Prior medication | Rhesus | Diabetes | Antibiotics | CMV | Pneumocystis |
| Immunosuppression | DVT | Ulcer | Bone
Prior medication
Anti-hypertensives are taken as usual pre-operatively except ACE inhibitors and angiotensin II antagonists are omitted. Other anti-hypertensives may also be selectively omitted post-operatively and re-introduced if required
Also omit
- NSAIDS
- Diuretics
- Warfarin (reverse if necessary)
- Aspirin - should be reviewed
- Phosphate binders (usually) - see Bone and calcium below
Rhesus +/-
Rh -ve young female recipients with a Rh +ve donor require anti D immunoglobulin at induction. This can be given up to 72 hours later if overlooked initially.
Subcutaneous insulin should be omitted. Insulin/Dextrose infusion must be established pre-operatively:-
BM < 6 mmol/l add 6 units Actrapid in 500mls Glucose 10%
BM 6 - 9 mmol/l add 10 units Actrapid in 500mls Glucose 10%
BM >9 mmol/l add 14 units Actrapid in 500mls Glucose 10%
Run Infusion at 100 ml/hr.
BM should be checked every hour
(see sample drug kardex – appendix VII)
Antibiotic prophylaxis
Given at induction of anaesthesia - Piperacillin/Tazobactam 4.5g IV, unless patient is allergic to penicillin &- If patient is allergic to penicillin give Vancomycin 1 Gram IV in Normal Saline over 2 hours and Ciprofloxacin 400 mgs infused over 60 min.
Valganciclovir
All transplant recipients except CMV –ve recipients of CMV –ve donors should receive valganciclovir, which has replaced Ganciclovir for prevention of CMV disease. Prescriptions should be initiated in hospital within 10 days of transplantation. Therapy will be continued in primary care for up to a total of 180 days treatment for which a shared-care protocol will be provided (see appendix VIII). See full CMV protocol
The initial Valganciclovir dose is dependent on creatinine clearance (Cockcroft and Gault equation) as shown in the table below:
| Creatinine clearance (ml/min) | Prophylactic dose |
| >60 | 900mg od |
| 40 to 59 | 450mg od |
| 25 to 39 | 450mg every 2 days |
| 10 to 24 | 450mg twice weekly |
| <10 |
100mg three times a week after dialysis |
Valganciclovir is available as 450mg tablets (pink) or oral solution for dialysis patients and the brand name is Valcyte. The tablets should be taken with food and not broken or crushed.
Pneumocystis prophylaxis
- Co-trimoxazole 480mg per day for 3 months. Full pneumocystis protocol
Immunosuppression
See separate Immunosuppression protocol
DVT prophylaxis
- Heparin 5000U/SC at anaesthetic induction and 5000U/SC/bd thereafter until mobile post operatively.
Peptic ulcer prophylaxis
- Ranitidine 150mg bd preferred; alternative omeprazole 20mg daily.
Bone and calcium
- Calcichew 2 tabs at night and alfacalcidol 0.25micrograms od unless corrected calcium is >2.5mmol/l. If requiring more alfacalcidol/calcitriol pre-op, usually continue higher dose. If on cinacalcet or other therapy for calcium, discuss but usually continue in early post-op period.
- Bisphosphonates may be considered for second or subsequent grafts or known osteoporosis (See p.22)
All these drugs including immunosuppression should be prescribed in the drug kardex pre-operatively.
Further info
- NHS Lothian shared care protocols
- Lothian joint formulary (click on Adult or Children etc. Other useful links on this page)
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