ANESTHESIA CONSIDERATIONS FOR SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION AND POST-REPERFUSION SYNDROME: A CASE REPORT AND REVIEW OF THE LITERATURE

1
ANESTHESIA CONSIDERATIONS FOR SIMULTANEOUS
PANCREAS-KIDNEY TRANSPLANTATION AND
POST-REPERFUSION SYNDROME A CASE REPORT AND
REVIEW OF THE LITERATURE

• Christopher J. Patton, BSN
• Barnes-Jewish College

2
CASE STUDY
3
REPEAT SPKT

• 43-year-old, ASA 3, 47 kg female
• Underwent primary SPKT two years earlier
• Pancreatic graft failure due to severe
  pancreatitis
• Renal graft failure secondary to rejection
• History IDDM, ESRD, Anemia, GERD, HTN, HLD
• Anesthesia History Unremarkable
• Allergy Cephalexin (rash)

4
PREOPERATIVE ASSESSMENT

• Airway Mallampati III, TM distance 5 cm,
  normal cervical extension
• Hypertensive MAP 100 - 125 mm Hg
• ECG NSR with poor R-wave progression
• Negative nuclear stress test
• TTE Normal EF, mild LVH/LAE, trace MR/TR
• CXR Remarkable only for an in situ left
  subclavian HD catheter with its tip at the
  atriocaval junction

5
PREOPERATIVE ASSESSMENT

• Lungs CTA bilaterally
• Normal heart tones
• No carotid bruits
• Labs
• Elevated Cr and PO4 (4.43/6.0 mg/dL,
  respectively)
• Decreased H H (9.9/28.8 g/dL)
• Severe N/V three episodes of emesis in the
  holding area
• Treated with transdermal scopolamine, two doses
  of odansetron, famotidine, and metoclopramide
• Midazolam 2 mg administered prior to leaving
  holding

6
INDUCTION
7
MAINTENANCE OF ANESTHESIA

• Desflurane titrated between 4.2-6.5
• NMB maintained with atracurium
• Serum glucose assessed Q30 minutes
• Regular insulin administered IV in small doses
  throughout the case as directed by surgeon

8
IMMUNOSUPPRESSIVE THERAPY

• Induced with methylprednisolone 350 mg IV (15
  min)
• Followed by infusion of anti-thymocyte globulin
• Infusion rate halved after hypotension noted
• Small boluses of phenylephrine, calcium chloride
  and ephedrine to maintain MAP 80 mm Hg
• BP stabilizes with 1.5 L of 0.9 NS, 250 mL of 5
  albumin, and dopamine infusion at 5 ?g/kg/min

9
WERE CRUISING

• Prepare for pancreas graft insertion
• Heparin 3,000 units
• Mannitol 12.5 g
• Graft inserted
• Vascular anastamoses completed
• Surgeon announces venous clamp will be released
• Student experiences SEVERE pudendal neuropathy as
  this happens

10
PANCREATIC REPEFUSION
11
OVER THE NEXT 80 MINUTES

• Norepinephrine infusion titrated to 0.25
  ?g/kg/min
• Six 64 ?g boluses of norepinephrine were
  administered
• 2L NS bolused to maintain a MAP gt 60 mm Hg
• Recall, goal MAP 80 mm Hg
• Diphenhydramine (25 mg) and esmolol (10 mg)
  administered
• No observed response
• Heart rate remained 120 140 bpm
• Four hours into the case, MAP stabilized at 70 mm
  Hg
• Heparin and mannitol administered prior to
  vascular clamping and reperfusion of renal graft
• Anesthesia grimaces.

12
RENAL GRAFT REPEFUSION

• MAP acutely fell from 72 to 51 mm Hg after
  reperfusion
• 128 ?g norepinephrine bolus administered
• Second unit of PRBCs transfused
• 10 mg furosemide administered, per the surgeons
  request
• CardioQ SV monitor utilized to assess volume
  status
• 4.5 L of crystalloid infused over remainder of
  case,
• Fluid total 8 L crystalloid and 1.5 L colloid
• Estimated blood loss was 500 mL
• A total of three ampules of sodium bicarbonate
  were administered to correct acidosis

