Renal Transplants & the Collaborative Care Plan

A Collaborative Care Plan has been developed to help coordinate our response to the relatively infrequent renal transplants that we encounter in the OR.  The ‘package’ should come down to the OR with the patient.  Different packages are provided depending on the rejection risk of the recipient, because of differing anti-rejection drug management.  If the package does not arrive, it can be obtained from the ECU.

The most notable anesthetic issues are:

1. Recipients may be sent to the OR before all their immunosuppressants have been given. Some cold ischemic times were being prolonged simply because some of the drugs need to be given slowly. We are now being asked to give some drugs when necessary. Copies of the relevant drug info sheets are in the packet. The nurses are to send down medication sheets that clearly indicate what drugs still need to be given. The drug menu varies with the risk of rejection and will be determined by nephrology.

2. We are being asked to place a triple lumen CVP line in all recipients. It should be sent down with the patient. (The ICU also has them). When Thymoglobulin is asked for in a high risk patient it must be given via a central line with a 22 u filter over 4 hours. It has been agreed that the central line can be placed after induction and the drug started then.

3. Patients will likely come down with just one IV. If nurses on the ward can’t get an IV after 2 tries anesthesia will be notified and we may be asked to help. (That one is our judgment call!) If cylcosporin is still running on arrival in the OR we can discontinue it during the induction and finish running it in after the patient is asleep.

4. 250 mg of furosemide is still wanted. The large vials are available. Just ask.

5. The primary responsibility for recording warm ishemic time lies with nursing.

6. Epidurals are still not an option for the recipient. PCA is OK.

7. Arterial lines are to be left in post op.

8. Anesthesia and nephrology are to set PACU targets for CVP, BP and urine output in consultation with each other and cosign the pre-printed PACU orders.

If you see errors or encounter problems let me know.