Difference between revisions of "Kidney transplant"

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| anesthesia_type = General
| anesthesia_type = General
| airway = ETT
| airway = ETT
| lines_access = PIV x2, arterial line
| lines_access = PIV x2 <br/> Arterial line <br/> +/- Central line
| monitors = Standard, 5-lead ECG
| monitors = Standard, 5-lead ECG
| considerations_preoperative = ESRD patients should have potassium checked preop
| considerations_preoperative = ESRD patients should have potassium checked preop
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|-
|-
|Neurologic
|Neurologic
|
|Peripheral neuropathy may be concurrent with diabetic nephropathy, and may also signal autonomic neuropathy
|-
|-
|Cardiovascular
|Cardiovascular
|
|CHF is common in undialyzed patients
|-
|-
|Respiratory
|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
|-
|-
|Endocrine
|Endocrine
|
|If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
|-
|-
|Other
|Other
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=== 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


== 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.
 
* 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
* 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 nomeperidine > 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


=== 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 needed 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). --> ==

Revision as of 19:39, 28 June 2022

Kidney transplant
Anesthesia type

General

Airway

ETT

Lines and access

PIV x2
Arterial line
+/- Central line

Monitors

Standard, 5-lead ECG

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
Comprehensive
User likes
2

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).

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
Endocrine If diabetic nephropathy is cause of ESRD, patient is likely to have other complications of severe diabetes
Other

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

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
  • 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 nomeperidine > 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

Potential complications

  • Fistula thrombosis if improperly padded
  • Hemorrhage
  • Delayed urine output, dialysis may be needed 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