Kidney transplants

[urge]

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Do your surgeons make a big deal out of them?

Where I did my residency they were a big deal. You need an a-line, couple of IV's, CVP, Dopamine, bp 160's systolic when un-clamped, and ICU stay. At my current place the surgeons don't really care about much. Just give some lasix, mannitol, and steroids when I ask you. No a-line, cvp, dopamine, BP requirements, or ICU stay.

I find the whole thing funny.

How is it at your place?

 

[Arch Guillotti]

Pretty much the way you described your experience in residency. The whole 9 yards.

 

[Fastrach]

They're no big deal at my crib either. Guess it just comes down to comfort level with them on everyone's part. We do a ton of them, in fact, I know I've done at least twice as many kidneys as I have appy's as a resident. New attendings are indeed surprised when I tell them our standard is a tube, 2 big IV's (no a-line or CVP), basiliximab, steroids, lasix, mannitol, and maybe some dopamine if needed to keep MAP's over 70.

 

[Bertelman]

Ditto, Fastrach. No special lines, just the second IV for the basiliximab

 

[seinfeld]

standard case, did more than lap choles. 1 big IV, one other, no aline unless comorbities dictate it. Only thing is deep paralysis until starting of closure as no one wants a kidney on the floor from bucking.

 

[KungPOWChicken]

Avoid a-line. Transplant surgeons flip out at possibly damaging a future fistula site.

 

[Noyac]

Avoid a-line. Transplant surgeons flip out at possibly damaging a future fistula site.

Thats a crock of **** on the surgeons part.

 

[OB1🤙]

For those out there doing these with CVP monitoring (which is required here, a-line is optional), what are your targets?

Our surgeons demand CVP 15 or greater, which I have (shamefully) never looked at the data on, though I always assumed was based on less than granite-solid research.

CVP 15? All is well, everyone's happy.

CVP 14? "ZOMG DOPAMINE NOWNOWNOW YOU SUCK AT ANESTHESIA."

A little tweakage of the transducer height I find fixes this situation better than an arrhythmogenic pressor, but that's just me. Unless the kidney looks or feels suboptimally perfused, then I'm happy to throw on the dop.

 

[Arch Guillotti]

For those out there doing these with CVP monitoring (which is required here, a-line is optional), what are your targets?

Our surgeons demand CVP 15 or greater, which I have (shamefully) never looked at the data on, though I always assumed was based on less than granite-solid research.

CVP 15? All is well, everyone's happy.

CVP 14? "ZOMG DOPAMINE NOWNOWNOW YOU SUCK AT ANESTHESIA."

A little tweakage of the transducer height I find fixes this situation better than an arrhythmogenic pressor, but that's just me. Unless the kidney looks or feels suboptimally perfused, then I'm happy to throw on the dop.

As I am sure you know relying on a single standard number for a CVP target is kind of dumb. But if I had to pick a number I would say 10, MAYBE 12.

 

[Bertelman]

standard case, did more than lap choles. 1 big IV, one other, no aline unless comorbities dictate it. Only thing is deep paralysis until starting of closure as no one wants a kidney on the floor from bucking.

I bet that rumor persists at every hospital doing kidney transplants.

"So-and-So said back when he was a CA-1, one of the seniors told him about a guy that did one of these, let the patient get to light, and the transplant kidney shot out onto the floor. He was sent straight to the PD's office, they drew blood, matched his HLA, and he had to give one of his kidneys to finish residency. Shitty thing was, once his donor operation was over, they woke him up, then took him straight back to the recipient's room, made him finish the damn case the RIGHT way, with adequate paralysis.

The transplant surgeon never talked to him again".

 

[Bertelman]

cvp 14? "zomg dopamine nownownow you suck at anesthesia."

lmfao

 

[huktonfonix]

For those out there doing these with CVP monitoring (which is required here, a-line is optional), what are your targets?

Our surgeons demand CVP 15 or greater, which I have (shamefully) never looked at the data on, though I always assumed was based on less than granite-solid research.

CVP 15? All is well, everyone's happy.

CVP 14? "ZOMG DOPAMINE NOWNOWNOW YOU SUCK AT ANESTHESIA."

A little tweakage of the transducer height I find fixes this situation better than an arrhythmogenic pressor, but that's just me. Unless the kidney looks or feels suboptimally perfused, then I'm happy to throw on the dop.

That always annoyed me. glad to see the junior residents are still following my bad habit of adjusting the transducer. I stopped arguing after a while.. "you know her starting BP was 90 over 60, right? It may not be really, you know, realistic to ask for 130/80......"

 

[proman]

Everyone gets an aline. Everyone goes to IMC for urine measurement. Almost all get central lines. I don't transduce CVP so no one sees it. A ton are done by CRNAs. I kind of like the transplants.

 

[huktonfonix]

must be an institutional thing. I never saw the point of an aline. Most of these patients are otherwise pretty stable in order to make it to the transplant. Not much in the way of fluid shifts. Very rare for major hemodynamic instability to occur. Nothing that I cant figure out with a blood pressure cuff.

 

[ZA_Gasman]

We don't put in a-lines unless significant cardiac comorbidity. The whole CVP issue grates me though. Surely, pushing the CVP is going to decrease venous return and cause congestion of the kidney? (assuming VR is equal to mean systemic venous pressure less CVP) I worry more about arterial pressure. I don't use dopamine - i think it is a Sh**ty inotrope, and I can't see the benefit.

I may have been guilty of adjusting tranducer height. But, I'll never admit to it.

 

[Green912]

CA1 here. Of the five or six kidney transplants I've done I think only one had an A-line due to co-morbidity. Our charting is computerized and in the script it specifically prompts you to ensure full relaxation prior to the donor organ coming out of ice. Apparently someone bucked years ago and the kidney plopped onto the floor. Probably an urban legend but wouldn't the three second rule apply?