Anesthesia for Organ Transplantation

Milligan, Amanda; Nath, Andrew; Pace, Nick; Logan, Neil

Preoperative Assessment: Extensive preoperative assessment of the patient will have taken place by the transplant team, a multidisciplinary team dedicated to investigation and optimization of patients preoperatively. Each patient will also have predictable morbidity associated with their underlying pathological process, and for this reason they are cared for by specialist transplant teams. Extensive investigation is important in patients presenting for transplantation and where possible optimization of conditions such as anaemia can be made preoperatively. Heart Transplantation: Increasing numbers of patents are in-patients in critical care areas and are receiving inotrope infusions pre-operatively. Internationally, 43% of patients receive Mechanical Circulatory Support (MCS) at the time of transplant. The most commonly used method is Left Ventricular Assist Device (LVAD) support. The principles of anesthesia for other types of cardiac surgery apply and many different anesthetic agents and techniques have been used. The technique of choice varies according to individual transplant centers. There is no evidence that any one technique leads to a better outcome than any other. Lung Transplantation: Lung transplantation is, in fact, a group of operative procedures comprising single-lung transplant, bilateral sequential lung transplant, lobar transplant and en-block heart-lung transplantation. Primary graft dysfunction (PGD) is the commonest cause of post-operative mortality and occurs in 10–57% of patients. Its presentation is analogous to ARDS, and the principles of management are similar. Liver Transplantation: Liver transplantation is the sole definitive treatment for end-stage liver disease. There are many systemic changes associated with liver disease that make the management of patients with ESLD challenging peri-operatively. Cardiopulmonary events are the leading cause of non-graft related deaths in liver transplant. Renal Transplantation: Renal transplants are the treatment of choice for end stage renal failure (ESRF). The procedure is carried out in many centres and are predominantly cadaveric renal transplants. However, Live donor Transplants numbers are increasing. Patients receiving renal transplants show an almost immediate improvement in quality of life, morbidity, and mortality compared with dialysis. Patients are usually dialysed prior to theatre, causing hypovolemia which may be exaggerated by general anesthesia. Pancreatic Transplantation: Successful pancreatic transplant provides durable glycemic control and improves survival for patients with diabetes. Diabetic patients are more at risk of peri-operative complications including infection and poor wound healing. In the USA there has been a decline in pancreas transplants over the last decade. Postoperative Care: Postoperative care is vital to ensure the viability of the newly transplanted graft. Continued optimization of hemodynamic stability and oxygen delivery means the patient must be cared for in the appropriate environment, which usually mandates level 2 or 3 critical care depending on the level of organ support required. Conclusion: The anesthetic management of patients presenting for organ transplantation is challenging yet rewarding.