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Child Health Guideline Identifier

Anaesthesia - paediatric renal transplant

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All paediatric transplant recipients should be anaesthetised by a paediatric anaesthetist.

Preparation and equipment

  • Operating theatre temperature should be kept at >23ÂșC.
  • Forced underbody air-warming blanket available.
  • Fluid warmer should be primed with plasmalyte (in line burette without flow restrictor added to standard giving set for < 20kg).
  • Paediatric equipment trolley should include various sizes of central venous catheters and epidural needles (including 18G 5cm touhy needle).
  • At least two infusion pumps should be available.

Monitoring

  • Routine monitorings include SpO2, ECG, non-invasive BP, ETCO2, BIS and temperature.
  • Central venous pressure and often arterial pressure monitoring are also required.
  • Pre-existing CVL for haemodialysis line could be accessed with aseptic technique. If the kidney is from a deceased donor, the child is likely to require postoperative dialysis and the renal team would prefer the haemodialysis line to be left undisturbed.
  • If accessing a haemodialysis line, it is MANDATORY to aspirate 3 times the dead-space to ensure heparin withdrawn.

Anaesthesia

  • Epidural anaesthesia is the preferred analgesia modality especially where intra-peritoneal surgical access is required for placement of donor kidney. This would generally be inserted after induction of general anaesthesia.
  • However, variation of the above technique would be used at the discretion of the anaesthetist as determined by the medical condition of individual patient.

Immunosuppression and antibiotics

  • Immunosuppression therapy will be prescribed by the renal team and drug ampoules available when the patient arrives in the operating theatre.
    The current regimen is Methylprednisolone 10mg/kg IV at induction
  • Antibiotics should be given at the same time: Cefuroxime 20mg/kg IV
    If the child has an allergy to cefuroxime, the renal team will individualise the protocol. Vancomycin would be the usual substitute in this scenario.

Reperfusion

Anaesthetist will be informed prior to the release of vascular clamps to ensure the following are administered to prepare for reperfusion of donor kidney:

  • Fluid bolus or transfusion to raise CVP > 8cmH2O
  • Mannitol 1g/kg
  • Frusemide 2mg/kg

Persistent hypotension in face of adequate CVP may require inotropic support until adequate urine output is achieved.

Perfusion pressure will be determined by the adult allograft. Generally a systolic BP > 100 is acceptable. The exception would be for organs that were retrieved from hypertensive deceased donor which may require a higher perfusion pressure. Ideally the perfusion pressure should be within the autoregulatory range of the donor.

Post-operative

  • Intravenous infusion of morphine, PCA or epidural infusion of local anaesthesia would be used to provide postoperative analgesia.
  • Substitution with intravenous fentanyl is advised if there are concerns regarding perfusion of the transplanted kidney, such as kidneys from deceased donor. Generally with the living donor kidney there are no concerns regarding immediate function. Delayed graft function is common with deceased donor kidneys.
  • Patient will be transferred to PICU/HDU from theatre.

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Document Control

  • Date last published: 01 March 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Anaesthesia, Paediatric Nephrology
  • Author(s): Peggy Yip
  • Editor: Michael Tan
  • Review frequency: 2 years

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