Kidney Transplant

PreOp

Setup

• Alaris Pump with NS carrier and 2 channels
  • Channel 1 will be anti-rejection med
  • Channel 2 will be phenylephrine gtt (start at 0.1-0.2 mcg/kg/min)
• Lower body bear hugger
• Art line, central line, PIV, Fluid warmer
• HME

Antibiotic

• Ancef prior to incision (Clindamycin if Ancef contraindicated)

Solu-Medrol IV

• Dose and timing dependent on surgeon and whether dose was given as a premed for Thymoglobulin

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Intraop

• Plan for A-line on non-fistula arm
• Central line to monitor CVP
• 2 PIV both NS (Albumin is OK)
• Tap block may be of benefit (consider Exparel)

Prior to Incision

• Immunosuppressant (Surgeon ordered)
  • Start in central line once available (but may give via PIV)
  • Simulect or Thymoglobulin:
    • Simulect
      • Infuse over 30 minutes
      • No premed required
      • Preferred route is via central line, but may give via PIV
    • Thymoglobulin
      • Infuse over 6 hours
      • Must premedicate: Tylenol, benadryl, steroid (usually Solu-Medrol)

Arterial Anastomosis

• Solu-Medrol
  • May be requested to be given now (unless given preoperatively)
  • Dr. Palmer requests 10mg/kg
• Mannitol
  • Will be requested by surgeon after arterial anastomosis
  • Dose: 0.5 - 1 gm/kg
  • Max dose: 50 gm
• Lasix IV
  • Will be requested by surgeon (usually right after mannitol)
  • Dr. Palmer will request dose at 20mg x preop creatinine
• Papaverine
  • Surgeon may inject intra-arterial
  • Prepare for pressure to drop
  • May need to bolus with volume
  • May need to start phenylephrine at 0.1 mcg/kg/min
  • May need to give boluses of phenylephrine as well

Blood Pressure Management

• Systolic goal: >120mmHg (or 95% of normal for age)
• Preferred to use volume before a pressor
• If pressor needed, use phenylephrine infusion (avoid dopamine)
• If pressure too high, use nicardipine (0.5mcg/kg/min up to 5)
• Goal CVP: 8-12mmHg
• On clamp removal-expect BP drop. So plan ahead with fluid load up front 30-60ml/kg and possible colloid
• Plan presser gtt to start around anastomosis to keep means at goal 100-120% of baseline SBP

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Post Op

• Go straight to ICU
• They will have urine replaced cc/cc with crystalloid so you can be liberal with fluids
• Heparin
  • Surgeon may request it be started in OR (10 units/kg/hr)

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Blood Product Administration

• 10-20kg: will receive one unit of blood
• Over 20kg: preference is to try an avoid transfusion