13
POST-REPERFUSION SYNDROME
14
EMERGENCE

• By the end of the case, hemodynamics stabilized
• Norepinephrine infusion decreased to 0.08
  ?g/kg/min
• Dopamine infusion discontinued
• Anti-thymocyte globulin infusion reinitiated at
  full dose
• NMB antagonized with 0.5 mg glycopyrrolate and
  3.5 mg neostigmine after surgical incision closed
  (fascia left open)
• Patient awoke and followed commands, but was
  determined to be too weak to safely extubate
• Propofol infusion initiated and patient
  transported to ICU in stable condition

15
POSTOPERATIVE COURSE

• Patient was extubated the following morning and
  transferred out of the ICU two days later
• Patient back to OR for closure of fascia POD 8
• Wound infection and edematous pancreas with
  multiple necrotic areas discovered
• Returned to OR on POD 12 for ID and closure of
  the fascia and skin
• Patient remained hospitalized for one month prior
  to being discharged to a rehabilitation facility

16
DISCUSSION
17
WHO BENEFITS FROM SPKT?

• Patients with brittle diabetes and ESRD
• 50-60 of insulin-dependent diabetics develop
  diabetic nephropathy
• Leading cause of renal failure requiring
  hemodialysis in young and middle-aged adults in
  the United States
• While pancreatic transplantation may be indicated
  for the treatment of disease states such as
  pancreatitis or cancer, an overwhelming 96 of
  the total pancreatic transplants in the US are
  performed in patients with underlying IDDM
• (Lin, 2007 Yost Niemann, 2010 Gruessner,
  2011)

18
SPKT vs. PTA PAK
(Gruessner, 2011)
19
WHAT HAPPENS WHEN SPKT FAILS?

• Uncommon
• Serious
• Few institutions with much experience

(Gruessner, 2011)
20
PANCREATIC ANASTAMOSES

• During bench preparation of pancreatic graft, the
  bifurcation of donors Iliac A. is anastamosed
  with the Superior Messenteric A. Splenic A.
  from graft for ease of anastamosis to recipients
  R Common Iliac A. during transplantation

21
RENAL ANASTAMOSES
ACS Surgery Principles and Practice
22
ANESTHESIA CONSIDERATIONS

• Preoperative Assessment, Planning Collaboration
• Minimizing Consequences of IDDM and ESRD
• Glycemic Control
• Autonomic Neuropathy
• Renal pharmacological considerations
• Management of Immunosuppressive Therapy
• Optimization of Graft Function
• Fluid Management
• Commonly Utilized Intraoperative Drugs
• Adequate Graft Perfusion
• Management of Post-Reperfusion Syndrome (PRS)

23
PREOPERATIVE ASSESSMENT

• Begins with a review of the health history
• Special attention to co-existing diseases that
  often accompany ESRD and IDDM
• Hypertension, anemia, uremia, and cardiac disease
  
• Cardiac workup warranted due to risk for silent
  ischemia secondary to autonomic neuropathy
• Coronary angiography vs. non-invasive testing
  such as EKG, TTE, Nuclear Stress Testing, etc

(Garwood, 2008 Evenson Fryer, 2009 Ouellette,
2010 De Lima, et al., 2003)
24
PREOPERATIVE LABS

• Laboratory tests should include CBC, CMP,
  hemoglobin A1C, coagulation studies, and TC for
  at least two units of washed PRBCs
• The transplant workup will also include screening
  tests for a multitude of infectious diseases, as
  well as ABO and human leukocyte antigen (HLA)
  compatibility

(Busque, 2009 Ouellette, 2010)
25
PREOPERATIVE EXAM

• Primary concerns cardiopulmonary system and
  airway
• Orthostatics and dialysis details facilitate
  estimation of blood volume status
• Difficult airway?
• Few studies propose intubation difficult in
  diabetics
• Subsequent studies did not substantiate these
  fears
• Nonetheless, prudent to assess joint mobility in
  neck and jaw and to prepare for difficult
  visualization of laryngeal structures
• Identify HD shunts/fistulas and verify adequate
  padding, as pressure may cause thrombosis

(Yost Niemann, 2010 Garwood, 2008 Busque,
2009 Palmer, 2010)
26
GLYCEMIC CONTROL

• Many proposed management strategies
• Most authors agree BG should be assessed at least
  Q30-60 min
• Treat with regular insulin IVP or via continuous
  infusion
• Mitigates risk for ketoacidosis, depressed immune
  function, decreased wound healing, and worsened
  neurologic insult in the setting of cerebral
  ischemia
• Keep BG gt 150 mg/dL prior to pancreatic graft
  insertion
• Serum glucose decreases 50 mg/dL/hr after
  reperfusion
• Hypoglycemia difficult to detect due to
  anesthesia and diabetic and renal disease-related
  neuropathy
• Another complicating factor is routine
  administration of high-dose corticosteroid for
  immunosuppressive therapy

