Pancreas transplant

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
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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).

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

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