Peri-Operative Management-CPG

38. PERI-OPERATIVE MANAGEMENT

38.1 Specific issues to be addressed:
38.1.1 Assessment of recipient’s fluid status (to keep 1-2 kg above dry weight in adults if possible).1

38.1.2 Organise dialysis before transplant. Decision to dialyse a patient depends on the timing of the previous dialysis, volume status, and serum electrolyte levels, particularly serum potassium.1

38.1.3 CAPD patients should have their usual exchanges until day of transplant, then the peritoneal dialysis fluid should be drained from the abdominal cavity, examined and sent for cell count and culture.2

38.1.4 Determination of any intercurrent problems that may preclude or complicate surgery (e.g. fever, URTI, recent onset of cardiac or respiratory disease, uncontrolled BP).

38.1.5 Document residual urine, previous abdominal surgery, obesity (if present), femoral catheter insertion, position of Tenckhoff catheter if on CAPD, CMV status, cytotoxic cross-match result, viral status and infective screen as well as pre-transplant sensitisation.

38.1.6 The site of vascular access should be clearly marked and demonstrated to the OT staff. Protection of the vascular access site is advisable using non-circumferential padding to reduce the risk of occlusion by inadvertent external occlusion.

38.1.7 Knowledge of the donor status is important.

38.2 Immediate pre-transplant investigations:
38.2.1 Renal profile

38.2.2 Ca2+, PO4, LFT

38.2.3 FBS/RBS

38.2.4 FBC

38.2.5 PT/APTT

38.2.6 Urine C&S

38.2.7 Swabs: nasal, throat, ear

38.2.8 CMV serology (if not available)

38.2.9 Chest radiography

38.2.10 ECG

38.2.11 Cross match 4 units packed cells

38.2.12 Cyclosporin or tacrolimus level (for LRRT only, before serving cyclosporine or tacrolimus on the morning of operation, EDTA tube)

38.3 Consent for donor nephrectomy:
3 signatures required for LRRT:
38.3.1 Urology or Nephrology consultant

38.3.2 Urology Specialist

38.3.3 Nephrology Specialist

38.4 Prophylactic antibiotic is recommended3,4,5,6,7,8
Perioperative prophylactic antibiotic drugs are beneficial in reducing the incidence of wound infections (not UTI), although there is considerable variation in practice. (Level C) The regimen depends on local bacterial epidemiology but should attempt to cover Staph. aureus and common enteric coliform bacteria. Instilling antibiotic into the bladder is of no additional benefit9,10

38.5 Immunosuppressive protocol
Refer to chapter 40 for prophylactic/induction therapy

38.6 Intra-operative management
38.6.1 Central line to be inserted in OT

38.6.2 To maintain CVP at 10-15 cmH2O2 (Level D)
38.6.3 Urinary catheter to be inserted

38.6.4 Anaesthetist to document clamp and release time

38.6.5 Measures to decrease the likelihood of delayed graft function entail maintenance of adequate blood pressure and fluid status with IV colloid or crystalloid (the latter being preferable). In living related transplant, it is common practice to administer mannitol before the kidney is reperfused, which helps to trigger an osmotic diuresis2,9 (Level D)

38.7 Post-operative care
38.7.1 Isolation nursing until all tubes/drains removed

38.7.2 Proper hand wash before and after examining the patient

38.7.3 Hourly fluid balance (input, output, CVP), daily weight

38.7.4 Daily investigations: biochemistry, haematology, micro-
biology, and urinalysis

38.8 Intravenous fluids2 (Level D)
38.8.1 Aggressive replacement, aim to keep patient well hydrated

38.8.2 If patient is adequately hydrated with good graft function, replace previous hours’ urine output

38.8.3 If patient is adequately hydrated but remains anuric, restrict
intravenous fluid to 500-1000 ml/day

38.8.4 Use normal saline alternate with D5%; if K+ < 4, use Hartmann’s solution or K+ supplement

38.8.5 CVP line to be removed at the discretion of nephrologist

38.9 Bladder catheter
38.9.1 Indwelling bladder catheter should be inserted in OT

38.9.2 Urine output to be measured hourly

38.9.3 If urine output declines (< 100 ml/hour) or blood clots
present to inform doctor immediately

38.9.4 Bladder washout should be only done under strict aseptic
technique by urologist if deemed necessary

38.9.5 Catheter usually removed at Day 5 or at the discretion of
urologist

38.10 Wound drain
To be removed at the discretion of urologist

38.11 Stents
If there is an internal J stent ensure removal by 3 months post transplant or earlier if patient has UTIs

38.12 Investigations
38.12.1 Renal profile twice daily for 48 hours then daily (can be altered at the discretion of nephrologist)

38.12.2 Daily FBC, MSU

38.12.3 Chest radiography

38.12.4 LFT, Mg2+, Ca2+, PO4 3 x a week

38.12.5 Cyclosporin / tacrolimus level 3 x a week or when indicated

38.12.6 Doppler US Day 1, or immediately if primary non-function, delayed graft function or sudden drop in urine output

38.12.7 DPTA scan as indicated (usually done on Day 2 – 4)

38.13 Other medications
38.13.1 Intravenous ranitidine 50 mg tds for 2 days then change to
oral ranitidine 150 mg bd for 3 – 6 months

38.13.2 Nystatin 250 000 units gargle and swallow qid for 3 months

38.13.3 Cotrimoxazole 480 mg at night, to commence when renal function is stable

38.13.4 CMV prophylaxis in high risk recipients












References
1. Danovitch G. Handbook of Kidney Transplantation. 1996, 2nd edition
2. Allen R, Chapman J. A Manual of Renal Transplantation. 1994
3. Cohen J, Rees AJ, Williams G. A prospective randomized controlled trial of perioperative antibiotic prophylaxis in renal transplantation. J Hosp Infect 1988; 11(4): 357-63
4. Lapchik MS, Castelo Filho A, Pestana JO, Silva Filho AP, Wey SB. Risk factors for nosocomial urinary tract and postoperative wound infections in renal transplant patients: a matched-pair case-control study. J Urol 1992; 147(4): 994-8
5. Goodman CM, Hargreave TB. Survey of antibiotic prophylaxis in European renal transplantion practice. Int Urol Nephrol 1990; 22(2): 173-9
6. Judson RT. Wound infection following renal transplantation. Aust NZ J Surg 1984; 54(3): 223-4
7. Midtvedt K, Hartmann A, Midtvedt T, Brekke IB. Routine perioperative antibiotic prophylaxis in renal transplantation. Nephrol Dial Transplant 1998; 13(7): 1637-41
8. Townsend TR, Rudolf LE, Westervelt FB Jr, Mandell GL, Wenzel RP. Prophylactic antibiotics therapy with cefamandole and tobramycin for patients undergoing renal transplantation. Infect Control 1980; 1(2): 93-6
9. Morris P. Kidney Transplantation: Principles and Practice. 2001, 5th edition
10. Salmela AD, Ekland B, Kyllonen L et al. The effects of intravesically applied antibiotic solution in the prophylaxis of infectious complication of renal transplantation. Transplant Int 1990; 3: 12