Difference between revisions of "Kidney transplant"
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| anesthesia_type = General | | anesthesia_type = General | ||
| airway = ETT | | airway = ETT | ||
| lines_access = PIV x2 | | lines_access = PIV x2 <br/> +/- Arterial line <br/> +/- Central line | ||
| monitors = Standard, 5-lead ECG | | monitors = Standard, 5-lead ECG, +/- continuous NIBP if not using arterial line | ||
| considerations_preoperative = ESRD patients should have potassium checked preop | | considerations_preoperative = ESRD patients should have potassium checked preop | ||
| considerations_intraoperative = Mannitol, | | considerations_intraoperative = Mannitol, Lasix, and heparin should be prepared, intraop immunosuppression should be running before reperfusion, potassium free IVF should be used | ||
| considerations_postoperative = Replace UOP with IVF, may have delayed graft function if increased cold storage time | | 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. 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). | 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 25: | Line 25: | ||
|CHF is common in undialyzed patients | |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. | |Pleural effusions and pleuritis may occur in this patient population. Increased susceptibility to infection is common in patients with uremia. | ||
|- | |- | ||
| Line 35: | Line 35: | ||
|- | |- | ||
|Renal | |Renal | ||
|Most patients will have ESRD, will need preop potassium check. May need to avoid or decrease dose of renally-metabolized meds | |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 | |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. --> === | ||
BMP (pay attention to K which may be elevated in ESRD) | * 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 | * Prepare arterial line setup | ||
* Have mannitol, furosemide, heparin in room | * 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, | * 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 | * Epidural or CSE may be used for postop pain management | ||
*Pre-emergence TAP catheter vs single-shot | |||
== Intraoperative management == | == Intraoperative management == | ||
| Line 66: | Line 68: | ||
=== 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 | * 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 | ||
* Anticipate prolonged drug effects for renally metabolized/excreted medications | **Choice of fluids: balanced electrolyte solution (Plasmalyte, Normosol, or Lactated Ringer) vs normal saline | ||
** Avoid meperidine (which may accumulate as | ***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. --> === | ||
| Line 99: | Line 110: | ||
* PCA | * PCA | ||
* Epidural | * 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. --> === | ||
| Line 104: | Line 116: | ||
* Fistula thrombosis if improperly padded | * Fistula thrombosis if improperly padded | ||
* Hemorrhage | * Hemorrhage | ||
* Delayed urine output, dialysis may be | * 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 | * Bucking or coughing during emergence may lead to forceful tugging on transplanted kidney and disruption of anastomoses | ||
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)