Pre-op management

General management

Fasting – All patients should be fasted from four hours prior to the anticipated theatre time unless otherwise stated by surgeons or anaesthetists.

Fluid balance – A critical appraisal of the patient's fluid status must be performed, and should include - supine and erect blood pressure recordings, detailed assessment of JVP and peripheries. Patients may well be relatively fluid deplete, especially those undergoing haemodialysis.  Once the final results are known and it is accepted that the patient is going ahead to transplant, then any obvious fluid depletion should be corrected, by intravenous therapy.  The insertion of a central line in the pre-operative phase is not indicated, except in unusual circumstances. (A central venous line is inserted immediately after induction of anaesthesia to allow central venous pressure monitoring and guide fluid replacement, both pre-operatively and post-operatively)

Peritoneal dialysis – continue CAPD until immediately pre-op (abdomen should be emptied 30 - 45 minutes pre-operatively).  APD as usual if transplant delayed till morning.  Otherwise, only if indicated by biochemistry.

Haemodialysis – patient may require haemodialysis because:

• dialysis is due irrespective of transplant
• based on the results of admission U’s & E’s.

In practice, unscheduled haemodialysis is unlikely to be required except for hyperkalaemia.

Pre-operative Management of serum potassium

The objective is to ensure that the serum [K+] is £ 5 mmol/l when the patient goes to theatre.  It is the responsibility of the renal Doctor to obtain the potassium result and act upon it.

• If serum [K+] >6.5, the patient will usually require haemodialysis.  Inform registrar/consultant and follow immediate measures for hyperkalaemia (see Renal Unit Handbook)
• If admission serum K+ >5.5, discuss with consultants, plan will depend on circumstances.
• If serum [K+] 5 - 5.5:

Initial treatment; maintenance regime plus insulin/dextrose given as 5 units actrapid and 50 ml 50% dextrose over 15 minutes.

Nebulised salbutamol 5 mg six hourly Potassium and BM should be checked after 60 minutes.

Patients who fail to respond may require dialysis.

• If serum [K+] ≥ 4 and surgery is likely to be more than six hours later:

  500ml of 10% dextrose at 40 ml/hr (non-diabetic patients)

  500ml of 10% dextrose with 16 units Actrapid at 40 ml/hr (for diabetic patients)

Notes

1. Post-dialysis potassium must be checked from a venous sample taken at least 5 minutes after the end of dialysis.
2. The maintenance regime is only designed to prevent a rise in serum [K+] and is not appropriate when the serum [K+] requires reduction.
3. There is no place for calcium resonium or sodium bicarbonate in the control of pre-transplant potassium.

Medication

Transplant protocols developed on the Edinburgh Transplant Unit. This page first published March 2002 by Amit Adlakha, updated November 2006 and last updated Tuesday, August 11, 2009.

NOTE that the accuracy of any statements in this information CANNOT be guaranteed. It is published in the belief that it is correct, and we endeavour to keep it so - but we do make mistakes. Furthermore, over some subjects there are differing opinions, or differing degrees of certainty. We have usually not attempted to discuss these here because the aim has been to provide an immediate and brief guide. In all areas, prior medical knowledge is assumed. The EdRenHANDBOOK is not suitable for use by those without such a background. Contact us by email or at the address given at the foot of the contents page with any comments or corrections.