Basic clinical management of Anaesthesia for Renal Transplant Surgery is discussed in nutshell.

1. Anaesthesia for Renal
Transplant Surgery 

Lt Col Md Rabiul Alam
MBBS, MCPS, FCPS
Classified Anaesthesiologist
Kidney Transplant Unit
Combined Military Hospital Dhaka
Bangladesh


2. Scopes
 The major surgical deals…
 Anaesthesia for the Donor
 Renal perfusion
 Anaesthesia for the Recipient
 Monitoring
 Sequences of vessels’ clamping & anastomosis
 Kidney transplant (KT) ICU
 Other essentials
 Conclusion

3. The Major Surgical deals at a glance...
Usually, the Left Kidney is taken from the Donor &
placed on the Right side of the Recipient

4.  A healthy person
 Not a patient, Rather a rescuer
 So, morbidity is not accepted
Anaesthesia
FOR THE DONOR
caution

5. FOR DONOR
 Check 
 The Anaesthesia machine
 Disposable breathing circuit with Bacterial filter
 Equipments (use sterile laryngoscope blades,
disposable airways)
 Infusion/pressure/extension lines
 Anaesthesia drugs preparations
 Pre-fill syringes: Ephedrine, Norad, Labetolol, GTN

6. Donor Anaesthesia (Continued)
Anaesthesia
Workstation

7. Donor Anaesthesia (Continued)
Exhaled gas
scavenging
system

8. Donor Anaesthesia (Continued)
Timers &
Film Viewer

9. Donor Anaesthesia (Continued)
Video
Laryngoscope

10. Donor Anaesthesia (Continued)
Pendant
Monitors

11. Donor Anaesthesia (Continued)
Ultraviolet
Light

12. Donor Anaesthesia (Continued)
Portable USG
Machine for
Safe Vascular
Access & Nerve
blocks

13. Donor Anaesthesia (Continued)
Intubation
Trolley

14. Donor Anaesthesia (Continued)
Pre-filled
Syringes

15. Donor Anaesthesia (Continued)
Prepared OT
Table

16. Donor Anaesthesia (Continued)
OT Lights

17. Donor Anaesthesia (Continued)
 Go through the P/A check up form with care
 Personalise the monitors as per patient’s profiles
 Receive the donor in the OT 
 Introduce yourself to the patient
 Little talk is likely to be helpful during recovery
 Correctly identify the Donor as per WHO protocol
 Exercise the Patient Preparation Protocol

18. WHO-SSC

19. Donor Anaesthesia (Continued)
 Ask the patient about fasting 
 Clear fluid is to be allowed to take till 2 hrs back
 Prevent pre-op dehydration
 Establish a peripheral I/V line (B/Brown 18G)
 On forearm of the same side to the donor kidney
 Administer antibiotics as per Nephrology
Antibiotic Protocol
 Attach the monitors   ECG leads  SpO2 probe
 BP cuff over a soft roll cotton

20. Donor Anaesthesia (Continued)
 Pre-medicate with:
 Pantoprazole  40 mg I/V over 5 min
 Ondansetron  8 mg I/V over 2-5 min
 Glycopyrolate  10 mcg/kg
 Oxygenate the patient for at least 3 min
 Induct with 
 Midazolam  0.02-0.04 mg
 Fentanyl  1.5-2 mg/kg and
 Propofol  1-2mg/kg

21. Donor Anaesthesia (Continued)
 Intubate with 
 Artracurium  0.5 mg/kg
 Check  the ETT length
 Auscult the chest for equality of breath sounds
 Then, fix and secure the tube properly
 Check the cuff pressure
 Maintain anaesthesia with 
 Isoflurane  MAC 1-1.5% in
 O2  40-50% in Medical air

22. Donor Anaesthesia (Continued)
ETT Cuff
Pressure Gauge

23. Donor Anaesthesia (Continued)
 Post-induction actions 
 Eye protection
 ETCO2 monitoring (<30 mmHg)
 Insert the Temp probe (throat) & monitor (35C)
 Insertion and secure the Ryle’s tube
 Apply the Leg compressing socks (both leg)
 Start patient warmer
 Start fluid warmers
 Catheterisation of bladder (bag in head-end)

24. Donor Anaesthesia (Continued)
Multi-
parameter
Monitor

25. Donor Anaesthesia (Continued)
Ventilator
Monitor &
Gas
Analyser

26. Donor Anaesthesia (Continued)
Patient
Warmer

27. Donor Anaesthesia (Continued)
 Consider (optional):
 TAP or
 Quadratus Lumborum block in Lap cases
USG-guided
 For intra and post-op analgesia
 Epidural is not recommended… because
accidental dural puncture may cause
hypotentsion…