(Yost Niemann, 2010 Csete Glas, 2009
Busque, 2009 Palmer, 2010)
27
ANESTHETIC TECHNIQUE

• Regional anesthesia has been successfully used
  for isolated pancreas and kidney transplants
• Most authors encourage general endotracheal
  anesthesia for the following reasons
• The long, tedious nature of these surgeries
• The benefit of muscle relaxation
• The potential for hemodynamic instability
• Furthermore, splanchnic perfusion to the
  transplanted organs is a major concern and the
  sympatholytic effect of regional anesthesia may
  pose a danger to adequate graft perfusion

(Hadimioglu, Ertug, Bigat, Yilmaz, Yegin,
2005 Pichel Macnab, 2005 Busque et al., 2009
Csete Glas, 2009 Palmer, 2010 Yost Niemann,
2010).
28
IMMUNOSUPPRESSIVE THERAPY

• Transplant function dependent on
  immunosuppression
• Induction Agents Started at time of
  transplantation
• May continue for a few doses while maintenance
  agents initiated
• Maintenance Agents Will be continued
  indefinitely
• Commonly encountered induction regimens include
  either monoclonal or polyclonal antibodies which
  may or may not be supplemented with a large dose
  of corticosteroid
• Regimens vary between patients and institutions
• Imperative that anesthetist clarifies schedule
  and dosing with transplant team

(Csete Glas, 2009 Evenson Fryer, 2009
Kaufmann et al., 2002)
29
SIDE EFFECTS
Millers Anesthesia, 7th ed., 2010
Clinical Anesthesia, 6th ed., 2009
30
AUTONOMIC NEUROPATHY

• Diabetics, especially those with ESRD, prone to
  autonomic neuropathy that may cause
• Gastroparesis increases risk for aspiration
• Cardiovascular lability possible intraoperative
  hypotension requiring pressors, dysrhythmias, and
  bradycardia resistant to atropine
• Regardless of volume status, patients with ESRD
  often experience exaggerated hypotension with
  induction of anesthesia

31
INDUCTION OF ANESTHESIA

• No standard induction drugs specifically
  contraindicated
• May require increased dose of propofol
• Titration better than large single bolus
• All patients presenting for SPKT should be
  considered at risk for aspiration
• RSI with cricoid pressure and slight reverse
  trendelenberg positioning indicated

32
NEUROMUSCULAR BLOCKADE

• Succinylcholine usually safe in patients with
  ESRD
• Serum potassium should be lt 5.5 mEq/L
• 0.6 mEq/L increase in potassium after intubating
  dose
• Increased risk for patients with motor and
  sensory neuropathy
• Alternative to succinylcholine for RSI is
  rocuronium
• All short and intermediate acting NDNMBs safe
  with careful titration based upon TOF monitoring
•  Cisatracurium and atracurium ideal due to
  extrarenal metabolism via Hoffman degredation and
  plasma cholinesterase
• Primary metabolite, laudanosine, may cause
  seizures via stimulation of CNS at high plasma
  concentrations

(Busque et al., 2009 Csete Glas, 2009 Palmer,
2010 Yost Niemann, 2010 Ouellette, 2010 Ma
Zhuang, 2002 )
33
MAINTENANCE OF ANESTHESIA

• Balanced anesthetic technique likely best method
  to sustain hemodynamic stability
• Drugs selected based upon known side effects
• N2O often omitted
• Morphine and meperidine should also be avoided
  due to the action of their metabolites
• Desflurane and isoflurane are commonly used
• While the metabolism of sevoflurane has been
  implicated in nephrotoxicity, there is a lack of
  evidence clearly substantiating these concerns

(Yost Niemann, 2010 Garwood, 2008)
34
FLUID CHOICES

• Multiple considerations
• Electrolyte Balance
• Edema/Third-Spacing
• Acid-Base Balance
• Which Crystalloid?
• NS vs. LR vs. Plasmalyte?
• NS widely used, but LR and Plasmalyte may be
  better
• Which Colloid?
• Albumin vs. HES Solutions?
• Albumin demonstrated to be best colloid

