Fasting
All patients should be fasted from four hours prior to the anticipated theatre time unless otherwise stated by surgeons or anaesthetists.
Fluid balance
A critical appraisal of the patient's fluid status must be performed, and should include - supine and erect blood pressure recordings, detailed assessment of JVP and peripheries. Patients may well be relatively fluid deplete, especially those undergoing haemodialysis. Once the final results are known and it is accepted that the patient is going ahead to transplant, then any obvious fluid depletion should be corrected, by intravenous therapy. The insertion of a central line in the pre-operative phase is not indicated, except in unusual circumstances. (A central venous line is inserted immediately after induction of anaesthesia to allow central venous pressure monitoring and guide fluid replacement, both per-operatively and post-operatively).
Potassium and pre-op dialysis
(i) Patients on peritoneal dialysis
Continue peritoneal dialysis until immediately pre-op (abdomen should be emptied 30 - 45 minutes pre-operatively.
(ii) Patients on haemodialysis
Patient may require haemodialysis because:
a. dialysis is due irrespective of transplant
b. based on the results of admission U’s & E’s.
In practice, unscheduled haemodialysis is unlikely to be required except for hyperkalaemia.
(iii) Pre-operative Management of serum potassium
The objective is to ensure that the serum [K+] is between 5 and 5.5 mmol/l when the patient goes to theatre.
It is the responsibility of the renal FY2/ST or HAN team to obtain the potassium result and act upon it.
If serum [K+] ≥ 4 and surgery is likely to be more than six hours later:
Standard maintenance:
- 500ml of 10% dextrose at 40 ml/hr (non-diabetic patients)
- 500ml of 10% dextrose with 16 units Actrapid at 40 ml/hr(for diabetic patients)
- nebulised salbutamol 5 mg six hourly
If serum [K+] is 5 - 5.5 treatment is required.
- Initial treatment; maintenance regime plus insulin/dextrose given as 5 units Actrapid and 50 ml 50% dextrose over 15 minutes.
- Potassium and BM should be checked after 60 minutes.
- Patients who fail to respond may require dialysis.
If serum [K+] >5.5 the patient will usually require haemodialysis.
The registrar or consultant should be informed.
- Immediate measures are continuous ECG monitoring and 10 ml calcium gluconate slow IV, if ECG changes present, and repeated once if required.
Notes
- Post-dialysis potassium must be checked from a venous sample taken at least 5 minutes after the end of dialysis.
- The maintenance regime is only designed to prevent a rise in serum [K+] and is not appropriate when the serum [K+] requires reduction.
- There is no place for calcium resonium or sodium bicarbonate in the control of pre-transplant potassium.
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