Kidney Transplant Anesthesia Cheat Sheet
Kidney transplantation, whether cadaveric or living related, typically consists of the
placement of a donor organ into the right iliac fossa of the recipient. Although
perioperative management is typically uneventful from a hemodynamic and resuscitation
standpoint, these patients possess specific comorbidities which can make their course
challenging. Suggested perioperative management is as follows:
A. Preoperative Management:
1. Ensure potassium is present from the day of surgery. A post dialysis (if patient
requires dialysis) is preferred.
2. If peripheral access is poor and hemodialysis catheter is present, utilization of
the HD catheter is reasonable. Ensure that 3-5cc of blood is aspirated from each
catheter port prior to use (to avoid systemic heparinization).
3. Inquire if patient is participating in any studies.
4. If etiology of renal failure is diabetes and hypertension, assume autonomic
neuropathy with subsequent gastroparesis.
5. Obtain dialysis history (if present)
6. Type and Cross should be present
B. Intraoperative Management:
1. Plan for rapid sequence induction (especially in the setting of autonomic
neuropathy)
2. Succinylcholine use is reasonable with preoperative potassium <5.5meq/L
3. Preferred NMB is cisatracurium although vigilant rocuronium use is
acceptable.
4. Access should consist of peripheral intravenous catheter(s) plus/minus central
access for CVP monitoring. Traditionally, all of our surgeons have wanted central
access however this trend is changing. Be prepared to place central access,
however confirm necessity with the surgeon prior to doing so. Arterial access is
rarely needed.
5. Intraoperative immunosuppression should be present in room
-Methylprednisolone (500mg-1000mg) – given always
-Inquire about thymoglobulin (1.5mg/kg over 6 hours)
-Administer steroids prior to thymoglobulin in order to prevent
thymoglobulin related acute lung injury and anaphylaxis.
-If hypotension occurs from thymoglobulin administration, stop
infusion and discuss with surgeons
6. Intraoperative diuresis should be present in room. Doses vary from surgeon to
surgeon.
-Furosemide (20-100mg)
-Mannitol (12.5-50g)
7. Analgesia should consist of:
-Fentanyl or Hydromorphone opioid therapy
-Intravenous acetaminophen
-Ilioinguinal nerve block/unilateral TAP block
8. Intraoperative fluid management should consist of 1-2L of plasmalyte/NS
9. Ensure full neuromuscular blockade reversal
-Patients are often still weak despite cisatracurium use and full reversal
* Mannitol, Lasix and Solumedrol are all found in the transplant box. Thymoglobulin is
ordered from the pharmacy, by the surgical team.
Kidney/Pancreas Transplant Cheat Sheet
Patients requiring kidney/pancreas are typically suffering from the sequelae of lifelong
type I diabetes mellitus. Unlike an isolated kidney transplant, the organs are placed
through a midline incision with the kidney being placed into the left iliac fossa and the
pancreas being placed into the right lower abdomen. All perioperative management
points of kidney transplantation apply. However, because of the addition of the pancreas
transplant, a few additional strategies should be noted.
A. Preoperative Management
1. Check finger stick glucose level
a. If glucose greater than 300mg/dL, initiate insulin infusion with
goal blood sugar less than 180mg/dL
b. Obtain detailed history regarding patient’s home insulin use
2. Consider preoperative epidural. This is especially true if patient
possesses chronic pain with high preoperative opioid consumption
(greater than 50mg of daily morphine equivalent).
B. Intraoperative management
1. Access is identical to that of kidney transplantation. Again, typically
intra-arterial access is not needed.
2. Approximately 10-15 minutes prior to pancreas reperfusion,
discontinue insulin infusion
3. Have dextrose 5% or 50% or D5LR available in the room for potential
post reperfusion hypoglycemia. Check venous blood gas or finger stick
glucose every 10-15 minutes for one hour after pancreas reperfusion.
* Note: Some surgeons do not want hyperglycemia treated at all. Please confer with the
surgeon prior to staring an insulin infusion.
Revised 7-24-14