DDKT fluids?

[waterbottle10]

What are your styles for managing these type of cases in terms of fluids? Our surgeons here think pressors will absolutely kill the transplanted kidney and thus want FLUIDS! Most of our patients end up getting 5-6L by the end of the case (obviously we still do pressors if needed) which usually lasts around 4 hours on average. I am curious as to what other anesthesiologists around the country do? It seems like the management is fine if the kidney works right away, but can run into problems if the kidney does not, as you are left with close to a ESRD patient with 5+ more liters of fluid.

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[coffeebythelake]

What are your styles for managing these type of cases in terms of fluids? Our surgeons here think pressors will absolutely kill the transplanted kidney and thus want FLUIDS! Most of our patients end up getting 5-6L by the end of the case (obviously we still do pressors if needed) which usually lasts around 4 hours on average. I am curious as to what other anesthesiologists around the country do? It seems like the management is fine if the kidney works right away, but can run into problems if the kidney does not, as you are left with close to a ESRD patient with 5+ more liters of fluid.

give around 3-4 liters crystalloid (LR or plasmalyte) for a standard kidney transplant case, but cardiac comorbidity and fluid status may alter this
we run phenylephrine if needed. never had surgeon complain about this. it is what it is. hypotension is worse than giving the pressor. fluid overload has negative effects on BP too.....
no opioids during meat of case and 0.7 MAC (or lower) gas to prevent hypotension
muscle relaxed throughout
bis monitor if running pt light

 

[IMGASMD]

What are your styles for managing these type of cases in terms of fluids? Our surgeons here think pressors will absolutely kill the transplanted kidney and thus want FLUIDS! Most of our patients end up getting 5-6L by the end of the case (obviously we still do pressors if needed) which usually lasts around 4 hours on average. I am curious as to what other anesthesiologists around the country do? It seems like the management is fine if the kidney works right away, but can run into problems if the kidney does not, as you are left with close to a ESRD patient with 5+ more liters of fluid.

I’ve never personally given more than 3L. We give Neo if the BP needs some support. There is one surgeon in particular who would ask if we are giving anything. Just happens that person is the newest addition to the transplant team. Rest of our surgeons know better and *gasp* actually trust and expect the Anesthesiologists actually know what they’re doing.

 

[deleted875186]

Anyone know of any actual evidence that low dose press or during kidney transplant is actually harmful?

 

[dannyboy1]

Standard kidney usually gets around 3 liters. Run a straightforward general anesthetic. Our surgeons don’t care about pressors. If they did I would continue my usual routine and add a small dose of lies...

 

[anbuitachi]

Standard kidney usually gets around 3 liters. Run a straightforward general anesthetic. Our surgeons don’t care about pressors. If they did I would continue my usual routine and add a small dose of lies...

you lie to teh SURGEON? outrageous

 

[leviathan]

Renal perfusion pressure is also dependent upon the venous pressures, CVP, etc. Drowning someone in fluid and causing an effective renal compartment syndrome is worse for perfusion than correcting vasoplegia with a vasopressor.

 

[Psai]

We also give around 3L, they rarely need pressors. In any case they have a new kidney that can handle the fluid now amirite 😛

 

[Ronin786]

Renal perfusion pressure is also dependent upon the venous pressures, CVP, etc. Drowning someone in fluid and causing an effective renal compartment syndrome is worse for perfusion than correcting vasoplegia with a vasopressor.

Bingo. Then just add on the insult of "kidney failure = 0.9% NS", where studies comparing NS to LR/PL have consistently shown an increased incidence of renal failure. Good combination.

 

[IMGASMD]

Bingo. Then just add on the insult of "kidney failure = 0.9% NS", where studies comparing NS to LR/PL have consistently shown an increased incidence of renal failure. Good combination.

But but but.... a whole bag of LR has 10 meq of K?!!!!! You’ll make my patient hyperkalemic!!!!!!!!

Instead of 4.0, now they are 4.3!!!!!!!

 

[Ronin786]

But but but.... a whole bag of LR has 10 meq of K?!!!!! You’ll make my patient hyperkalemic!!!!!!!!

Instead of 4.0, now they are 4.3!!!!!!!

I know you're only joking, but LR has a concentration of 4 meq/L and consistently lowers serum potassium when compared with NS. It is impossible for LR to cause hyperkalemia greater than 4.0 meq/L even with huge volumes of administration, mainly due to the vast volume of distribution of potassium.

Great review found here:
Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS.

 

[IMGASMD]

Thanks. I’ve always known it’s negligible K difference. Our surgeons always demanded NS. The last point in the article with the Randomized Trial ended early, make me feel that we should do a Journal Club about the issue.

 

[anbuitachi]

Thanks. I’ve always known it’s negligible K difference. Our surgeons always demanded NS. The last point in the article with the Randomized Trial ended early, make me feel that we should do a Journal Club about the issue.

it doesn't matter if you do journal club on the issue. the surgeon will still keep on demanding it