(O'Malley, Frumento, Bennett-Guerrero, 2002
Csete Glas, 2009 Garwood, 2008 Ouellette,
2010 O'Malley et al., 2005 Hadimioglu et al.,
2008 Groeneveld, Navickis, Wilkes, 2011)
35
MONITORING

• Standard ASA monitors placed upon entering OR
• HD catheters may be used if CVC access warranted
• CVP 10 15 mm Hg optimizes CO/Renal Blood Flow
• Pulmonary Artery Catheter based upon HP
• Higher filling pressures (gt20/15 mm Hg)
  indicative of better graft function than lower
  pressures in one study
• A-Line based upon HP
• Non-invasive cardiac stroke volume monitors
• These have been found to facilitate goal directed
  fluid therapy
• Demonstrated to PONV, morbidity, and hospital
  stay

(Yost Niemann, 2010 Csete Glas, 2009
Busque, 2009 Bundgaard-Nielsen, 2007 Benes et
al., 2010)
36
INTRAOPERATIVE HEMODYNAMICS

• Major hemodynamic shifts are common during organ
  transplantation
• One illustration of these hemodynamic shifts was
  provided by a large series that found substantial
  changes in intraoperative hemodynamics, with
  hypotension more likely than hypertension (49.6
  vs. 26.8)

(Csete Glas, 2009)
37
SPKT HEMODYNAMICS

• Another study following 17 patients presenting
  for SPKT reported similar hemodynamic shifts

(Mazza, et al., 1998)
38
POST-REPERFUSION SYNDROME

• PRS was first described by Aggarwal (1987), in
  the context of orthotopic liver transplantation
  (OLT)
• A systemic phenomenon generally defined as a 30
  decrease in MAP, sustained gt 1 minute, occurring
  lt 5 minutes after organ reperfusion
• PRS has been reported in surgeries other than OLT
• Cardiopulmonary bypass, aneurysm repair, ischemic
  limb reperfusion, and intestinal and renal
  transplants
• Literature describing incidence of PRS is
  inconsistent, with rates between 20-55 of all
  OLT patients and 4 of renal transplants
  reported

(Bruhl et al., 2012 Chung et al., 2012 Fukazawa
Pretto, 2011 Lomax, Klucniks, Griffiths,
2010)
39
PRS PHYSIOLOGY

• While the exact mechanism of PRS remains
  controversial, some of the initially proposed
  causes included
• Cold preservation solution into systemic
  circulation
• Acid-base and electrolyte derangements
• Release of pro-inflammatory mediators, including
  nitric oxide (NO), due to massive induction of
  oxidative stress
• However, one prospective study found no
  statistical correlation between serum pH, core
  temperature, potassium and calcium levels, or
  arterial blood-gas tensions and PRS
• In the same study, a decreased SVR was the only
  variable that correlated significantly with PRS

(Bruhl et al., 2012 Chung et al., 2012 Fukazawa
Pretto, 2011 Lomax, Klucniks, Griffiths,
2010)
40
PRS PHYSIOLOGY CONTINUED

• Another study exploring PRS hemodynamics found
  preload was significantly lower in PRS patients
  than non-PRS patients despite equal LV function,
  as observed by TEE
• Acute vasodilation could explain both the
  decrease in SVR and preload
• Possibly mediated by release of vasoactive
  inflammatory mediators, secondary to an
  immunogenic response, resulting in a massive
  extracellular fluid shift
• Supported by another study that identified
  increased levels of neutrophil and macrophage
  activation, with simultaneous anaphylatoxin
  formation, in patients experiencing PRS
• Another proposed mechanism is the release of ROS

(Bruhl, 2012 Yost Niemann, 2010 Csete Glas,
2009)
41
WHY IS PRS IMPORTANT?

• PRS implicated in a number of undesirable
  outcomes
• Longer mechanical ventilation times and ICU
  stays, poor graft function, acute organ
  dysfunction unrelated to the surgical site, and
  increased mortality
• Bruhl reported a 10 increase in graft failure at
  six in renal transplant patients experiencing PRS
  
• The number of post-transplant hospitalization
  days was almost twice that of non-PRS patients
  who had the same surgery
• Another study, following OLT patients who
  developed PRS, reported the relative risk of
  severe kidney dysfunction to be over three times
  greater that the non-PRS group
• More frightening, the relative risk of death was
  determined to be almost three times greater than
  non-PRS cohorts

(Bruhl, 2012)
42
WHO IS AT RISK FOR PRS?

