There’s an apocryphal tale about an inadequately relaxed patient “coughing” out their perilously perched transplant kidney at a key moment. As a result, the surgeons ask every few minutes whether we are “happy with the relaxation”.
Pre-op
- Label fistula arm
- Establish “dry weight” and current weight
- Date of last dialysis
- Native urine output
- Co-morbidities – often many
- Aetiology of renal failure
Peri-op
- Ensure any necessary immunosuppressants are running
- Protect fistula arm – padding
- Place cannulae, BP cuff on contralateral side to fistula
- Central line/ arterial line if wanted by surgeon or otherwise indicated
- Prophylactic antibiotics
- Induction: Propofol ~150mg, fentanyl 250mcg, atracurium 50mg
- ETT
- Sevoflurane maintenance
- Nerve stimulator- keep flat
- Aim systolic >110, MAP >70 from reperfusion onwards (may be a dip at time of reperfusion)
- Roughly 2 litres IV fluid intra-op
- Further fentanyl to ~500mcg total
- Mannitol when the surgeon asks for it – 0.5g/kg of 20% over 10 mins (175ml for the typical 70kg man) – typically only for DBD/DCD kidneys
- Surgeons to place TAP catheter and load with bupivicaine. Or TAP block by anaesthetist
Post-op
- Fentanyl PCA
- Local anaesthetic infusor to TAP catheter, if placed
- Prescribe IV fluids “rate to match preceding hour’s output”
- Notify renal team that patient is in recovery
- If hypotensive after a few fluid boluses, then metaraminol infusion and ICU
Twists
- Propofol/ remifentanil TIVA. Only need ~250mcg fentanyl.
- Relaxation with rocuronium / sugammadex reversal works very well, but they are renally excreted
Anaesthetic Recipes 