Simulect vs Campath vs thymo induction
Started by coffeebythelake
Only ever done thymo and always at direction of surgeon. Always do cvc
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Do you put in a central line for thymo?? I’ve always given it through a dedicated peripheral IV with a filter
With central line you can run it faster….. 2x. Had a few patients couldn’t get central access. Transplant service was okay running thymo longer.
We do at least 1 kidney tx nearly every day and almost never place CVL's in anymore. Two good IV's. We run thymo over 6 hours and never have had an issue running it peripherally. We document the start time in the anesthesia EMR and relay this to the transplant ICU nurse who then finished whatever is left (usually 3-4 hours).
Do you still do a-lines? What's the thought du jour regarding fluids and pressors? Voodoo like mannitol and lasix?
It's been a few years since I've done kidneys so just wondering what busy centers are doing nowadays
We don't do a-lines for ours. Generally give a generous dose of fluids (~8-10cc/kg/hr) and we do Lasix and mannitol. They don't get too chuffed about using running a neo gtt during the anesthetic if necessary.
We weren't placing many CVLs for these historically but the transplant surgeons have started to ask for us to - they're often quite difficult to get reliable access on for the floor.
We do thymo or basiliximab (Simulect) - I'm not sure what makes the decision, I just give whatever transplant nephrology tells me to.
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We don't usually do arterial lines but I have a feeling that's about to change. We just had to reintubate for fluid overload in the OR a few minutes after extubation so we are going to want to use some kind of goal directed fluid management. Probably PPV/SVV on an arterial line instead of CVP on a central line but it's probably going to be one or the other. We do give mannitol and lasix, typically 2-4 liters of crystalloid, and avoid pressors.
Arterial line only if indicated due to patient comorbidities.
Used to do CVL for all patients. There were a couple central line complications and surgeons were impatient and asked us to stop doing CVLs so we switched to ALWAYS doing peripheral thymo (unless peripheral access found to be nearly impossible) for a while. We had new complications of patients with very difficult IV access on the floor or returning to the OR for some issue and having failed IVs, which has swung the pendulum back to doing CVL for most patients. Hilarious to observe.
One would think we could just use good judgement and do a central line when appropriate. 🤯
Thymo is the only drug I've used here for our kidneys. We administer whatever the surgical team requests. Basiliximab during most heart or lung transplants.
Used to do CVL for all patients. There were a couple central line complications and surgeons were impatient and asked us to stop doing CVLs so we switched to ALWAYS doing peripheral thymo (unless peripheral access found to be nearly impossible) for a while. We had new complications of patients with very difficult IV access on the floor or returning to the OR for some issue and having failed IVs, which has swung the pendulum back to doing CVL for most patients. Hilarious to observe.
One would think we could just use good judgement and do a central line when appropriate. 🤯
Thymo is the only drug I've used here for our kidneys. We administer whatever the surgical team requests. Basiliximab during most heart or lung transplants.
we do art lines for 99% of our kidney transplants,
we do cvc occasionally, usually for CVP monitor postop on floor or patients with poor peripheral access
we do cvc occasionally, usually for CVP monitor postop on floor or patients with poor peripheral access
The last place I worked that did kidneys, 100% got art lines and central lines. It's just their protocol. Not a hill worth dying on. And the residents need the reps, so ...
Training - no a-line. Preop cvp, for most. No CVP monitoring. If unable to get a central line, surgical team either forgo it or once in a while will do a cut down. We had many kidneys, it runs like clock work.
Very different now. A kidney a week at most. Team is very conservative.
Very different now. A kidney a week at most. Team is very conservative.
No art line but everyone gets a central line? That seems odd
Everyone got an a line and almost no one got a cvl unless tough access. Our transplant surgeons were worried about hypotension causing ischemia to the kidneys. 2-3 L during the case. They want to make sure the kidney stays perfusing but we try to avoid fluid overload as outlined above.
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If only there were some way to diagnose hypotension without an art line….
Most esrd pts aren't that healthy, so you could make a strong argument for one just based on comorbid conditions. Add anal surgeon who freak out about hypotension, possible swings in BP, unclear volume status, electrolyte or acid base disturbances, I think art line has more utility than a central line for jntraop management
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This is what we do as well
So you never place an a line is that what you're saying?