• A significant correlation was identified
  between PRS and patients who were either
  diabetic, Asian, older than 60, or transplanted
  with an organ from an extended criteria donor

(Bruhl, 2012)
43
PRS AUTONOMIC DYSFUNCTION

• Increased prevalence of PRS in patients with
  autonomic dysfunction
• Both IDDM and ESRD are associated with autonomic
  dysfunction
• Thus, these pathologies may be good markers for
  predicting PRS in surgical patients.

(Perez-Pena, et al., 2003)
44
PRS TREATMENTS?

• Unfortunately, there does not yet appear to be a
  consensus in the literature regarding effective
  treatment regimens for PRS
• Proposed strategies include
• Methylene Blue to inhibit inducible NO synthase
  and scavenge NO
• On retrospective study of 700 patients found
  methylene blue to have no effect on changes in
  MAP, vasopressor or blood transfusion
  requirements, or end-organ effects
• Prophylactic administration of epinephrine and
  atropine to attenuate hypotension and bradycardia
• Mannitol to scavenge ROS
• Sodium bicarbonate to buffer the increased acid
  load
• Nonetheless, despite 25 years of research, there
  remains much to learn about PRS
• However, as more definitive explanations of the
  mechanism and treatment of PRS emerge, it is
  reasonable to expect outcomes for a number of
  surgical procedures to improve

(Bruhl et al., 2012 Busque et al., 2009 Chung
et al., 2012 Csete Glas, 2009 Fukazawa
Pretto, 2011 Ouellette, 2010 Palmer, 2010 Yost
Niemann, 2010)
45
HINDSIGHT IS 20/20
46
AREAS FOR IMPROVEMENT

• More proactive/aggressive treatment of N/V
• Haldol/droperidol, diphenhydramine, etc
• Tighter glycemic control
• Continuous insulin infusion
• Earlier utilization of SV Monitor
• Aggressive treatment of early PRS with Epi?
• Fluid Selection
• LR only or more balanced ratio of LR/NS

