Difference between revisions of "Kidney transplant"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = General | ||
| airway = | | airway = ETT | ||
| lines_access = | | lines_access = PIV x2 <br/> +/- Arterial line <br/> +/- Central line | ||
| monitors = | | monitors = Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line | ||
| considerations_preoperative = | | considerations_preoperative = ESRD patients should have potassium checked preop | ||
| considerations_intraoperative = | | considerations_intraoperative = Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used | ||
| considerations_postoperative = | | considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time | ||
}} | }} | ||
Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated). | |||
== Preoperative management == | == Preoperative management == | ||
| Line 20: | Line 20: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |CHF is common in undialyzed patients | ||
|- | |- | ||
| | |Pulmonary | ||
| | |Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia. | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | |Gastroparesis may occur in diabetic patients with autonomic neuropathy | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Many patients will have chronic anemia as a result of low EPO | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds. Most recipients also suffer from long-standing, HTN and its systemic concequences. | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes | ||
|- | |- | ||
| | |Vascular | ||
| | |Many patients have coronary arterial, cerebrovascular, and peripheral vascular disease in addition to their HTN. | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production) | |||
* BMP (pay attention to K which may be elevated in ESRD) | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* Prepare arterial line setup | |||
* Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room | |||
*May need steroid and/or anti-thymocyte globulin prepared | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* Midazolam, Tylenol | |||
=== 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. --> === | === 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. --> === | ||
* Epidural or CSE may be used for postop pain management | |||
*Pre-emergence TAP catheter vs single-shot | |||
== 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<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* After induction of anesthesia, a 3-way Foley catheter is placed into the bladder. | |||
* Arterial line for blood pressure monitoring and frequent lab draws | |||
*IVs and arterial lines should avoid the side of AV fistula if present | |||
=== 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. --> === | === 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. --> === | ||
* If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Supine | |||
* Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded. | |||
=== 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<!-- 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. --> === | ||
* Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics | |||
**Choice of fluids: balanced electrolyte solution (Plasmalyte, Normosol, or Lactated Ringer) vs normal saline | |||
***Historically normal saline was the fluid of choice. Recent study showed are lower rates of delayed graft function (30 versus 40 percent in NS group; BEST-Fluids trial<ref>{{Cite journal|last=Collins MG, Fahim MA, Pascoe EM, et al|title=Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial|url=https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(23)00642-6.pdf|journal=Lancet}}</ref>). Additionally, many institutions have changed to balanced electrolyte solutions due to high rates of hyperchloremic metabolic acidosis<ref>{{Cite journal|last=Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E.|date=Jan 2015|title=An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial.|url=https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/01000/An_Acetate_Buffered_Balanced_Crystalloid_Versus.19.aspx|journal=Anesthesia & Analgesia|via=doi: 10.1213/ANE.0000000000000419}}</ref> seen in large volume NS administration (leading to similar intracellular K+ rates). NS also increased need for vasoactives intraop in this study. | |||
*Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates | |||
* After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg) | |||
*Anticipate prolonged drug effects for renally metabolized/excreted medications | |||
** Avoid meperidine (which may accumulate as normeperidine > CNS toxicity) | |||
* Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics | |||
*Will be instructed to clamp Foley by surgeons | |||
*May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
* Patients are usually extubated in the OR | |||
* Ensure adequate NMB reversal | |||
== Postoperative management == | == Postoperative management == | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* Usually to PACU | |||
* Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU | |||
=== 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. --> === | ||
* PCA | |||
* Epidural | |||
*TAP block | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* Fistula thrombosis if improperly padded | |||
* Hemorrhage | |||
* Delayed urine output, dialysis may be necessary until renal function returns | |||
* Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses | |||
== 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 14:35, 3 July 2023
Kidney transplant
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
PIV x2 |
| Monitors |
Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line |
| Primary anesthetic considerations | |
| Preoperative |
ESRD patients should have potassium checked preop |
| Intraoperative |
Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used |
| Postoperative |
Replace UOP with IVF, may have delayed graft function if increased cold storage time |
| Article quality | |
| Editor rating | |
| User likes | 2 |
Kidney transplantation provides patients with ESRD an opportunity to continue living without the need for frequent dialysis; improving quality of life and reduces mortality. Kidney transplants can either be from a deceased donor (aka cadaveric) or from a living donor, at times genetically related to the patient (aka living related), but not always (aka living-unrelated).
