Postoperative monitoring after

Size: px

Start display at page:

Download "Postoperative monitoring after"

Angelica Tucker
6 years ago
Views:

1 Postoperative monitoring after kidney transplantation Bundit sakulchairungrueng,md Vascular and Transplantation Unit Faculty of Medicine Ramathibodi Hospital Mahidol University

2 Reference

3 Introduction A successful long-term outcome for a new kidney transplant recipient depends on the early perioperative management and course after surgery. Cecka JM. The UNOS scientific renal transplant registry ten years of kidney transplants. Clin Transpl 1997;1 14

4 Perioperative Assessment Assessment of pretransplant fluid status of recipient to determine the need for dialysis Careful physical examination recipient (e.g. active ischemic heart disease, active infection, vascular disease) Knowledge of the donor status (e.g. living related donor,expanded criteria donors )

5 Perioperative Assessment Technical considerations include the need for vascular reconstruction, anatomical considerations that complicate the surgery Recipient factors : Significant risk factors for early posttransplant dysfunction (e.g. obesity, younger or older age)

6 Perioperative Management Early perioperative period, attention to fluid and electrolyte balance is crucial. Careful monitoring of urine output is essential.

7 The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines Recommend measuring urine volume every 1 2 hours for at least 24 hours after transplantation and daily until graft function is stable. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009;9(Suppl. 3):S1 155.

8 The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines Serum creatinine should be measured at least daily for 7 days or until hospital discharge. Creatinine should then be measured two to three times per week for a month, and a tapering frequency of measurements in ensuing weeks. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009;9(Suppl. 3):S1 155.

9 ,table 8.1

10 Postoperative Assessment Urine output early graft recovery Hemodynamic and respiratory stability Assessment of volume status Intraoperative immunosuppressive protocols Control blood glucose concentration (facillitate recovery of allograft,promote healing)

11 Postoperative Assessment Operative record information to assess - Fluid and blood loss and fluid replacement - Intraoperative events - Intraoperative perfusion characteristics of the kidney - Intraoperative urine volume - Details of the surgery (e.g., multiple donor vessels, recipient vascular condition, type of ureteral anastomosis)

12 Fluid Replacement Most common aspect is to ensure sufficient fluid replacement - maintain hemodynamic stability - urine output

13 Fluid Replacement Maintenance fluid -Insensible loss ~30 ml/h Replacement fluid -Urine output -Any Nasogastric fluid loss *Half- normal saline

14 Fluid Replacement Keep euvolemic or mildly hypervolemic Estimate volume losses at the operative site Urine volume must be monitored hourly and replaced accordingly

15 Hemodynamic Evaluation An adequate blood pressure and volume status is necessary to establish good graft function. Many patients are hypertensive after surgery

16 Hemodynamic Evaluation In acute setting, mild elevated blood pressure (systolic pressure < 180 mmhg) is acceptable.

17 Assessment and management of urine output Oliguria in the posttransplant situation usually refers to urine outputs of less than approximately 50 ml per hour.

18 figure 9.1

19 Post transplant oliguria/anuria Hemodynamic assessment Duplex ultrasound Bladder Ultrasound/Scan Hypovolemia Euvolemia / hypervolemia Good Kidney Purfusion Poor/No Kidney Purfusion No Urine In Bladder Urine In Bladder ml Fluid load No Urine Furosemide 250 mg IV. Irrigate Bladder Urine No Urine Treat AKI Immediate exploration Urine Protocol Kidney transplantation, Ramathibodi hospital Mahidol University

20 Duplex ultrasound

21 Duplex ultrasound

22 If the flow study reveals no demonstrable blood flow, a prompt surgical reexploration is necessary to attempt to repair any vascular technical problem.

23 Assessment and management of urine output Polyuria- amounts of urine (greater than 500 ml per hour) in the early posttransplant period. Potassium and calcium may need to be replaced in the polyuric patient.

24 Postoperative Bleeding Most hematomas will spontaneously tamponade Any combination of the triad of Hypotension, a decreasing hematocrit and pain significant postoperative bleeding Perinephric drain may fill with blood

25 Postoperative Bleeding

26 Postoperative Bleeding If bleeding continues can t maintain blood pressure with intravenous fluids or blood replacement, Surgical exploration may be required to find source of persistent bleeding.

27 Postoperative Hemodialysis If serum potassium concentration is elevated or if the patient is compromised by overhydration, dialysis should be performed for correct condition

28 The first postoperative week Sudden onset of severe pain or pain that appears to be aggravated by voiding,suggests the possibility of a urine leak. Urine wound / Drain

29 Urine leak Urine leaks usually occur at the ureteric anastomosis, most frequently in the first 72 hours. location vesicoureteric anatomosis, calyx (area of ischemia) Complication infection,abscess, urinoma Ultrasound, Renal scan

30 Urine leak Management depends on urologist surgical practice. If the leak persists, or if it is considered unlikely to heal, then re exploration is indicated to reimplant the ureter.

31 Delayed Graft Function DGF is defined as the need for dialysis during the first week after transplantation, and is the most frequent early posttransplant complication. Siedlecki A, Irish W, Brennan DC. Delayed graft function in the kidney transplant. Am J Transplant 2011;11(11):

32 Delayed Graft Function Diagnosis of DGF is apparent during the first 24hours after transplantation. Clinical scenario is a decline in urine output unresponsive to a fluid challenge. Usual time course of DGF is days. Chapter 14, 7 th Kidney transplantation,peter J.Morris

33 Delayed Graft Function The major differential diagnostic consideration an acute vascular or urological complication. Can be evaluated with urgent ultrasound Typically, a transplant with DGF shows good renal perfusion Chapter 14, 7 th Kidney transplantation,peter J.Morris

34 Delayed Graft Function Kidney transplant biopsy is the gold standard for diagnosis. When the diagnosis of DGF is established, careful attention to fluid status is paramount to decrease the frequency and necessity for dialysis. Chapter 14, 7 th Kidney transplantation,peter J.Morris

35 Allograft function The creatinine and the urine output can be used as measures of changes in kidney function and as markers of the development of new problems

36 Problem of Allograft function Rejection Problem with blood flow to the kidney Obstruction to urine flow CNI toxicity Infection

37 Chapter 14, 7 th Kidney transplantation,peter J.Morris

38 Thank you

Early Postoperative Urine Flow Predicts Delayed Graft Function Irrespective of Diuretic Use

Early Postoperative Urine Flow Predicts Delayed Graft Function Irrespective of Diuretic Use Sunil Bhandari, PhD, FRCP * David Eisinger, MD, FRACS Josette Eris, PhD, FRACP * *Department of Transplant Medicine,