KEY POINTS
Solid Organ Transplantation

1. Solid organ transplantation is an accepted treatment of end-stage organ disease.
2. The discrepancy between organ donors and organ recipients is increasing.
3. To increase the donor pool, living organ donors and marginal cadaveric donors are being used.
4. Preoperative evaluation of organ systems should consider interval changes.

1. Patients with ESRD are subject to accelerated atherosclerosis and should be considered to have a significant perioperative cardiac risk.
2. Maintenance of adequate perfusion pressure to the newly transplanted kidney is crucial for initial graft function.
3. Anesthetic drugs that are dependent on renal excretion, especially muscle relaxants or their metabolites, should be avoided.

1. Patients may undergo pancreas transplantation alone, in combination with kidney transplantation, or after kidney transplantation.
2. Close glucose monitoring is required throughout the procedure.
3. Administration of colloids is preferred intraoperatively.
4. The immunosuppressive drug OKT3 can cause significant hemodynamic instability and noncardiogenic pulmonary edema.

1. The model of end-stage liver disease (MELD) calculates the severity of liver disease.
2. Preparation for massive transfusion and significant hemodynamic instability is essential.
3. Extubation in the operating room can be safely performed in select patients.

1. Loss of sympathetic tone may be poorly tolerated, regardless of the anesthetics used—consider preinduction initiation of inotropic support or even extracorporeal circulation if warranted.
2. Separation from cardiopulmonary bypass is frequently uneventful but may be complicated by bradycardia, conduction block, acute right heart failure, or ischemia-related ventricular dysfunction.
3. Minimize the potential for acute right ventricular failure by optimization of pulmonary vascular resistance, provision of appropriate inotropic support, and if unavoidable, placement of a right ventricular assist device.
4. Consider intraoperative transesophageal echocardiography as a useful monitor for evaluation of intracardiac air, anastomotic problems, and postbypass right and left ventricular function.

1. Knowledge of the underlying pulmonary pathophysiology (i.e., restrictive, obstructive, and/or infectious) is essential to anticipate the best possible ventilation strategy.
2. Discuss with the surgeon whether cardiopulmonary bypass will be used for all, part, or none of the transplantation.
3. One-lung ventilation may be very challenging—minimize pulmonary vascular resistance, optimize ventilator settings, and consider inotropic support of the right ventricle.