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy |
| Cardiovascular | CHF is common in undialyzed patients |
| Pulmonary | Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia. |
| Gastrointestinal | Gastroparesis may occur in diabetic patients with autonomic neuropathy |
| Hematologic | Many patients will have chronic anemia as a result of low EPO |
| Renal | Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds. Most recipients also suffer from long-standing, HTN and its systemic concequences. |
| Endocrine | If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes |
| Vascular | Many patients have coronary arterial, cerebrovascular, and peripheral vascular disease in addition to their HTN. |
Labs and studies
- CBC (pay attention to Hb for likely chronic anemia secondary to low erythropoietin production)
- BMP (pay attention to K which may be elevated in ESRD)
Operating room setup
- Prepare arterial line setup
- Have mannitol (preferably warmed to prevent crystallization), furosemide, heparin in room
- May need steroid and/or anti-thymocyte globulin prepared
Patient preparation and premedication
- Midazolam, Tylenol
Regional and neuraxial techniques
- Epidural or CSE may be used for postop pain management
- Pre-emergence TAP catheter vs single-shot
Intraoperative management
Monitoring and access
- After induction of anesthesia, a 3-way Foley catheter is placed into the bladder.
- Arterial line for blood pressure monitoring and frequent lab draws
- IVs and arterial lines should avoid the side of AV fistula if present
Induction and airway management
- If K<5.5, succinylcholine may be used as a paralytic, otherwise, cisatracurium or rocuronium may be used
Positioning
- Supine
- Avoid pressure on AV fistula which may lead to thrombosis. Must be carefully padded.
Maintenance and surgical considerations
- Be generous with fluids to maintain a temporarily hypervolemic state prior to diuretics
- Choice of fluids: balanced electrolyte solution (Plasmalyte, Normosol, or Lactated Ringer) vs normal saline
- Historically normal saline was the fluid of choice. Recent study showed are lower rates of delayed graft function (30 versus 40 percent in NS group; BEST-Fluids trial[1]). Additionally, many institutions have changed to balanced electrolyte solutions due to high rates of hyperchloremic metabolic acidosis[2] seen in large volume NS administration (leading to similar intracellular K+ rates). NS also increased need for vasoactives intraop in this study.
- Choice of fluids: balanced electrolyte solution (Plasmalyte, Normosol, or Lactated Ringer) vs normal saline
- Avoid hypothermia with forced-air warmer +/- room temperature optimize allograft perfusion (2/2 increased release of catecholamines), bleeding, NMBD duration of action, cardiac events, and SSI rates
- After anastamoses are made, give mannitol (12.5 g-25 g) and Lasix (~100 mg)
- Anticipate prolonged drug effects for renally metabolized/excreted medications
- Avoid meperidine (which may accumulate as normeperidine > CNS toxicity)
- Renal artery and vein clamps will occur, though generally with minimal effect on overall hemodynamics
- Will be instructed to clamp Foley by surgeons
- May be requested to give steroids and anti-thymocyte antibody to prevent organ rejection
Emergence
- Patients are usually extubated in the OR
- Ensure adequate NMB reversal
Postoperative management
Disposition
- Usually to PACU
- Patients with other concurrent transplants (pancreas, liver, etc) may be monitored in the ICU
Pain management
- PCA
- Epidural
- TAP block
Potential complications
- Fistula thrombosis if improperly padded
- Hemorrhage
- Delayed urine output, dialysis may be necessary until renal function returns
- Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Collins MG, Fahim MA, Pascoe EM; et al. "Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial" (PDF). Lancet. Explicit use of et al. in:
|last=(help)CS1 maint: multiple names: authors list (link) - ↑ Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E. (Jan 2015). "An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial". Anesthesia & Analgesia – via doi: 10.1213/ANE.0000000000000419.CS1 maint: multiple names: authors list (link)