === 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 | === 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 == | == Postoperative management == | ||
=== Disposition | === 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 | === 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 22:24, 5 January 2023
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 | |
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