47
THANK YOU!
48
QUESTIONS?

• pattonc_at_anest.wustl.edu

49
References

• Benes, J., Chytra, I., Altmann, P., Hluchy, M.,
  Kasal, E., Svitak, R., . . . Stepan, M. (2010).
  Intraoperative fluid optimization using stroke
  volume variation in high risk surgical patients
  results of prospective randomized study. Crit
  Care, 14(3), R118. doi 10.1186/cc9070
• Bruhl, S. R., Vetteth, S., Rees, M., Grubb, B.
  P., Khouri, S. J. (2012). Post-reperfusion
  Syndrome during Renal Transplantation A
  Retrospective Study. Int J Med Sci, 9(5),
  391-396. doi 10.7150/ijms.4468
• Busque, S., L., M. M., Desai, D. M., Esquivel, C.
  O., Angelotti, T., Lemmens, H. J. M. (2009).
  Liver/kidney/pancreas transplantation. In R. A.
  Jaffe S. I. Samuels (Eds.), Anesthesiologist's
  manual of surgical procedures (4th ed., pp.
  679-712). Philadelphia, PA Lipincott Williams
  Wilkins.
• Cannesson, M., Pestel, G., Ricks, C., Hoeft, A.,
  Perel, A. (2011). Hemodynamic monitoring and
  management in patients undergoing high risk
  surgery a survey among North American and
  European anesthesiologists. Crit Care, 15(4),
  R197. doi 10.1186/cc10364
• Chung, I. S., Kim, H. Y., Shin, Y. H., Ko, J. S.,
  Gwak, M. S., Sim, W. S., . . . Lee, S. K. (2012).
  Incidence and predictors of post-reperfusion
  syndrome in living donor liver transplantation.
  Clin Transplant, 26(4), 539-543. doi
  10.1111/j.1399-0012.2011.01568.x
• Csete, M., Glas, K. (2009). Transplant
  anesthesia. In P. G. Barash, B. F. Cullen, R. K.
  Stoelting, M. K. Calahan M. C. Stock (Eds.),
  Clinical anesthesia (6th ed., pp. 1375-1392).
  Philadelphia, PA Lippincott Williams Wilkins.
• Dart, A. B., Mutter, T. C., Ruth, C. A.,
  Taback, S. P. (2010). Hydroxyethyl starch (HES)
  versus other fluid therapies effects on kidney
  function. Cochrane Database Syst Rev(1),
  CD007594. doi 10.1002/14651858.CD007594.pub2
• Davidson, I. J. (2006). Renal impact of fluid
  management with colloids a comparative review.
  Eur J Anaesthesiol, 23(9), 721-738. doi
  10.1017/S0265021506000639
• De Lima, J. J. G., Sabbaga, E., Vieira, M. L. C.,
  de Paula, F. J., Ianhez, L. E., Krieger, E. M.,
  Ramires, J. A. F. (2003). Coronary Angiography Is
  the Best Predictor of Events in Renal Transplant
  Candidates Compared With Noninvasive Testing.
  Hypertension, 42(3), 263-268. doi
  10.1161/01.hyp.0000087889.60760.87
• Evenson, A. R. (2009). Transplantation for the
  general surgeon. In S. Ashley D. W. Wilmore
  (Eds.), ACS Surgery Principles and Practice (pp.
  1-20). Hamilton, Ontario BC Decker.
• Fukazawa, K., Pretto, E. A. (2011). The effect
  of methylene blue during orthotopic liver
  transplantation on post reperfusion syndrome and
  postoperative graft function. J Hepatobiliary
  Pancreat Sci, 18(3), 406-413. doi
  10.1007/s00534-010-0344-7
• Garwood, S. (2008). Renal disease. In R. L. Hines
  K. E. Marschall (Eds.), Stoelting's anesthesia
  and co-existing disease (5th ed., pp. 323-348).
  Philadelphia, PA Churchill Livingstone.
• Groeneveld, A. B., Navickis, R. J., Wilkes, M.
  M. (2011). Update on the comparative safety of
  colloids a systematic review of clinical
  studies. Ann Surg, 253(3), 470-483. doi
  10.1097/SLA.0b013e318202ff00
• Gruessner, A. C. (2011). 2011 update on pancreas
  transplantation comprehensive trend analysis of
  25,000 cases followed up over the course of
  twenty-four years at the International Pancreas
  Transplant Registry (IPTR). Rev Diabet Stud,
  8(1), 6-16. doi 10.1900/RDS.2011.8.6
• Hadimioglu, N., Ertug, Z., Bigat, Z., Yilmaz, M.,
  Yegin, A. (2005). A randomized study comparing
  combined spinal epidural or general anesthesia
  for renal transplant surgery. Transplant Proc,
  37(5), 2020-2022. doi 10.1016/j.transproceed.2005
  .03.034
• Hadimioglu, N., Saadawy, I., Saglam, T., Ertug,
  Z., Dinckan, A. (2008). The effect of different
  crystalloid solutions on acid-base balance and
  early kidney function after kidney
  transplantation. Anesth Analg, 107(1), 264-269.
  doi 10.1213/ane.0b013e3181732d64
• Hokema, F., Ziganshyna, S., Bartels, M., Pietsch,
  U. C., Busch, T., Jonas, S., Kaisers, U.
  (2011). Is perioperative low molecular weight
  hydroxyethyl starch infusion a risk factor for
  delayed graft function in renal transplant
  recipients? Nephrol Dial Transplant, 26(10),
  3373-3378. doi 10.1093/ndt/gfr017
• Hunter, K. (2003). Anesthesiology in renal and
  pancreas transplantation. Current Opinion in
  Organ Transplantation, 8(3), 243-248.

