Perioperative considerations in kidney transplantation: An anaesthesiologist’s perspective

Table 2 Intraoperative considerations for kidney transplantation

Area of management	Anaesthesia considerations
Anaesthesia technique	General anaesthesia with intubation: Preferred
	Neuraxial blocks: Risk of spinal or epidural hematoma
	Dose of LA should be reduced
Anaesthesia monitoring	Monitoring: Standard ASA monitors (NIBP, SPO2, ECG, ETCO2, temperature)
	Arterial line: For beat-to-beat blood pressure monitoring and arterial blood gas analysis, avoided in fistula arm
	Central venous catheter: For infusion of induction therapy and vasopressors/inotropes
Fluid management	Fluid responsiveness by dynamic indices (SVV or PPV): Target 10%-15%
	Crystalloids: Low chloride solutions – preferred to avoid normal saline large doses, risk of hyperkalemia and lactic acidosis with ringer lactate
	Colloids: Avoid starches: Risk of coagulopathy, renal injury, routine use of albumin is not recommended
Transfusion management	Red cell transfusions: Transfusion trigger is haemoglobin < 70-80 g/L, Leukoreduced red cell preferred
	Fresh frozen plasma/ cryoprecipitate/ platelet: Avoided routinely, if required point of care coagulation monitoring guide suggested
Pain management	Multimodal analgesia and individualized approach: IV paracetamol, fascial plane block, intrathecal morphine, epidural analgesia, skin infiltration with local anaesthetic Avoid NSAIDS
Immunosuppression	Induction therapy: Antithymocyte globulin, 1-1.5 mg/kg or basiliximab, 20 mg
	IV methylprednisolone (10 mg/kg): 10-15 min before reperfusion of graft
Other interventions	Blood glucose: Target blood sugar 6-10 mmol/L
	Temperature: > 35.5 °C, forced air warming device or blankets, fluid warmers
	Antibiotic prophylaxis: Cefazolin 2 g IV, 30-60 min before surgical incision
	PONV prophylaxis: IV palanosetron 0.075 mg

LA: Local anaesthetic agents; ASA: American Society of Anaesthesiologists; NIBP: Noninvasive MAP; SPO2: Oxygen saturation; ECG: Electrocardiogram; ETCO2: End-tidal carbon dioxide; SVV: Stroke volume variation; PPV: Pulse pressure variation; IV: Intravenous; NSAIDS: Nonsteroidal anti-inflammatory drugs; PONV: Postoperative nausea and vomiting.