Peri-Operative Nursing Management of a Patient Undergoing a Cadaver Kidney Transplant - Literature review Example

Peri-operative nursing management of a patient undergoing a cadaver kidney transplant Name Institution Course Tutor Date Kidney transplantation is the preferred treatment method in renal replacement therapy (Baker, 2011). The kidney is got from a living donor or a deceased donor. Complications that may arise due to kidney transplantation include renal vain thrombosis, lymphocoele, renal artery thrombosis, ureteric obstruction, renal artery stenosis and ureteric leakage (Raftery and Delbridge, 2007). Renal transplantation is meant to reinstate quality of life as well as increase longevity for patients with end-stage renal failure (ESRF). After kidney transplantation, the expected graft survival at one year is 90% and 80% at five years (Raftery and Delbridge, 2007). However, the deterioration of graft function after the first year continues to be a problem due to decline in the quality of cadaveric donor, since most donors older with higher co-morbidity (Baker, 2011). An endeavor to preoperatively optimize disease status to reduce co-morbidity is the initial goal in cadaver kidney transplantation. Although deceased donor recipient transplants continue with urgency, it should not proceed if signs of concern are revealed in the immediate perioperative physical and history (Klein, 2011). This paper discusses perioperative nursing management issues related to cadaver kidney transplantation. Research indicates that mortality and morbidity in dialysis patients is majorly caused by cardiovascular disease, which accounts for more than 50% of deaths in such patient population. This is highly attributed to increased risk factors associated particularly with ESRF like hypertension, electrolyte abnormalities, anemia, and volume overload (Klein, 2011). Therefore, careful preoperative assessment to determine cardiovascular fitness is necessary in the transplant patient. In this case, it is appropriate for a nurse to initiate or continue to use perioperative beta blockage if a patient is identified to be exposed to high cardiovascular risk (Paramesh, 2013). Generally, diabetic patients are exposed to high risk for a cardiac problem as a result of increased prevalence of ischemic heart diseases. As a result, serial functional cardiac studies have to be initiated to make the patient with ESRF ready to receive a kidney from living or deceased donor (Baker, 2011). According to Dosch (2003) a registered nurse, through the nursing process, coordinates, and designs has the duty to meet the needs of patients whose protective impulses are potentially compromised due to influence of anesthesia during an invasive procedure like kidney transplantation. This implies that in order to effectively carry out a transplant, a nurse must understand the patient’s history and physical assessment, lab tests, pathophysiology and the nature of the kidney transplantation. It is also important to understand how the patient is likely to respond to stress, the associated risks as well as complications related to the surgical procedure (Heller and Hattoum, 2012). Klein (2011) observes that it is necessary to identify perioperative need for dialysis and a patient with hyperkalemia will be best dialyzed prior to kidney transplant so as to evade immediate post-transplant dialysis. In addition, finest ultra filtration is required. Usually, a nurse should tailor the dialysis prescription to avoid chances of hypotension and volume depletion (Shilliday and Sherif, 2005). The patient to undergo kidney transplant, and is on peritoneal dialysis should be exposed to peritoneum drainage in the best way possible prior to operation. Further, all operative team members have to recognize the presence as well as location of arteriovenous fistulae. This is because grafts may be compromised by unintended positioning of constrictive restraints (O’Hara Jr and Irefin, 2011). O’Hara Jr and Irefin (2011) argue that successful kidney transplantation in a patient is normally based on effective perioperative management of the donor, stabilizing recipient physiology, and limiting allograft ischemia. However, O’Hara Jr and Irefin (2011) note that the choice of invasive monitoring techniques, anesthetic, fluid management, renal preservation therapies, and inhalation agents can affect allograft as well as recipient outcomes. As indicated earlier, kidney may be obtained from the deceased or living, and they should be managed well before a transplant is performed. In case of a deceased donor anesthetic management commences in the critical care environment and is meant to maintain maximum urine output and organ perfusion in case the potential donor is considered brain dead (Baker, 2011). Management has to be continued during transportation up to the operating room where the organ is