28. Donor Anaesthesia (Continued)
 Secure a 2nd I/V line (16 or 18G) in opposite hand
 Position 
 The patient laterally
 Ensure that the axilla is padded and
 Dependent arm is not over-flexed
 Secure the genetalia in ♂ and the breast in ♀
 Start   Fentanyl 0.5 mcg/kg/hr and
 Atracurium 0.2-0.3 mg/kg/hr infusions
 Consider Morphine 3 mg  one or two doses

29. Donor Anaesthesia (Continued)
Donor on the
Table

30. Donor Anaesthesia (Continued)
AVF and
Peripheral
pulse Doppler

31. Donor Anaesthesia (Continued)
 Intra-op fluid RL 4-5 Litres (80-90 ml/kg)
 As Surgeons are dissecting near the hilum, give
20% Mannitol 100 ml (to be finished well before
the renal artery clamping)
 Urine output should be 1-2 ml/kg/hr
 If require use Frusemide 10/20 mg
 Ensure that temperature does not drop (34-35C)
 Note the time of:
 1st Warm Ischemia: Renal artery clamping
 Cold Ischemia: Perfusion of donor kidney & Bench surg

32. Donor Anaesthesia (Continued)
 Maint normal BP MAP>95 mmHg (Avoid
hypotension)
 Warm the patient
 Ensure infiltration of
 0.25% Plain Bupivaccaine 10 ml in the incision line
 Reverse the patient with 
 Neostigmine  0.05 mg/kg and
 Glycopyrolate  10 mcg/kg
 Extubate the patient when awake
 May consider an Oro/Nasophryngeal airway

33. Donor Anaesthesia (Continued)
 Post-op analgesia 
 Fentanyl infusion  0.5 mcg/kg/hr or
 Morphine infusion 1 mg/hr for 12 hours
 Morphine 1.5 mg bolus, if VAS score 4 or more
 Continue I/V Paracetamol 1 gm 8 hourly for 24 hrs
 No prick for analgesia & No Pethidine
 Watch out 
 Urine output and The drain

34. Renal Perfusion
Perfusion of harvested kidney 
 Hartman solution
 2% Lignocaine
 Heparin
 Papavarine

35. Anaesthesia
FOR THE RECIPIENT

36. ESRDCKD
 An irreversible
deterioration of
renal function
that
 Gradually
progresses to end-
stage renal
disease (ESRD)
 Evidence of structural or
functional kidney
abnormalities 
 Abnormal urinalysis
 Imaging studies, or
 Histology
 Persists for at least 3 months
 +/-  GFR= <60 mL/min per
1.73 m2 - KDOQI
A Little about the Transplant Candidate

37. CKD
The Most
Common
Causes
Ref: Salman M, Khan AH, Adnan AS, et al.
Attributable causes of chronic kidney disease in
adults: a five-year retrospective study in a tertiary-
care hospital in the northeast of the Malaysian
Peninsula. Sao Paulo Med J. 2015;133(6):502-9.

38. The Recipient
 An ESRD patient
 On HD for long time
 CVS involvement
 HTN, MI, CHF, LVH
 Pericardial effusion
 Pulmonary oedema
 Hepatic: Serology positive
 Metabolic: Acidotic
 Electrolyte imbalance
 Hyperkalemia
 Hyponatremia
 Haematology: Anaemia
 Platelet dysfunction
 Thrombotic phenomenon
Uraemic encephalopathy
 Impaired sensorium
 GIT involvement
 Gastritis
 Peptic ulcer disease
 Diverticulosis
 Diverticulitis
 Spontaneous colonic perforation
 Adynamic ileus
(pseudo-obstruction)
Bone: Hypocalcaemia
 Phosphorus, PTH
 Moreover 
on Immunosuppression

39. Recipient Anaesthesia (Continued)
 Check 
 The Anaesthesia machine
 Disposable breathing circuit + Bacterial filter
 Equipments (sterile laryngoscope blades,
disposable airways)
 Infusion/pressure/extension lines
 Drug preparations
 Pre-fill syringes with: Ephedrine, Noradrenaline,
Labetolol, GTN

