**5. Special cases**

#### **5.1. Trauma**

It is generally assumed that immunosuppressed patients are more susceptible to the effects of soft tissue damage and poor bone healing. Bone loss associated with chronic immunosuppressive therapy is a serious problem for most transplant recipients. These patients are prone to fractures (i.e. hip or compressive vertebral fracture) [97].

Only a few studies of traumatized transplant recipients have been reported. This is likely because of the infrequent presentation of these patients to trauma centers. The most common causes of trauma are car accidents and falls. The latest study by Scalea *et al.* determined that outcomes for traumatic injury in patients with organ transplants are not worse than that for non-transplant patients, despite common presumptions among physicians [98]. Transplant recipients sustaining trauma should receive the same initial resuscitation as any trauma victim. Patients should be assessed by a transplant surgeon as soon as possible and graft function should be closely assessed by a transplant team during hospitalization and after discharge from the trauma center [3]. Acute organ rejection within 6 months of admission for trauma is reported among 17% of solid organ recipients [99].

Transplant recipients, whose immune systems are already suppressed to prevent organ rejection, are presumed to be at greater risk of infection from traumatic injury. However, this was not observed in two latest studies [100]. Therefore, similar protocols of antimicrobial therapy should apply to both transplanted and non-transplanted patients to avoid the overuse of antimicrobial agents and ensure maintenance of the susceptibility patterns of pathogens.

Studies also show that transplanted organs are rarely injured in traumatic events. This is most likely related to careful selection of transplant recipients who are committed to self-care and continue to pursue healthy life style after transplantation.

#### **5.2. Pregnancy**

With the advances in transplantation medicine, female organ transplant recipients are able to conceive and carry pregnancies successfully to term. This state presents a unique challenge to attending physician, obstetrician, and anesthesiologist. These women are at an increased risk of comorbidities and obstetric complications. Therefore, all post-transplant pregnancies should be considered as high risk, and close monitoring is mandatory. Anesthesiologists are involved in the care of these patients for both labor analgesia and operative procedure. Anesthetic considerations include the effects of the physiologic changes of pregnancy on the transplanted organ, graft function in the peripartum period, and the maternal side effects and drug interactions of immunosuppressive agents. Anesthetic management should consider the important task of protecting graft function [101, 102].

**5.3. Laparoscopic surgery**

constantly increasing [108].

**5.4. Outpatient and esthetic surgery**

as steroids [117].

Laparoscopic surgery is currently a widely accepted approach to several surgical fields because of its advantages in terms of postoperative pain reduction and easy patient recovery. The number of minimally invasive surgical procedures performed in transplant recipients is

Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery

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Lymphoceles can be successfully treated surgically after kidney transplantation by laparoscopy under general anesthesia [109, 110]. There are also reports of successful laparoscopic bariatric surgery after simultaneous pancreas and kidney transplantation [111]. Laparoscopic cholecystectomy is considered to be safe procedure in the transplant population. It has advantage of short hospital stay, low morbidity, maintenance of oral immunosuppression, and early return to preoperative routines. There is however a slightly higher rate of conversion to an open cholecystectomy among transplant patients compared to general population (27% vs. 11%, respectively) [112, 113]. Generally, laparoscopic approach may be useful even in solid-organ transplantation surgery as a diagnostic or treatment procedure in some surgical complications.

With shorter medical procedure duration and fewer complications, there is growth in popularity of outpatient or ambulatory surgery. Procedures performed are broad in scope: knee, shoulder, spine and eye surgery (cataract, laser surgery), plastic surgery, some types of

Improved immunosuppression and lifespans have afforded solid organ transplant recipients the opportunity to seek outpatient and esthetic surgery. Most commonly performed procedures are soft tissue excisions with local flap coverage, facelifts, breast augmentation, and abdominoplasty. Among solid organ transplant recipients, kidney transplant recipients most often underwent plastic surgery, accounting for over 68% [115]. The complication rate is very low and ranges from 4 to 8% [116]. Delayed wound healing or wound disruption is reported as the most common complication and is associated with immunosuppression therapy, such

It is extraordinarily important to manage these patients with a multidisciplinary approach. They should obtain clearance from the transplant surgeon and from the organ-specific specialist. The anesthesiologist should be familiar with the organ-specific needs in the perioperative period (i.e. maintaining preload for heart transplant patients, judicious fluid management in the renal patient, and avoidance of volatile anesthetics in liver transplants) to avert unintended consequences. It is more reasonable to use of general anesthesia over regional in the heart transplant patients. Perioperative antibiotic prophylaxis and stress-dose steroids should be administered prior to surgery. NSAIDs should be avoided in postoperative pain regimen [118].

Elective esthetic surgery can be performed safely in patients with a history of solid organ transplantation after a careful patient selection and multidisciplinary approach. These patients can potentially experience significant improvements in their quality of life with low morbidity.

esthetic surgery, and upper gastrointestinal endoscopy and colonoscopy [114].

Data are lacking regarding the optimal transplant-conception interval. The 2005 American Society of Transplantation Consensus Conference suggested that pregnancy 1 year after transplant is safe as long as the patient has stable graft function. This means: no episodes of rejection in the past year, a low risk for opportunistic infections, stable renal function (including in those receiving organs other than a kidney), and a low stable dose of maintenance immunosuppression [103].

Pregnancy does not appear to cause excessive or irreversible problems with graft dysfunction if the function of the transplanted organ was stable prior to pregnancy [104]. Maternal side effects of immunosuppression therapy include nephrotoxicity, hepatotoxicity, diabetes, and arterial hypertension, which could lead to possible dangerous complications. In kidney, heart, or heart-lung transplant recipients, the rate of complications, such as preeclampsia, premature labor, and risk of acute allograft rejection postpartum, is higher than that in the non-transplant population [105].

Current immunosuppressant drugs are not thought to be teratogenic and their use cannot be discontinued during pregnancy. All immunosuppressants cross the placenta. They are not strongly associated with the increased risk of congenital anomalies in the first trimester. However, they affect the immune system of fetus during the second and third trimesters and may result in premature delivery and low birth weight in newborn [106].

The anesthetic technique for cesarean section depends on indication, functional status of transplanted organ, and cardiovascular and hematological status. Central neuraxial blocks are not contraindicated if coagulation status is normal. However, documentation of paresthesia is important if regional anesthesia is planned. In the case of general anesthesia, all intravenous anesthetics and inhalational agents are safe. Neuromuscular function should be monitored particularly if the patient is receiving magnesium. Postoperative pain relief is provided with narcotics by epidural or spinal route if regional anesthesia is used or by parenteral opioids. Non-steroidal anti-inflammatory drugs should be avoided. Thromboprophylaxis should be administered because of the high risk of thromboembolic complications in these patients, especially after cesarean delivery. The threshold for admission to an intensive care or highdependency unit should be low [107].