harvested. During the anesthesia management when preparations are being made to harvest the organ, it is necessary to maintain enough blood pressure and intravascular volume. Vasopressors like dobutamine, isoproterenol, low-dose dopamine or dopamine may be administered to reduce the possibility of acute rejection, but in stead improve graft survival upon completion of transplantation (O’Hara Jr and Irefin, 2011). Research also indicates that continuous infusion of nor-epinephrine in the deceased donor reduces the need for dialysis after making allograft transplantation (SarinKapoor et al, 2007). Heparinization and cooling has to be timed in management of the deceased donor to improve allograft outcomes (O’Hara Jr and Irefin, 2011). Generally, donor management requires nurses to address fluid management, haemodynamic instability, hypothermia, ventilation, diabetes insipidus, and hormone levels (Raftery and Delbridge, 2007). Donations after cardiac death require the nursing care team to manage the patients until they are taken in the surgical room. However, this is not involved in the kidney recovery process. The organ is harvested for the patient only after being declared dead through confirmation of asystole (O’Hara Jr and Irefin, 2011). Nursing management in living donor patient is approached differently and such a person has to be healthy. General anesthesia in such patient is prepared with large-bore intravenous access in lap-aroscopic as well as open approach just in case unexpected blood loss occurs (O’Hara Jr and Irefin, 2011). Irrespective of the surgical technique, the main reason for the care is to promote renal perfusion by induction of moderate hypervolemic state. Mannitol should be routinely administered to the patient before the time for allograft ischemia begins so as to give a renal preservation therapy (Kdigo, 2009). It is important to explain the risk of kidney transplant to the patient and needs to be instituted in the preoperative planning. This forms part of informed consent process. The patient should be fully aware of the planned kidney transplantation process, and any form of coercion towards the patient should be avoided (Larijani et al, 2004). Since a living donor is a patient exposed to risk of surgery and anesthesia for the benefit of another person, the health professionals should inform the donor of the occurrence of significant morbidity like bowel obstruction, hernia, or hemorrhage. In deed morbidity rate has been reported to be close to 1.6% (O’Hara Jr and Irefin, 2011). Another significant concern arises when a high-risk recipient takes part in the living donor kidney transplant. In such circumstances, the donor is supposed to understand the possibility of allograft dysfunction as well as recipient exposure to risk of death, especially if the patient has advanced cardiopulmonary diseases (O’Hara Jr and Irefin, 2011). There is need to optimize the recipient’s dialysis coordination, comorbidity, and an appreciation of dynamic effects in preparation of the patient for anesthesia and surgical operation. This is basically important in the setting of planned living donor kidney transplantation (Klein, 2011). In such setting, Durrbach et al, (2010) argues that renal transplantation is considered an elective surgical procedure. Although there is need for urgency for allograft in transplantation in deceased donor as far as increase in cold ischemia in concerned, this should not actually prelude nursing management steps so as to optimize a recipient for the organ (O’Hara Jr and Irefin, 2011). Although, regional anesthesia is depicted as an anesthetic technique applied in renal transplantation, general anesthesia remains the main choice. In many cases, intraarterial catheter and central venous catheters are used in patients undergoing a cadaver kidney transplant (Klein, 2011). In particular, central venous pressure monitoring equipment as used as a guide to enhance adequate intravascular volume, acquire laboratory values, administer pharmacological therapies, and sustain postoperative intravenous access (O’Hara Jr and Irefin, 2011). A new regional technique is a transverse abdominis plane method that uses catheter infusion of local anesthetics. Perioperative nursing management in kidney transplant also involves optimizing cardiac output when reestablishing kidney allograft perfusion. This is achieved through relevant kidney preservation therapies such as perioperative fluid management and pharmacological therapies which help to facilitate successful kidney transplantation in patients (O’Hara Jr and Irefin, 2011). Perioperative fluid management is significant in kidney transplant (Raftery and Delbridge, 2007). In this case, a crystalloid and colloid solutions are used in the initial stages of volume replacement therapy in kidney transplantation (Klein, 2011). Either a balanced crystalloid solution or