CHAPTER 64: Critical Care Considerations in the Management of Renal Transplant Patients

INTRODUCTION

The purpose of this section is to review the management of adult renal transplant patients, which may warrant critical care intervention. The physicians caring for this complex patient population ideally should have experience and training in¹:

• Transplant and routine intensive care unit (ICU) skills and algorithms

• Managing the complexity of end organ failure

• Complex surgical procedures used in transplantation

• Immunosuppressive medications and their complications

This chapter will place special emphasis on:

1. Immediate postanesthesia care unit (PACU) postoperative considerations

2. Immediate ICU postoperative considerations

3. Late ICU postoperative considerations

POSTOPERATIVE PERIOD

Following transplantation, the immediate care is typically rendered in the PACU, with emphasis on optimizing respiratory and hemodynamic performance

• Goals

  • Expedite the transfer of the patient to a specialized renal transplant unit (typically geographically aggregated medical-surgery floor beds)

  • Continuation of induction immunosuppression (IS)

  • Renal replacement therapy when required

  • Observation for potential infections, urinary obstruction, vascular complications of the graft

Immediate PACU Postoperative Considerations

Major limiting factors for a timely transfer to the specialty renal transplant unit include:

• Persistent respiratory compromise

• Respiratory alkalosis/acidosis

• Hemodynamic Instability

• Cardiovascular problems

• Severe hypertension

• Uncontrolled hyperglycemia (including diabetic ketoacidosis [DKA])

• Transfusion-related complications, including transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO)

• Cytokine release syndrome associated with the use of rabbit anti thymocyte globulin (rATG/Thymoglobulin)

• Graft mechanical complications producing inflow or outflow vascular obstruction as a result of torsion/kinking and/or thrombosis

Persistent respiratory compromise

• Delayed metabolism of anesthetics and sedatives in these patients with renal insufficiency may result in prolonged respiratory and cognitive depression

• Body habitus, preexisting cardiac and medical conditions may complicate extubation

• Despite these factors, most patients under careful observation are discharged from the PACU without major ventilatory support within a few hours

• Persistent hypoxemia with Ventimask, signs of airway obstruction, significant respiratory acidosis, and neurologic depression may require longer PACU admission or consideration for transfer to a critical care unit, usually a surgical or dedicated transplant ICU

• Management: Noninvasive positive pressure ventilation in extubated patients may be required before transition to supplemental oxygen by either mask or nasal cannula. Patients with preexisting chronic obstructive pulmonary disease (COPD) will benefit the most with this intervention

• The decision to transfer the patient to the critical care unit should be made collaboratively by the transplant, PACU, and surgical intensive care unit (SICU) teams, ideally to a dedicated transplant SICU

Certain conditions, if persistent, may warrant further management in the critical care unit

• Respiratory alkalosis

  • Causes

    • Usually results from pain and discomfort and rarely from significant hemorrhage

    • If associated with a widened A-a gradient, could indicate volume overload, TACO, aspiration, and pneumonia and infrequently systemic infection, pulmonary embolus, or acute coronary syndromes

  • Management: Careful monitoring of standard clinical parameters: O₂ saturation, ...