40. Recipient Anaesthesia (Continued)
 Go through the P/A check up form with care
 Personalise the monitors as per patient’s profiles
 Watch out the KT ICU Preparations taken by the
Nephrology nurses 
 Prep & checking of the mechanical ventilator
 Ensure the options and keep readiness of post-op
HD in the Tx ICU

41. Recipient Anaesthesia (Continued)
Scrub Point
Water Purifier

42. Recipient Anaesthesia (Continued)
 Receive the Recipient in the OT:
 Patient should be with sterile clothing, with mask & cap
 Introduce yourself to the patient
 Little talk is likely to be helpful during recovery
 Identify the Recipient as per WHO protocol
 Exercise the Patient Preparation Protocol
 Ask the patient about fasting
 Clear fluid is allowed to take till 2 hours back
 Oral fluid intake as per Nephrology guidelines
 Follow sterile precautions strictly

43. Recipient Anaesthesia (Continued)
 Place a soft roll around the arm with AVF 
 AVF hand should be place on padded arm board
 Not tacked by the side of the patient
 Ensure that NO inadvertent pressure on the fistula
 SpO2 probe is to be attached to this hand
 Secure a peripheral I/V line (B/Brown 18G) 
 On the dorsum of the hand opposite to AVF arm
 Start & ensure speed of fluid is minimal
 Administer antibiotics as per Nephrology Antibiotic
protocol

44. Recipient Anaesthesia (Continued)
 Attach the monitors 
 ECG leads
 SpO2 probe to the AVF arm
 BP cuff over cotton roll opposite to AVF arm
 BP may in intermittent or continuous mode
 Pre-medicate with 
 Pantoprazole  40 mg I/V over 5 min
 Ondansetron  4-8 mg I/V over 2-5 min
 Glycopyrolate  10 mcg/kg
 Oxygenate the patient for at least 3 min

45. Recipient Anaesthesia (Continued)
 Induct with 
 Midazolam  0.02-0.04 mg
 Fentanyl  1.5-2 mg/kg
 Propofol  1-2mg/kg
 In incremental doses till loss of verbal responses
 Intubate (preferably RSI) with 
 Artracurium  0.5 mg/kg
 Check   the ETT length
 Auscult the chest for equality of breath sounds
 Fix & secure the tube properly; Check cuff pressure

46. Recipient Anaesthesia (Continued)
 Maintain anaesthesia with 
 Isoflurane MAC 1-1.5% in O2 40-50% in Med air
 Post-induction actions 
 Eye protection (Hydroxypropyl Methylcellulose Ophthalmic gel 0.3%)
 ETCO2 monitoring (<30 mmHg)
 Insertion of Temp probe (throat) & monitoring (35C)
 Insert a Ryle’s tube (attach to an empty bag)
 Wear Leg compressing socks
 Start patient & fluid warmers
 Catheterisation of bladder (bag in head-end)

47. Recipient Anaesthesia (Continued)
Dual Patient
Warmer

48. Recipient Anaesthesia (Continued)
 Consider an arterial line (in cardiac disease) to 
 Dorsalis Pedis or Post Tibial - opposite to the transplant side
 Correlate with the NIBP & get a baseline ABG (1st ABG)
 Avoid Radial A. (keep it for AVF in future if necessary)
 Insert a Central line by guidance of USG in 
 Right IJV - prior rule out thrombus by USG scan
 Left IJV - if there is a Perm Cath
 Avoid Subclavian approach
 Consider (optional) USG-guided 
 TAP or Quadratus Lumborum block for analgesia

49. Recipient Anaesthesia (Continued)
 Position  The patient in supine posn
 Attach the patient with CO monitor (Arterial line)
(CO = 4-6 L/min; SVV = 5-10ml)
 Attach BIS monitoring probe  (60-80)
 Start   Fentanyl  0.5 mcg/kg/hr and
 Atracurium  0.2-0.3 mg/kg/hr
 An increase in HR/BP >20% - titrate with
boluses of Propofol/Fentanyl
 May consider Clonidine; Avoid Dexmeditomidine

50. Recipient Anaesthesia (Continued)
Bi-spectral
Index(BIS)
Monitor for
monitoring
the Depth of
Anaesthesia

51. Recipient Anaesthesia (Continued)
Cardiac
Output
Monitor

52. Recipient Anaesthesia (Continued)
Recipient
on the
Table

53. Recipient Anaesthesia (Continued)
 Intra-op fluid 
 RL 4-5 Litres or Plasmalyte (80-90 ml/kg) - if
K+<4.5 mmol/L or
 ½% NS + 25 ml NaHCO3 - if K+>4.5 mmoml/L
 Fluids are infused slowly unless patient is
hypotensive (always use warmers)
 Fluids can be administered at a greater speed to
reperfusion of the new kidney

