Live Donor, Laparoscopic Nephrectomy

James Whiting MD
Updated Apr 2007

1) Anesthesia: General, ET; avoid nitrous oxide if possible
2) Preop Antibiotics
3) IV Hydration: 5-6 Liters of LR or NS; give 2 liters BEFORE insufflation
4) Start Renal Dopamine @ 1-2 mcg/kg/min (okay to give through peripheral IV)
5) Follow urine output closely
6) Mannitol per surgeon
7) Heparin & Protamine will be asked for by surgeon
8) Analgesia: does not need epidural analgesia postop

Kidney, Recipient from Living Donor

James Whiting MD
10/02; mod. 7/04

1. Anesthesia: General, ET
2. Central Line: none, unless poor peripheral access; if a Live Donor Recipient has a central dialysis catheter, it may be used for central administration of drugs.
3. Administer 500mg Solumedrol IV; wait at least 60 minutes after Solumedrol to begin Thymoglobulin (presumably to attenuate any possible allergic reaction). In scheduled cases (vs. nights, weekends), Solumedrol will be given in ASU prior to OR transport.
4. Start Thymoglobulin* at induction of anesthesia. It's not critical when you start it, but it should be running when the crossclamp comes off the transplanted kidney. Use a dedicated (i.e., second) peripheral IV or dedicated port on a central line, as PACU nurses are not allowed to run the thymoglobulin with other meds that the patient receives.

-Thymoglobulin 1.5mg/kg will be ordered by nephrologist or surgeon.
- Made up by pharmacy in one liter bag of NS (Cost:~$1000)
- Hydrocortisone 20 mg & Heparin 1000 units added to bag by pharmacy (to decrease incidence of phlebitis when run through peripheral IV)
- run @ 125 cc /hour; use special 0.22 micron filters (anesthesia workroom, back wall, eye level, next to Bair Huggers)

5. Hydration: 3 Liters Normal Saline

+/- 25gm Mannitol per MD
+/- Lasix per MD
+/- Heparin per MD

6. Analgesia: AVOID epidural analgesia.

Kidney, Recipient from Cadaver Donor

James Whiting MD
10/02; mod. 7/04

1. Anesthesia: General, ET
2. Central Line: Triple lumen before / after induction, for immunosuppressant administration.
3. Administer 500mg Solumedrol IV; wait at least 60 minutes after Solumedrol to begin Thymoglobulin (presumably to attenuate any possible allergic reaction). In scheduled cases (vs. nights, weekends), Solumedrol will be given in ASU prior to OR transport.
4. Start Thymoglobulin* at induction of anesthesia. It's not critical when you start it, but it should be running when the crossclamp comes off the transplanted kidney. Run the thymoglobulin through a dedicated port on the central line.

-Thymoglobulin 1.5mg/kg will be ordered by nephrologist or surgeon.
- Made up by pharmacy in one liter bag of NS (Cost:~$1000)
- Hydrocortisone 20 mg & Heparin 1000 units may be added by pharmacy to bag (to decrease incidence of phlebitis)
- run @ 125 cc /hour; use special 0.22 micron filters (anesthesia workroom, back wall, eye level, next to Bair Huggers)

5. Hydration: 3 Liters Normal Saline

+/- 25gm Mannitol per MD
+/- Lasix per MD
+/- Heparin per MD

6. Analgesia: epidural analgesia rarely necessary due to low abdominal incision;  in general, AVOID it.

*Thymoglobulin may cause an allergic reaction in those patients allergic to rabbits.

-these patients frequently have renal transplant concomitantly; occasionally, a pancreas transplant only will be done. The pancreas, like the kidney, is implanted heterotopically.

-same lines/techniques as cadaver kidney recipient, above.

-Check blood glucose q1h until donor pancreas hooked up
-Antibiotics (Cipro, Flagyl) are generally ordered & administered prior to OR.

-SCU postop; extubation is case-dependent (these cases go 4-5h, with significant fluid shifts).

-no epidural (post-op anticoagulation).

Organ Donation from Brain Dead Donor:NEW
Guidelines for Anesthesia
New England Organ Bank 5/96; Rev 3/05 (Nancy Quint)

Anesthesia services for physiological support of brain dead organ donors include administration of fluids and blood, monitoring and maintenance of temperature, blood pressure, electrolytes, and ventilation/oxygenation, obtaining blood specimens, and administration of medications. 

While the organ recovery procedure may last from less than one to more than five hours, on average, the interval of surgery will be approximately three hours, from incision to cross-clamp. At the time of aortic cross-clamping, cold preservation solutions are infused via cannulae inserted into the appropriate vessels, and the organs are subsequently removed for backtable dissection and packaging for transport. Anesthesia support is discontinued at the time of aortic cross-clamp. 

Specific guidelines and parameters for support of organ donors include the following:

1. Adequate monitoring of vital signs is critical to successful organ recovery
   ● Radial arterial line is preferred for BP monitoring and obtaining blood specimens
   ● Adequate venous access for CVP monitoring and rapid volume infusion is preferred 
   ● Core temperature should be maintained above 35° C using warming blanket and 
other means as needed. It is helpful to keep the OR temperature at 75° F.

2. Adequate organ perfusion is critical
   ● For adults, systolic BP > 100 mm Hg should be maintained (consult with surgical team 
      regarding preferred means for maintaining BP)
   ● In general, dopamine is the vasopressor of choice
   ● Urine output should be monitored closely. Goal is 2 to 3 cc/kg/hr.

3. Oxygenation
   ● Arterial PaO2 should be maintained at > 100 mm Hg, while FIO2 should be kept at 40% unless otherwise 
      indicated (e.g., progressive arterial hypoxemia). PEEP of 5 cm H20 is preferred. 
   ● Arterial blood gases should be obtained periodically.

4. Administration of blood products and medications
   ● In general, the patient's hematocrit should be maintained at 30. Five units of PRBC's should be 
      typed, crossed and available. Other blood products (platelets, FFP) should be given in consultation    
      with surgical team.
   ● Heparin 30,000 Units and Mannitol 25 gm should be given at the direction of the surgical team. 
      Other medications e.g. Lasix, Pavulon may be requested on occasion.