Kidney Transplant Anesthesia Cheat Sheet
Kidney transplantation, whether cadaveric or living related, typically consists of the placement of a donor organ into the right iliac fossa of the recipient. Although perioperative management is typically uneventful from a hemodynamic and resuscitation standpoint, these patients possess specific comorbidities which can make their course challenging. Suggested perioperative management is as follows:
A. Preoperative Management:
1. Ensure potassium is present from the day of surgery. A post dialysis (if patient requires dialysis) is preferred.
2. If peripheral access is poor and hemodialysis catheter is present, utilization of the HD catheter is reasonable. Ensure that 3-5cc of blood is aspirated from each catheter port prior to use (to avoid systemic heparinization).
3. Inquire if patient is participating in any studies.
4. If etiology of renal failure is diabetes and hypertension, assume autonomic neuropathy with subsequent gastroparesis.
5. Obtain dialysis history (if present)
6. Type and Cross should be present
B. Intraoperative Management:
1. Plan for rapid sequence induction (especially in the setting of autonomic neuropathy)
2. Succinylcholine use is reasonable with preoperative potassium <5.5meq/L
3. Preferred NMB is cisatracurium although vigilant rocuronium use is acceptable.
4. Access should consist of peripheral intravenous catheter as well as central venous catheter (for CVP monitoring and postoperative access). Arterial access is rarely needed.
5. Intraoperative immunosuppression should be present in room
-Methylprednisolone (500mg-1000mg)
-Inquire about thymoglobulin (1.5mg/kg over 6 hours)
-Administer steroids prior to thymoglobulin in order to prevent thymoglobulin related acute lung injury and hypotension
-If hypotension occurs from thymoglobulin administration, stop infusion and discuss with surgeons
6. Intraoperative diuresis should be present in room
-Furosemide (40-100mg)
-Mannitol (12.5-50g)
7. Analgesia should consist of:
-Fentanyl or Hydromorphone opioid therapy
-Intravenous acetaminophen
-Ilioinguinal nerve block/unilateral TAP block
8. Intraoperative fluid management should consist of 1-2L of plasmalyte/NS
9. Ensure full neuromuscular blockade reversal
-Patients are often still weak despite cisatracurium use and full reversal
Kidney/Pancreas Transplant Cheat Sheet
Patients requiring kidney/pancreas are typically suffering from the sequelae of lifelong type I diabetes mellitus. Unlike an isolated kidney transplant, the organs are placed through a midline incision with the kidney being placed into the left iliac fossa and the pancreas being placed into the right lower abdomen. All perioperative management points of kidney transplantation apply. However, because of the addition of the pancreas transplant, a few additional strategies should be noted.
A. Preoperative Management
1. Check finger stick glucose level
- If glucose greater than 300mg/dL, initiate insulin infusion with goal blood sugar less than 180mg/dL
- Obtain detailed history regarding patient’s home insulin use
2. Consider preoperative epidural. This is especially true if patient possesses chronic pain with high preoperative opioid consumption (greater than 50mg of daily morphine equivalent).
B. Intraoperative management
1. Access is identical to that of kidney transplantation. Again, typically intra-arterial access is not needed.
2. Approximately 10-15 minutes prior to pancreas reperfusion, discontinue insulin infusion
3. Have dextrose 5% or 50% or D5LR available in the room for potential post reperfusion hypoglycemia. Check venous blood gas or finger stick glucose every 10-15 minutes for one hour after pancreas reperfusion.