**4.4. Liver transplant recipients**

Liver synthetic tests should normalize over time pointing out a good liver graft function. There is also gradual decrease of all liver enzyme levels, as graft function becomes normal. Recovery of drug metabolism capacity occurs immediately after reperfusion of the liver graft. Liver transplantation itself results in reversal of the hyperdynamic state that characterizes patients with end-stage liver disease and cardiac performance improves in the months after transplantation. Hypoxemia caused by ventilation/perfusion mismatch is reversed over the course of the first postoperative months. Patients with pre-existing true shunts may require more time to achieve reversal of hypoxemia, or hypoxemia may not resolve at all [86]. Hepatorenal syndrome gradually diminishes, renal function improves over time, and creatinine level may become normal. However, kidneys are still in danger of injury due to immunosuppression side effects [87].

**4.6. Intestine transplant recipients**

and its thrombotic complications [96].

**5. Special cases**

**5.1. Trauma**

There are three types of intestine transplantation: isolated intestinal transplantation, transplantation of combined intestine, and liver graft or multivisceral transplantation. The biggest problem in intestinal transplantation is graft rejection, and it is the main reason for morbidity and mortality. The diagnosis of rejection is confirmed by clinical symptoms, endoscopic

Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery

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Denervation and lymphatic dysfunction of the intestine affect intestinal permeability and absorption. If the intestinal mucosa barrier is damaged by ischemia, rejection, or enteritis, bacteria translocate into the bloodstream and infections are often observed [95]. Some of these patients develop diarrhea and lose weight in the early post-transplantation period. Any imbalance in the electrolyte and acid-base status should be timely corrected. Fluid administration should be closely monitored to assure sufficient splanchnic perfusion. Venous access is of major consideration for the anesthesiologist due to chronic use of total parenteral nutrition

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

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

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 anti-

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

microbial agents and ensure maintenance of the susceptibility patterns of pathogens.

appearance, and pathological specimens taken by endoscopy [94].

to fractures (i.e. hip or compressive vertebral fracture) [97].

reported among 17% of solid organ recipients [99].

continue to pursue healthy life style after transplantation.

The most severe complication of liver transplantation is hepatic artery thrombosis. It has often been associated with massive transfusion of blood products leading to hemoconcentration. Therefore, liver transplant recipients should have minimal blood viscosity (hematocrit approximately 28%) during the perioperative period [88].

No individual general anesthetic agents are contraindicated when hepatic and renal function is normal. If an epidural or spinal anesthesia is planned, clotting studies and platelet counts should be normal. Neither regional nor general anesthetic techniques were associated with deterioration of liver function assuming proper anesthetic and intensive care management [3, 25].

#### **4.5. Pancreas transplant recipients**

Pancreas transplantation provides the most effective method of glycemic and metabolic control. It can be done as a single organ transplant or simultaneously with kidney (predominantly in type 1 diabetes) (SPKT). SPKT is a treatment of choice for uremic diabetic patients when a living-related kidney donor is unavailable. After successful transplantation, pancreas transplant recipients do not require insulin to compensate for the stress response to surgery [89].

However, due to long-lasting diabetes effect, these patients are in high risk of developing cardiovascular diseases. It is prudent to manage these patients with the assumption that they have coronary artery disease [90]. Pancreas recipients still have persistent complications of diabetes such as gastropathy and neuropathy. Aspiration risk may be increased as a result of delayed gastric emptying. This population is also at increased risk for lymphoproliferative disorders secondary to immunosuppressant drugs and lymphoproliferative growth may compromise any part of the airway or mediastinum and cause life-threatening airway obstruction during sedation and anesthesia [91].

Amylase levels in serum and urine should be closely monitored. They can be our only window in the graft rejection recognition [92]. Glucose levels should also be monitored perioperatively. In normal functioning grafts, the suppression of endogenous insulin secretion during hypoglycemia is sufficient to enable a normal glucagon response from the transplanted pancreas, even in surgical stress [93]. In patients with failed pancreatic grafts, perioperative management of glucose levels and acid-base status is the same as that for any diabetic patient.