saline-based fluids may be used, but the former is preferred since it does not cause high acid-base disturbances usually observed as a result of high chloride load. In addition, potassium with solutions should always be used cautiously or even avoided on a patient undergoing kidney transplantation since it exposes the patient to the risk of hyperkalemia (O’Hara Jr and Irefin, 2011). The surgical team may consider using expanding volume by use of human albumin since research indicates that it helps improve both the short-term and long-term outcomes in kidney transplantation (Schnuelle and Johannes, 2006). However, they observed that there are no controlled studies to investigate only the effects associated with albumin therapy in this particular clinical setting. On the other hand, O’Hara Jr and Irefin (2011) assert that synthetic colloid administration should be cautiously used in preoperative fluid management since it is revealed to cause kidney dysfunction in particular clinical settings. Several studies have been conducted to determine the effect of dopamine agonists, diuretics, and calcium channel blockers in facilitating allograft function in kidney transplantation (Klein, 2011). Mannitol is highly recognized in pharmacological therapies and can be used as well as administered to the patients before allograft reperfusion. When administered in doses up to 50g, Mannitol leads to decreased possibility of delayed graft function as well as reduced necessity for immediate postoperative dialysis (O’Hara Jr and Irefin, 2011). Early kidney transplant clinical studies by use of dopamine therapy since 1980s have had conflicting results. It has been confirmed that use of dopamine is not associated with benefit of direct kidney preservation. In addition, calcium channel blockers are believed to improve kidney transplant results by direct afferent arteriole dilation as well as elevated cyclosporine A levels (Schnuelle and Johannes, 2006). According to O’Hara Jr and Irefin (2011) improved clinical outcomes in kidney transplant was reported upon direct injection of 10mg of calcium channel blockers through the kidney artery accompanied by a fourteen day dosing schedule. Further review of calcium channel blocker research in kidney recipient patients, revealed that there was a decrease in incidence of delayed functioning of the graft with no long-term allograft gain (Klein, 2011). Calcium channel blockers in this clinical setting should not be treated as a therapeutic intervention, but should be considered as part of a multimodal hypertensive contingent in ESRF patients before renal transplantation (O’Hara Jr and Irefin, 2011). Thus, in addition to preoperative fluid management and possible pharmacological therapies, the patient undergoing kidney transplant has to be evaluated while in the recovery room to ascertain if there is surgical bleeding, oxygenation, consciousness, volume status, and metabolic stability. In conclusion, cadaver kidney transplantation is the clinical treatment of choice for ESRF patients when successful and is considered cost effective unlike dialysis. Effective nursing management, donor and anesthetic management, allograft ischemic times, and surgical techniques determine kidney transplantation outcome for patients. It is evidence that preoperative assessment by use of perioperative beta blockage for a patient undergoing kidney transplant is important to determine cardiovascular fitness in the transplant patient. It is also important for nursing professionals to understand the patient’s history and physical assessment, lab tests, pathophysiology and the nature of the kidney transplantation to enhance positive patient outcome. Both the deceased and living donor kidney transplant should be effectively managed since they put their lives in danger in the benefit of the recipient. Most important, nursing management must seek a patient consent prior to kidney transplantation. Generally, it can be argued that successful cadaver kidney transplantation is based on minimized allograft ischemia, stabilized recipient physiology, and most significantly perioperative nursing management. References Baker, R. J 2011 “Renal transplantation”, Medicine, 39(8), pp.448-455. Dosch, M. P 2003 “Nursing management of the perioperative patient”, AANA journal. Durrbach A, Francois H, Beaudreuil S, Jacquet A, Charpentier B 2010 “Advances in immunosuppression for renal transplantation”, Nat Rev Nephrol; 6: 160e7. Heller, M. T., & Hattoum, A 2012 “Kidney–pancreas transplantation”, Emergency radiology, 19(6), pp.527-533. Kdigo 2009 “Clinical practice guideline for the care of kidney transplant recipients: Am J Transplant, Nov; 9(suppl 3): S1e155. Klein, E. A 2011 “Current Clinical Urology: Kidney and Pancreas Transplantation”, A Practical Guide, Springer New York Dordrecht Heidelberg London. 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