Clinical assessment including current weight and usual post-dialysis weight
FBC, U’s &E’s. Check that blood has been grouped and saved.
All patients require basiliximab pre-operatively.
Fasting
Patients should fast for four hours pre-op. Longer periods of fasting are neither necessary nor desirable.
DVT prophylaxis
This includes subcutaneous heparin and compression stockings.
Potassium control
Many patients are chronically hyperkalaemic and tolerate this well
In general, aim for [K+] < 5.0 mmol/l-1
Mild hyperkalaemia may be treated with dextrose/insulin but K >5.5 is an indication for dialysis. See transplant work up protocol for more detail.
Pre-med
- Benzodiazepine (at discretion of anaesthetist)
- Usual medication (except NSAIDs , diuretics and ACE - inhibitors)
- If gastro-oesophageal reflux, oral ranitidine.
Diabetic patients
Diabetics are given 10% dextrose and insulin infusion throughout the peri-operative period with hourly blood sugar measurements. Good glycaemic control should be ensured.
Anaesthetic room
Do NOT use limbs with shunts for monitoring or IV access
Monitoring
- ECG, SpO2, NIBP pre induction
- Triple lumen central line inserted after induction
- Arterial line not usually required: insert only if clear indication
- (Minimise damage to vessels which may be required for shunts)
IV access
peripheral cannula 14G or 16G dorsum of hand or forearm
Induction
- Propofol or thiopentone
- Atracurium for muscle relaxation (Suxamethonium may be indicated, but this is unusual and carries risk of hyperkalaemia)
Antibiotics
- Tazobactam/piperacillin 4.5g at induction
- For patients allergic to penicillin: Vancomycin 1 gram IV in Normal saline infused over 2 hours and Ciprofloxacin 400 mg infused over 60 mins.
DVT prophylaxis Minihep 5000U s.c. unless given on ward.
Theatre
Maintenance
- IPPV Isoflurane in oxygen/air or oxygen/nitrous oxide.
- Morphine for analgesia. Atracurium for muscle relaxation.
Temperature
- All patients should have HME and warming mattress.
- All fluids should be given through a warmer.
Fluid and haemodynamic management
Avoid hypotension (relative to patient’s normal BP) and hypovolaemia. In general aim for CVP ~ 10 mmHg. 0.9% saline is used for basal fluids, with colloids as required.
Treat hypotension with fluid challenge. Try to avoid use of vasoconstrictors.
Blood is not generally required.
Intravenous heparin approx. 3000 units may be given after discussion with the surgeon.
Reperfusion
- Methylprednisolone 500 mg i.v.(to be given again 24 hour post transplant)
- It is particularly important to avoid hypovolaemia or hypotension at the time of reperfusion: fluid bolus may be required.
Recovery
Neuromuscular block is reversed at the end of the operation and the patient extubated
Analgesia: I.V. Fentanyl boluses as required, followed by PCA Fentanyl.
Ensure minihep is prescribed.
Return to transplant unit
The renal physician on call should be notified when the patient is leaving theatre and will meet the patient on return to the Transplant Unit. The anaesthetist should return to the Transplant Unit with the patient and handover to the renal physician on call. It is essential that there is no breakdown of communication at this stage.
Potassium is checked on return to the transplant unit.
Initial fluid replacement:
0.9% NaCl at previous hours urine output + 60 ml. Target CVP +5 – 11cmH2O.
This is only a guide. The amount required depends on clinical assessment and CVP. Remember that oliguria may be secondary to hypotension and/or hypovolaemia. These must be avoided as they may contribute to the development of delayed graft function. Equally however fluid overload in the presence of anuria will cause pulmonary oedema
Note
Diuretics (dopamine, mannitol, frusemide) are not given routinely intra or post-op.
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