54. Recipient Anaesthesia (Continued)
Syringe
pumps

55. Sequences of vessels’ clamping
& Anastomosis
 IN DONOR:
 Ureter
 Artery
 Vein
 IN RECIPIENT:
 Vein
 Artery
 Ureter

56. Recipient Anaesthesia (Continued)
 2nd ABG 
 When the renal artery is clamped on the donor
 Once the donor kidney comes packed in ice into
the OT, the following medications are to be
administered over 30-40 min 
 Methyl Prednisolone - 7.5 mg/kg (usually 500 mg for adult)
- in pump
 20% Mannitol - 100 ml
 Frusemide - 80 mg (in paediatric patient 1.3 mg/kg)

57. Recipient Anaesthesia (Continued)
 Ensure that temperature does not drop (34-35C)
 Note the time of 
 Kidney placement in the body
3rd ABG: When anastomosis is started
 End of anastomosis
4th ABG: 5 min after release of clamp
(reperfusion) - Watch for rise of K+

58. Recipient Anaesthesia (Continued)
In-
Theatre
Blood Gas
Analysers

59. Recipient Anaesthesia (Continued)
 After anastomosis 
 Increase rate of I/V fluid administration
 Target CVP is minimum 10-12 cmH2O
 BP maintainance 
 In hypertensives: Target MAP  95-110 mgHg
Boluses of Propofol or GTN infusion may be required
 In normotensives: Target MAP Closed to preoperative
values

60. Recipient Anaesthesia (Continued)

61. Recipient Anaesthesia (Continued)
 Attempting to reversal 
 Reduce dose of Atracurium once reperfusion is
over
 Once muscle layer is over, stop Atracurium
infusion, aspirate and flush the line to clear the
drug
 Stop Fentanyl, once skin suturing is started and
note the time in proforma
 Warm the patient

62. Recipient Anaesthesia (Continued)
 Ensure infiltration of 
 0.25% Plain Bupi 10 ml in incision line & drain site
 Watch for urine output, K+ & signs for acute
rejection 
 If urine output is <2 ml/kg/hr Consider elective
ventilation for few hrs or overnight
 Hb% if <7 gm/dL, consider leukocyte filtered PRBC
 Bleeding Consider tranexamic acid/cryoprecipitate
 Reverse with   Neostigmine 0.05 mg/kg +
 Glycopyrolate 10 mcg/kg

63. Recipient Anaesthesia (Continued)
 Extubate the patient when awake
 Be ready with GTN/Labetolol/Fentanyl to control BP as
needed
 Post-op analgesia:
 Start Morphine infusion 1 mg/hr for 12 hours (if urine
output is adequate)
 Morphine 1.5 mg bolus, if VAS score 4 or more
 Continue I/V Paracetamol 1 gm 8 hourly for 24 hrs

64. KT ICU
2nd POD

65. Kidney Transplant ICU
 Principally managed by the Nephrologists
 Dedicated nephrology/transplant-trained nurses
 Prevention of rejection modalities
 Isolation, Asepsis and Infection control
 Visitors/Bystanders management
 Analgesia, respiratory & the issue of mechanical
ventilation – managed by the Anaesthesilogists
 Equipment – Patient warmers, Leg compressors,
Chest vibrator, MiniLab, Blood gas analyser etc.
 Provision of HD in the ICU

66. Scrub in ICU

67. Chest Vibrator

68. Leg Compressors

69. Other Essentials
 Patient : Nurse ratio  1 : 1
 Infection Control Dept – headed by Microbiologist
and other doctors & dedicated staffs
 Fully Automated Medical Record Data (MRD) system
 Pneumatic Sample Transfer System
 Academic environment & PG residents’ support
 Standard Nursing support
 Research Labs
 Ample of dormitories
 Bio-Med Engineering Dept – Preventive, Calibration, Repair

70. Other Essentials (Continued)
Pneumatic Sample
Transfer System

71. Conclusion
Nephrology
 Patient preparation
 Immunosuppression
 Post-Transplant Care
Urology
 Harvesting
 Anastomosis
 Bleeding control
Anaesthesiology
 Pressure & Hydration
 Acid-Base & Electrolytes
 Renal protection
Overall
 Infection control
 Nursing Care
 Support
Successful
Kidney
Transplantation