{"id":1514,"date":"2018-09-12T10:35:16","date_gmt":"2018-09-12T10:35:16","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=1514"},"modified":"2025-03-25T16:36:06","modified_gmt":"2025-03-25T16:36:06","slug":"anaesthetic-protocol","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/anaesthetic-protocol\/","title":{"rendered":"Anaesthetic Protocol"},"content":{"rendered":"<h3><strong><span style=\"color: #993300;\">Pre-op assessment<\/span><\/strong><\/h3>\n<ul style=\"list-style-type: disc;\">\n<li>Clinical assessment including current weight and usual post-dialysis weight FBC, U&amp;Es.<\/li>\n<li>Check that blood has been grouped and saved.<\/li>\n<li>Check immunosuppression regime has been discussed and prescribed.<\/li>\n<li>All patients require basiliximab pre-operatively.<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Fasting<\/span><\/strong><\/h3>\n<p>Patients should be fasted as per Lothian guides (Solids 4-6 hrs Clear Fluid 2hrs).<\/p>\n<h3><strong><span style=\"color: #993300;\">DVT prophylaxis<\/span><\/strong><\/h3>\n<p>The hospital policy should be followed. This includes subcutaneous heparin and compression stockings.<\/p>\n<h3><strong><span style=\"color: #993300;\">Potassium control<\/span><\/strong><\/h3>\n<p>Many patients are chronically hyperkalaemic and tolerate this well<br \/>\nIn general, aim for [K<sup>+<\/sup>] &lt; 5.0 mmol\/l<sup>-1<br \/>\n<\/sup>Mild hyperkalaemia may be treated with dextrose\/insulin but K &gt;5.5 is an indication for dialysis. See transplant work up protocol for more detail.<\/p>\n<h3><strong><span style=\"color: #993300;\">Pre-medication\u00a0<\/span><span style=\"color: #993300;\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/span> <\/strong><\/h3>\n<ul style=\"list-style-type: disc;\">\n<li>Usual medication (except NSAIDs , diuretics and ACE &#8211; inhibitors)<\/li>\n<li>If gastro-oesophageal reflux, oral ranitidine.<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Diabetic patients<\/span><\/strong><\/h3>\n<p>Diabetics are given 10% dextrose and insulin infusion throughout the peri-operative period with hourly blood sugar measurements. Good glycaemic control should be ensured.<\/p>\n<h3><strong><span style=\"color: #993300;\">Anaesthetic room<\/span><\/strong><\/h3>\n<p>Do NOT use limbs with AV dialysis access for monitoring or IV access.<\/p>\n<p><strong><span style=\"color: #993300;\">Monitoring<br \/>\n<\/span><\/strong>ECG, SpO2, NIBP pre induction<br \/>\nTriple lumen central line inserted after induction<br \/>\nArterial line not usually required: insert only if clear indication<br \/>\n(Minimise damage to vessels which may be required for shunts)<\/p>\n<p><strong><span style=\"color: #993300;\">IV access<\/span><br \/>\n<\/strong>peripheral cannula 14G or 16G dorsum of hand or forearm<\/p>\n<p><strong><span style=\"color: #993300;\">Induction\u00a0\u00a0\u00a0\u00a0<\/span><\/strong><br \/>\nPropofol or thiopentone<br \/>\nAtracurium for muscle relaxation (Suxamethonium may be indicated, but this is unusual and carries risk of hyperkalaemia)<\/p>\n<p><strong><span style=\"color: #993300;\">Antibiotics\u00a0\u00a0<\/span><\/strong><br \/>\nPiperacillin\/tazobactam 4.5 G at induction<br \/>\nFor patients allergic to penicillin: Vancomycin 1 gram IV\u00a0 in Normal saline infused over 2 hours and Ciprofloxacin 400 mg infused over 60 mins.<br \/>\nIf Piperacillin\/tazobactam not available (supply issue in 2017), we will use Metronidazole 400mg, Temocillin 1g and Amoxicillin 1g<\/p>\n<p><strong><span style=\"color: #993300;\">DVT prophylaxis<br \/>\n<\/span><\/strong>Minihep 5000U s.c. unless given on ward.<\/p>\n<h3><strong><span style=\"color: #993300;\">Theatre<\/span><\/strong><\/h3>\n<p><strong><span style=\"color: #993300;\">Maintenance<br \/>\n<\/span><\/strong>IPPV\u00a0\u00a0\u00a0 Isoflurane in oxygen\/air or oxygen\/nitrous oxide.<br \/>\nMorphine\/Fentanyl for analgesia. Atracurium for muscle relaxation.<\/p>\n<p><strong><span style=\"color: #993300;\">Temperature<\/span><br \/>\n<\/strong>All patients should have HME and warming mattress.<br \/>\nAll fluids should be given through a warmer.<\/p>\n<p><strong><span style=\"color: #993300;\">Fluid and haemodynamic management<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Avoid hypotension (relative to patient\u00e2\u20ac\u2122s normal BP) and hypovolaemia.<\/li>\n<li>In general, aim for CVP ~ 10 mmHg.<\/li>\n<li>0.9% saline is used for basal fluids, with colloids as required.<\/li>\n<li>Treat hypotension with fluid challenge. Try to avoid use of vasoconstrictors.<\/li>\n<li>Blood is not generally required.<\/li>\n<li>Intravenous heparin approx. 3000 units may be given after discussion with the surgeon.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Reperfusion\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/span> <\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Methylprednisolone 500 mg i.v. prior to removal of clamps (to be given again 24 hour post transplant).<\/li>\n<li>It is particularly important to avoid hypovolaemia or hypotension at the time of reperfusion: fluid bolus may be required.<\/li>\n<\/ul>\n<h3><strong><span style=\"color: #993300;\">Recovery<\/span><\/strong><\/h3>\n<p>Neuromuscular block is reversed at the end of the operation and the patient extubated.<br \/>\nAnalgesia: I.V. Fentanyl boluses as required, followed by PCA Fentanyl.<br \/>\nEnsure minihep is prescribed.<\/p>\n<h3><strong><span style=\"color: #993300;\">Return to transplant unit<\/span><\/strong><\/h3>\n<p>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 or in recovery&#8230;<\/p>\n<p><strong><span style=\"color: #993300;\">Potassium<\/span> <\/strong>is checked on return to the transplant unit\/recovery.<br \/>\n<strong><span style=\"color: #993300;\">Initial fluid replacement<\/span>\u00a0<\/strong>as per inpatient protocol<\/p>\n<p><strong><span style=\"color: #993300;\">Note:\u00a0\u00a0<\/span><\/strong>Diuretics (dopamine, mannitol, furosemide) are not given routinely intra or post-op.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Pre-op assessment Clinical assessment including current weight and usual post-dialysis weight FBC, U&amp;Es. Check that blood has been grouped and saved. Check immunosuppression regime has been discussed and prescribed. All patients require basiliximab pre-operatively. Fasting Patients should be fasted as per Lothian guides (Solids 4-6 hrs Clear Fluid 2hrs). DVT\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/anaesthetic-protocol\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":1453,"menu_order":173,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-1514","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1514","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=1514"}],"version-history":[{"count":4,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1514\/revisions"}],"predecessor-version":[{"id":3874,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1514\/revisions\/3874"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1453"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=1514"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}