No a-line unless cardiac issues.
Protocol is thymo via central line or have to request pharmacy to reconstitute with heparin to give peripherally. Apparently clotting risk peripherally.
Tylenol/cellcept/benadryl/solumedrol/lasix/mannitol
Couple liters of LR in before they unclamp.
Used to use nimbex but now roc since sugammedex. Although been a few cases or recurarization.
Secret pressors so surgeon doesn’t have a stroke.
Protocol is thymo via central line or have to request pharmacy to reconstitute with heparin to give peripherally. Apparently clotting risk peripherally.
Tylenol/cellcept/benadryl/solumedrol/lasix/mannitol
Couple liters of LR in before they unclamp.
Used to use nimbex but now roc since sugammedex. Although been a few cases or recurarization.
Secret pressors so surgeon doesn’t have a stroke.
My Shop still believes NS0.9% is better for these patients because ESRD. Oh well
They like acidotic hypernatremic hyperkalemic patients?
I guess they didn't get the memo
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I’m hoping to one day imbue in surgeons the understanding that pressors improve renal blood flow. Hell might freeze over first
Plastic surgeons are coming around very nicely. Weird because they do general surgery so they should know that excessive fluids is bad for patients
Our Vascular surgeons are very keen to avoid a-lines in any renal patients. They view it as a protective strategy for patients that may end up needing fistula formation for dialysis down the line.
We do CVCs and no a-lines as routine. CVC for both CVP and drugs... but I'm not really sure how strong the evidence is for either of those... Renal write up anti-thymocyte globulin if they want it and if it's not in by the time they get down, then we give it via the CVC, but there's no mandate it has to be given centrally.
What is the statistical risk for significant injury to radial artery from art line (i think the stats are like 1 in 10,000), vs injury to vein (stenosis, clot, etc) from central line.? I imagine both such things can be a problem down the line.
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I honestly don't know 😄
Surgeons at my place believe heavily in dopamine…
Oh god..
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Say what???
There’s been 3-4 suspected cases since roc/suga switch. Oddly all are after renal tx cases.
Hasn’t happened to me personally and obviously no way to know for sure if that was the issue.
When reviewing cases the common theme was high total dose of roc for the case. One case in particular they gave like 400mg of roc over just 3-4 hours. Surgeons always ask for more paralysis and I guess some people actually listen.
One of our surgeons: "why can't you give more roc? What's the problem??? I need more paralysis!"
When such massive dosea of roc are given... makea you wonder if they even checked twitches.
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You’ve seen recurarization in these patients? I’m told it can happen, just haven’t seen it yet. We’re they appropriately dosed w/ sugammedex?
D
deleted87051
Does recurarization mean the kidney ain’t working?
Art line is 3 units, CVL is 4 units. Guess who is doing art line and CVL, cha ching 🤣
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I find that really hard to believe. Maybe the surgeons should work faster to suture it in?
Edit: probably not an appropriate location to discuss.
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D
deleted87051
Pretty much.
I am really surprised at this. I was under the impression that even though the black box on sugammadex says not to use with CrCl<30 that recurarization wasn't really a thing. I'm struggling to figure it out mechanistically - sug essentially "chelates" (I realize this is probably the wrong term) the roc molecule, right? What happens to then release the roc back into circulation?
We had a cough that tore the anastomosis to the iliac vein a while back, so we're pretty similar.
My guess was maybe they didn't check twitches and just gave 200mg without a 2nd thought. So rather than recurarization, it was inadequate reversal to begin with (especially giving 400mg rocuronium).
Hahahah.
While at it, should float the swan too.
For whatever reasons, we didn’t. Either just not worth the time/work. Or maybe the patient/hospital receive only 1 lump sum fee? Or like other posters have said, we didn’t want to damage any vessels any further?
There are a few attending, couldn’t careless for the cvl either.
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Never understood this. We give roc to cirrhotic liver failure patients without batting an eye but get nervous giving it to a patient that has maybe impaired clearance of the minor pathway for elimination.
