TRANSPLANT ANAESTHESIA

Dr. Dilip Wasnik

Principal Consultant
Department of Anaesthesia, Critical Care and Transplant Anaesthesia
Max Super Speciality Hospital, Nagpur

“Transplant anesthesia” refers to the specialized field of anesthesia focused on managing patients undergoing organ transplant surgery, requiring a deep understanding of the complex medical conditions of transplant recipients, careful monitoring of vital signs, and specific anesthetic techniques to optimize surgical outcomes and minimize complications during the procedure and post-operative period; this often involves close collaboration with the transplant team to address unique challenges related to the patient’s underlying disease and immunosuppressive medications. 

Organ transplantation has undergone remarkable revolution in the last two decades and offers a scope for survival amongst patients with end-stage organ failure. Along with availability of advanced surgical equipment and haemodynamic monitors, minimally invasive surgical techniques have emerged as options for surgery both amongst the donors and recipients. Newer trends in haemodynamic monitoring and expertise in ultrasound guided fascial plane blocks have changed the management in both donors and recipients. The availability of factor concentrates and point-of-care tests for coagulation have allowed optimal and restrictive fluid management of patients. Newer immunosuppressive agents are useful in minimizing rejection following transplantation.

Key points about transplant anesthesia:

• Complex patient population:
  Transplant recipients often have significant medical issues due to their underlying disease, requiring careful assessment and management of co-morbidities like heart failure, liver cirrhosis, or kidney dysfunction. 
• Preoperative evaluation:
  Thorough review of the patient’s medical history, including previous anesthesia experiences, bleeding disorders, and current immuno-suppressive medications is     crucial. 
• Airway management considerations:
  Due to potential anatomical variations, careful airway assessment and planning are essential to ensure smooth intubation. 
• Hemodynamic management:
  Maintaining stable hemodynamics is critical, especially during organ reperfusion, which can cause significant fluctuations in blood pressure. 
• Fluid management:
  Precise fluid management is necessary to prevent complications like organ edema or fluid overload. 
• Anesthetic drug selection:
  Consideration of drug interactions with immuno-suppressive medications, such as cyclosporine and tacrolimus, is vital when choosing anesthetic agents. 
• Monitoring techniques:
  Extensive monitoring including invasive blood pressure, central venous pressure, and sometimes trans-esophageal echo-cardiography is used to closely monitor the patient’s physiological status. 

Different types of transplant surgery with specific anesthetic considerations:

• Liver transplant:
  Managing coagulopathy, portal hypertension, and potential hemodynamic instability due to liver dysfunction. 
• Kidney transplant:
  Addressing electrolyte imbalances and optimizing renal function post-transplant. 
• Heart transplant:
  Careful management of cardiac function and potential arrhythmias during the procedure. 
• Lung transplant:
  Consideration of pulmonary mechanics and managing ventilation strategies to optimize graft function. 

Transplant surgeries are the finite treatment in the correction of end-stage organ diseases. Several advancements including robot-assisted laparoscopic surgery and newer improved immuno-suppressive agents have contributed to better graft function and patient outcomes. The extended criteria donor, marginal donors and ABO incompatible renal and liver transplantation have made it possible to narrow the gap between the organ donors and increasing number of patients awaiting transplant. The organs from marginal donors are at a higher risk of early allograft dysfunction which underlines the importance of optimising the peri-operative care of these patients. Goal-directed therapy is being increasingly utilised in transplantation and is also a part of the enhanced recovery after surgery (ERAS) guidelines.The benefits of protocolised fluid management are uncertain and will need validation in the future. The introduction of ultrasound-guided fascial plane blocks (FPBs) amongst recipients has eliminated or reduced the need for postoperative opioids. This has allowed fast tracking (FT) of surgeries and on-table extubation which, besides reducing costs, has allowed improved graft functions and shorter hospital stay.

The transplant anaesthesiologist needs to be aware of the recent innovations and practices in monitoring and to modify the conduct of anaesthesia to suit the expanding surgical profiles. Large randomised trials amongst the subset of Indian patients may provide clearer insights and guidelines for optimal patient management in the future.