• Kaufman, D. B., Leventhal, J. R., Gallon, L. G.,
  Parker, M. A., Elliott, M. D., Gheorghiade, M., .
  . . Stuart, F. P. (2002). Technical and
  immunologic progress in simultaneous
  pancreas-kidney transplantation. Surgery, 132(4),
  545-553 discussion 553-544.
• Lin, L. (2007). Endocrine and nutritional
  disease. In R. K. Stoelting R. D. Miller
  (Eds.), Basics of anesthesia (5th ed., pp.
  437-452). Philadelphia, PA Churchill
  Livingstone.
• Lomax, S., Klucniks, A., Griffiths, J. (2010).
  Anaesthesia for intestinal transplantation.
  Continuing Education in Anaesthesia, Critical
  Care Pain. doi 10.1093/bjaceaccp/mkq043
• Ma, H., Zhuang, X. (2002). Selection of
  neuromuscular blocking agents in patients
  undergoing renal transplantation under general
  anesthesia. Chin Med J (Engl), 115(11),
  1692-1696.
• Mazza, E., De Gasperi, A., Corti, A., Amici, O.,
  Roselli, E., Notaro, P., . . . Santandrea, E.
  (1998). Hypotension after pancreatic reperfusion
  during combined kidney-pancreas transplantation.
  Transplant Proc, 30(2), 265-266.
• O'Malley, C. M., Frumento, R. J.,
  Bennett-Guerrero, E. (2002). Intravenous fluid
  therapy in renal transplant recipients results
  of a US survey. Transplant Proc, 34(8),
  3142-3145.
• O'Malley, C. M., Frumento, R. J., Hardy, M. A.,
  Benvenisty, A. I., Brentjens, T. E., Mercer, J.
  S., Bennett-Guerrero, E. (2005). A randomized,
  double-blind comparison of lactated Ringer's
  solution and 0.9 NaCl during renal
  transplantation. Anesth Analg, 100(5), 1518-1524,
  table of contents. doi 10.1213/01.ANE.0000150939.
  28904.81
• Ouellette, S. M. (2010). Renal anatomy,
  physiology, pathophysiology, and anesthesia
  management. In J. J. Nagelhaut K. L. Plaus
  (Eds.), Nurse anesthesia (4th ed., pp. 694-726).
  St. Louis, MO Saunders-Elsevier.
• Palmer, T. J. (2010). Hepatobiliary and
  gastrointestinal disturbances and anesthesia. In
  J. J. Nagelhaut K. L. Plaus (Eds.), Nurse
  anesthesia (4th ed., pp. 727-770). St. Louis, MO
  Saunders-Elsevier.
• Perez-Pena, J., Rincon, D., Banares, R.,
  Olmedilla, L., Garutti, I., Arnal, D., . . .
  Clemente, G. (2003). Autonomic neuropathy is
  associated with hemodynamic instability during
  human liver transplantation. Transplant Proc,
  35(5), 1866-1868.
• Pichel, A. C., Macnab, W. R. (2005).
  Anaesthesia for pancreas transplantation.
  Continuing Education in Anaesthesia, Critical
  Care Pain, 5(5), 149-152. doi
  10.1093/bjaceaccp/mki040
• Pihusch, R., Holler, E., Muhlbayer, D., Gohring,
  P., Stotzer, O., Pihusch, M., . . . Kolb, H. J.
  (2002). The impact of antithymocyte globulin on
  short-term toxicity after allogeneic stem cell
  transplantation. Bone Marrow Transplant, 30(6),
  347-354. doi 10.1038/sj.bmt.1703640
• Rang, S. T., West, N. L., Howard, J., Cousins,
  J. (2006). Anaesthesia for Chronic Renal Disease
  and Renal Transplantation. EAU-EBU Update Series,
  4(6), 246-256. doi 10.1016/j.eeus.2006.08.005
• SarinKapoor, H., Kaur, R., Kaur, H. (2007).
  Anaesthesia for renal transplant surgery. Acta
  Anaesthesiol Scand, 51(10), 1354-1367. doi
  10.1111/j.1399-6576.2007.01447.x
• Shrestha, B. M. (2006). Simultaneous pancreas and
  kidney transplantation for end-stage renal
  failure secondary to diabetic nephropathy
  principles and practice. JNMA J Nepal Med Assoc,
  45(163), 323-330.
• Sollinger, H. W., Odorico, J. S., Becker, Y. T.,
  D'Alessandro, A. M., Pirsch, J. D. (2009). One
  thousand simultaneous pancreas-kidney transplants
  at a single center with 22-year follow-up. Ann
  Surg, 250(4), 618-630. doi 10.1097/SLA.0b013e3181
  b76d2b
• Vincent, J. L., Rhodes, A., Perel, A., Martin, G.
  S., Della Rocca, G., Vallet, B., . . . Singer, M.
  (2011). Clinical review Update on hemodynamic
  monitoring--a consensus of 16. Crit Care, 15(4),
  229. doi 10.1186/cc10291
• Wall, R. T. I. (2008). Endocrine disease. In R.
  L. Hines K. E. Marschall (Eds.), Stoelting's
  anesthesia and co-existing disease (5th ed., pp.
  365-406). Philatelphia, PA Churchill
  Livingstone.