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Early post-operative period

Post-operative review:

  • Patients (including live donor recipients) often remain in recovery up to 2 hours after operation is completed. During this period a member of the transplant team must review them in theatre recovery.
  • Surgical registrar contacts renal team on #6394 once patient in recovery to    communicate intraoperative course / concerns and facilitate nephrology review.
  • Post op review by surgical team (either in recovery or HDU) to consider fluid status, wound and drain output.

Fluid management:

  • Initial IV fluid replacement is Normal Saline at 60 mls/hr + last hour’s urine output. This should be guided by the CVP with a target of 8-10
    • Aim for CVP 8-10
  • Fluid regimen should take into consideration: amount of fluid given in theatre, total blood loss, native urine output, cardiac status of patient, age of patient (caution if >65), if DGF expected.

Guide to fluid replacement

1.    (1)  If passing urine >40ml/hr:

  • CVP <6 : GELOFUSINE 250MLS BOLUS + TOTAL OUTPUT +60mls/hr
  • CVP 6-10:  TOTAL OUTPUT +60mls/hr
  • CVP >10:  TOTAL OUTPUT +40mls/hr

Total output should include drain losses (especially important in SPK recipients)


(2)  If expected immediate graft function and urine output <40mls/hr
 

  •  Ensure catheter not blocked. Member of surgical team should flush out catheter at this early stage.
  • Arrange Doppler ultrasound. Discuss with surgeons.
  • Gelofusine bolus 200mls to achieve CVP of 8-10.
  •  Consider IV NaCl at continuous rate of 100 mls/hr initially.
  • Response must be carefully assessed (hourly initially) before continuing infusion at this rate and especially if remains oligoanuric.

NB Any concerns should be discussed with transplant surgeon and renal team.

(3)  If expected DGF

  • CVP <6: GELOFUSINE 250MLS BOLUS + TOTAL OUTPUT +60mls/hr
  • CVP 6-10:  TOTAL OUTPUT +60mls/hr
  • Careful monitoring of fluid status is required as higher risk of precipitating pulmonary oedema

Failure of the patient to respond to IV Fluid with a rise in CVP or BP should raise possibility of bleeding. If there is a possibility of bleeding a transplant surgeon must be contacted.


Maintenance IV fluids:
 

Continuing IV fluid replacement should be maintained with alternating 5% Dextrose and Normal Saline.

 
Biochemistry:

  • Check FBC and U&E's immediately post-op.
  • Serum K+ must be know and result discussed with Registrar.
  • Hyperkalaemia should be managed with Insulin/Dextrose and nebulised Salbutamol rather than haemodialysis when possible.
  • Subsequent repeat U&Es 12 hourly (more frequently if indicated or as decided by Registrar).

Other aspects of early post-operative management:

  • Arrange chest X-ray for position of central line (may be performed in recovery – ensure checked).
  • Analgesia is by PCA morphine/Fentanyl. Inadequate pain relief may herald serious pathology and should be discussed with a senior surgical colleague/Anaesthetist. NSAIDs are absolutely avoided.


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This page last modified 07.10.2013 13:45 by Emma Farrell. edren and edrep are produced by the Renal Unit at the Royal Infirmary of Edinburgh and the University of Edinburgh. CAUTIONS and Contact us.