Early post-operative period
- Patients (including live donor recipients) often remain in recovery up to 2 hours after operation is completed. During this period a member of the transplant team must review them in theatre recovery.
- Surgical registrar contacts renal team on #6394 once patient in recovery to communicate intraoperative course / concerns and facilitate nephrology review.
- Post op review by surgical team (either in recovery or HDU) to consider fluid status, wound and drain output.
- Initial (e.g. first 2 hours) IV fluid replacement is Normal Saline at 60 mls/hr + last hour’s urine output. This should be guided by the CVP with a target of 8-10.
- Aim for CVP 8-10.
- Fluid regimen should take into consideration: amount of fluid given in theatre, total blood loss, native urine output, cardiac status of patient, age of patient (caution if >65), if DGF expected.
Guide to fluid replacement
Fluid replacement in polyuric patients - replacing urine
PLASMALYTE/SALINE ARE NOT SUITABLE REPLACEMENT FLUIDS FOR URINE
Remember that each litre of saline/plasmalyte contains 1.5 days worth maximum salt intake
First 6-8h alternating (1:1) electrolyte/5% glucose
Thereafter to 48h 2:1 Glucose: electrolyte solutions - but in review and reduce t 3:1 or 4:1. If a patient has failed to drink enough to keep up, the appropriate replacement fluid is usually 5% glucose.
Some patients lose more salt. This usually becomes apparent after a few days. Increasing dietary salt minimises the need for IV replacement.
If passing urine >40ml/hr:
- CVP <6 : PLASMALYTE 250MLS BOLUS + TOTAL OUTPUT +60mls/hr
- CVP 6-10: TOTAL OUTPUT +60mls/hr
- CVP >10: TOTAL OUTPUT +40mls/hr
Total output should include drain losses (especially important in SPK recipients)
(2) If expected immediate graft function and urine output <40mls/hr
- Ensure catheter not blocked. Member of surgical team should flush out catheter at this early stage.
- If requested by surgeons arrange Doppler ultrasound.
- Plasmaltye bolus 200mls to achieve CVP of 8-10.
- Consider IV NaCl at continuous rate of 100 mls/hr initially.
- Response must be carefully assessed (hourly initially) before continuing infusion at this rate and especially if remains oligoanuric.
NB: Any concerns should be discussed with transplant surgeon and renal team.
(3) If expected DGF
- CVP <6: PLASMALYTE 250MLS BOLUS + TOTAL OUTPUT +60mls/hr
- CVP 6-10: TOTAL OUTPUT +60mls/hr
- Careful monitoring of fluid status is required as higher risk of precipitating pulmonary oedema.
Failure of the patient to respond to IV Fluid with a rise in CVP or BP should raise possibility of bleeding. If there is a possibility of bleeding a transplant surgeon must be contacted.
Maintenance IV fluids:
Continuing IV fluid replacement should be maintained with alternating 5% Dextrose and Normal Saline. At least twice daily reviews should occur while patients require IV fluids. IV fluids may often be stopped by the second post-operative day.
- Check FBC and U&E's immediately post-op.
- Serum K+ must be know and result discussed with Registrar.
- Hyperkalaemia should be managed with Insulin/Dextrose and nebulised Salbutamol rather than haemodialysis when possible.
- Subsequent repeat U&Es 12 hourly (more frequently if indicated or as decided by Registrar).
Other aspects of early post-operative management:
- Arrange chest X-ray for position of central line (may be performed in recovery – ensure checked).
- Analgesia is by PCA morphine/Fentanyl. Inadequate pain relief may herald serious pathology and should be discussed with a senior surgical colleague/Anaesthetist. NSAIDs are absolutely avoided.