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Preop Check

  • dialysis within 24 hours – check K+
  • CVS: ECG, ?cardio consult, ?ECHO
  • ?Diabetes: glycemic control

    Procedure

  • usually RLQ abdominal incision -graft kidney in (R) iliac fossa
  • kidney vessels to iliac artery and vein - ureter to recipient bladder

    Choice of Anesthesia

  • usually GA
  • epidural possible but: uremic platelet dysfunction, residual heparin from dialysis

    Monitors/Prep

  • adequate venous access – potential for rapid blood loss
  • 3-lumen CVP
  • arterial line – usually; useful for postop blood tests as well
  • body warmer / temp probe

    Challenges/Considerations

  • if diabetic, possible gastropareis – RSI w/ CP
  • preop antibiotics
  • drug selection
    • propofol, midazolam – no change in dosages
    • succinylcholine – OK if preop K+ < 5 mEq/L
    • cisatracurium (Hoffman degradation); rocuronium can be used but may be prolonged
    • fentanyl, sufentanil, remifentanil – all OK, no changes in dosages
    • desflurane OK; sevoflurane – safety is unclear (↑ [F]; transient ↑creat; cmpd A ?OK)
  • maintain/promote graft renal blood flow
    • BP – close to awake less 20% - at least syst > 90 and mean > 60 mmHg
    • CVP – TOH wants > 15 mmHg (some centres OK with > 10)
    • use isotonic fluids to maintain BP – minimize vasopressors if possible
    • use of Pentaspan/Voluven to be avoided (TOH) – other centres OK if < 33mL/kg
  • promote graft renal function
    • after vessel anastomosis, initiate diuresis with:
      • furosemide 1.0 mg/kg
      • mannitol 0.5 Gm/kg
    • with DM, consider tight glucose control (? insulin) – some supporting ICU evidence
  • blood transfusions rarely required – patients may be on erythropoietin

    Postop analgesia

  • usually IV PCA
    • fentanyl safe – does not accumulate but not dialysable
    • hydromorphone – safe as long as pt dialysed (low toxicity 3-G metabolite removed)
    • avoid meperidine, morphine and codeine – toxic metabolites accumulate
  • epidural possible but:
    • pain not usually a big problem
    • subtle coagulation defects may be present; heparin for dialysis
    • may promote hypotension
  • NSAIDS contraindicated
Labels:
transplant transplant Delete
renal renal Delete
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