{"id":1524,"date":"2018-09-12T11:05:54","date_gmt":"2018-09-12T11:05:54","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=1524"},"modified":"2025-03-25T16:36:07","modified_gmt":"2025-03-25T16:36:07","slug":"post-op-and-fluids","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/post-op-and-fluids\/","title":{"rendered":"Post-op and fluids"},"content":{"rendered":"<h5><strong><span style=\"color: #993300;\">Early post-op review<\/span><\/strong><\/h5>\n<p><strong><span style=\"color: #993300;\">Early review: <\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Patients often remain in Theatre Recovery for up to 2h after operation is completed. During this period a member of the transplant team must review them there.<\/li>\n<li>Surgical registrar contacts renal team once patient in recovery to communicate intraoperative course \/ concerns, and facilitate nephrology review.<\/li>\n<li>Post op review by surgical team (either in recovery or HDU) to consider fluid status, wound and drain output.<\/li>\n<li><span style=\"color: #993300;\"><a style=\"color: #993300;\" href=\"#fluid\" data-cke-saved-href=\"#fluid\">Fluid management<\/a>:<\/span> <a href=\"#fluid\" data-cke-saved-href=\"#fluid\">see below<\/a> for details.<\/li>\n<li><span style=\"color: #993300;\">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.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #993300;\">If expected immediate graft function and urine output &lt;40mls\/hr \u00a0<\/span><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>\u00a0Ensure catheter not blocked. Member of surgical team should flush out catheter at this early stage.<\/li>\n<li>If requested by surgeons arrange Doppler ultrasound.<\/li>\n<li>Ensure CVP target is appropriate, and reached (see fluid management, below).<\/li>\n<li>Consider IV NaCl at continuous rate of 100 mls\/hr initially.<\/li>\n<li>Response must be carefully assessed (hourly initially) before continuing infusion at this rate and especially if remains oligoanuric.<\/li>\n<\/ul>\n<p>Any concerns should be discussed with transplant surgeon and renal team.<\/p>\n<p><span style=\"color: #993300;\">If expected Delayed Graft Function (DGF)<\/span><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Careful monitoring of fluid status is required as higher risk of precipitating pulmonary oedema.<\/li>\n<\/ul>\n<h5><strong><span style=\"color: #993300;\">Monitoring<\/span><\/strong><\/h5>\n<ul style=\"list-style-type: disc;\">\n<li>Check FBC and U&amp;E immediately post-op.<\/li>\n<li>Serum K+ must be known and result discussed with Registrar.<\/li>\n<li>Subsequently repeat U&amp;E 12 hourly for the first 48h (more frequently if indicated or as decided).<\/li>\n<\/ul>\n<h5><strong><span style=\"color: #993300;\">Other aspects of early post-op management<\/span><\/strong><\/h5>\n<ul style=\"list-style-type: disc;\">\n<li>Arrange chest X-ray for position of central line (may be performed in recovery \u00e2\u20ac\u201c ensure checked).<\/li>\n<li>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.<\/li>\n<\/ul>\n<h5><strong><span style=\"color: #993300;\">Fluid management<\/span><\/strong><\/h5>\n<p><span style=\"color: #993300;\">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.<\/span><\/p>\n<p><span style=\"color: #993300;\"><strong><a id=\"fluid\" style=\"color: #993300;\"><\/a><span style=\"color: #993300;\">Fluid management: first 2 hours<\/span><\/strong><\/span><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Immediately post-op IV fluid replacement is Normal Saline\/ Plasmalyte at 60 mls\/hr + last hour\u00e2\u20ac\u2122s urine output. This should be guided by the CVP.<\/li>\n<li>Usually aim for CVP 6-10. If &gt;10, reduce infusion rate. If &lt;6, give 250ml of Plasmalyte (or N saline) bolus and review. Repeat a max of once more before seeking surgical or senior advice.<\/li>\n<li>Fluid regimen should take into consideration: amount of fluid given in theatre, total blood loss, native urine output, cardiac status, patient age (extra caution if &gt;65), any additional losses, and whether delayed graft function (DGF) is to be expected.<\/li>\n<li>If there are additional losses (e.g. drains after pancreas transplantion), count total loss, not just urine, in replacement sums.<\/li>\n<li>If patient is <a href=\"#polyuria\" data-cke-saved-href=\"#polyuria\">polyuric<\/a>, shorten the period of replacement with high-salt solutions ( <a href=\"#polyuria\" data-cke-saved-href=\"#polyuria\">see Polyuria<\/a>, below).