Anesthetic concerns in organ transplant patients

Anesthetic management of kidney Transplant Patient for non transplant surgery
Preanesthetic Checkup 
HISTORY

• Evaluation of Graft Function
• Rule out other co-morbid health conditions
• Presence of infection
• Immunosuppressive regime and it's stability

Examination

Recent weight gain, reduced urine output, rash and fever, abdominal pain are to be ruled out
Lab Investigations
Complete blood counts,Kidney function tests, Blood sugar, coagulation profile if regional is planned, baseline electrocardiography and chest x-ray, liver function tests, serum electrolytes, ultrasonography of graft and colour Doppler studies to see blood supply

To rule out other comorbid health condition

CKD if long term could have other organ system affection like the cardiovascular system and also long term immunosuppressive therapy causes liver impairment,nephropathy ,type 2 Diabetes, musculoskeletal abnormalities, gastrointestinal intolerance
Preoperative Goals

1. To maintain steady levels of immunosuppression,if due to any undue events oral dosage is withheld than has to be supplemented with intravenous regimen
2. Preserve transplant organ status
3. Avoid infections

Intraoperative management

1. Surgical stress can lower graft  function so methods to reduce surgical stress like minimally invasive surgery are preferred and regional anesthesia also reduces surgical stress hence advisable whenever possible if coagulation profile is good

• Avoid injury to transplant organ by closely maintaining the perfusion pressures especially if laparoscopic surgeries are being done then intraabdominal pressures should be well maintained not to compromise perfusion. 
•  Arterial pressure monitoring is advised if major surgery with large fluid shifts is expected
• Maintaining circulating volumes by meticulous input/ output charting,replacing blood loss. 
• Avoiding high Central venous pressures and high levels of PEEP.   
• Avoiding excess uses of inhalation anesthetic agents .  
•  Avoiding nephrotoxic drugs as radiocontrast agents, NSAIDS,Aminoglycosides etc

1. Protection against infection - Strict asepsis is maintained during invasive procedures as Central lines and regional anesthesia.        Antibiotic prophylaxis is well maintained

Post operative management

1. Managing pain as painkillers are nephrotoxic and pain can increase the mean blood pressure which again reduces the perfusion pressures
2. Oral intake and fluid management
3. Close observation of immunosuppressant levels in blood and doses can be augmented if needed
4. Postoperative infection are to be closely gaurded as conventional signs of infection as fever and leucocytosis are generally absent
5. Strict urine output monitoring and if catheter in place then faster removal as soon as possible.