<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Fluid management: 2-12h<\/span> <\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Start with <em>alternating bags of 5% dextrose and Normal Saline<\/em> (or Plasmalyte) at a rate = urine output +60.<\/li>\n<li>As soon as patient is drinking, reduce infusion rate to compensate.<\/li>\n<li>See also the CVP guidance above.<\/li>\n<li><a href=\"#polyuria\" data-cke-saved-href=\"#polyuria\">Polyuria<\/a>: If patient is producing more than 200 ml\/h, the amount of salt in the regimen should be reduced to prevent salt overloading &#8211; <a href=\"#polyuria\" data-cke-saved-href=\"#polyuria\">see Polyuria<\/a>.<\/li>\n<li>If any signs of hypovolaemia (falling BP, CVP or JVP, tachycardia, \u00c2\u00b1 reduced urine output) give boluses of N Saline or Plasmalyte; check Hb. If no response or repeatedly needed, inform surgical team and seniors.<\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Fluid management from 12h<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Discontinue IV fluids as soon as patient is able to drink enough. This is often possible on the second post-op day.<\/li>\n<li>If polyuric, reduce the salt content in replacement regime &#8211; <a href=\"#polyuria\" data-cke-saved-href=\"#polyuria\">see Polyuria<\/a><\/li>\n<\/ul>\n<p><strong><span style=\"color: #993300;\">Subsequent fluid management<\/span><\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>If patient unable to keep up with urine output, check desired balance from ward round\/ notes.<\/li>\n<li>After the first 24h, infusion rates based on matching hourly urine output are not usually appropriate.<\/li>\n<li>If &gt;4-5L output in 24h, see <a href=\"#polyuria\" data-cke-saved-href=\"#polyuria\">polyuria<\/a>.<\/li>\n<li>If needed, suitable supplementary fluid may often be 4% glucose\/ 0.18% NaCl at a rate to compensated for the predicted shortfall. This is equivalent to 4 bags glucose to 1 NaCl. It can also be given as separate bags of glucose and Saline\/ Plasmalyte.<\/li>\n<li>Occasional patients lose more salt. This usually becomes apparent after a few days. Increasing dietary salt minimises the need for IV replacement. Hyponatraemia usually indicates water overload rather than salt deficiency, but this must be ascertained clinically.<\/li>\n<\/ul>\n<table width=\"938\">\n<tbody>\n<tr>\n<td>\n<h5><strong><span style=\"color: #993300;\">Fluid replacement in POLYURIA<\/span><\/strong><a id=\"polyuria\"><\/a><\/h5>\n<p><em>Urine is not a high-salt fluid<\/em><\/p>\n<p><strong><span style=\"color: #993300;\">PLASMALYTE\/SALINE ARE NOT SUITABLE REPLACEMENT FLUIDS FOR URINE<\/span> <\/strong><\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Each litre of Normal Saline or Plasmalyte contains 9g of salt, equivalent to 1.5 days of maximum healthy salt intake.<\/li>\n<li>Salt overloading causes pulmonary oedema, hypertension, peripheral oedema &#8211; and worsened polyuria. It increases the risk of complications and is likely to prolong hospital stay.<\/li>\n<li>Pay careful attention to the ratio of salt to water in replacement fluids.<\/li>\n<li>Reduce ratio of NaCl to Glucose bags quickly from 1:1 to 1:2, and later to 1:3 or lower.<\/li>\n<li>For a patient who is eating but falling short of fluid intake by a couple of litres, and who is not salt deficient, use 5% Glucose or 4% Glucose\/ 0.18% NaCl.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Early post-op review Early review: Patients often remain in Theatre Recovery for up to 2h after operation is completed. During this period a member of the transplant team must review them there. Surgical registrar contacts renal team once patient in recovery to communicate intraoperative course \/ concerns, and facilitate nephrology\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/transplant-handbook\/post-op-and-fluids\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":1453,"menu_order":174,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-1524","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1524","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=1524"}],"version-history":[{"count":4,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1524\/revisions"}],"predecessor-version":[{"id":3316,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/1524\/revisions\/3316"}],"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=1524"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}