*3.3.5. Postoperative care management*

In the group of non-depolarizing drugs, it is preferable to use short-acting relaxants (mivacurium) or intermediate-acting agents independent of kidney and liver function (cisatracurium, atracurium). Vecuronium, rocuronium, and pancuronium can have prolonged effects in the face of hepatic or renal insufficiency. They require dose adjustments, close neuromuscular monitoring, and evidence of full reversal before extubation [52]. Some immunosuppressive drugs (i.e. azathioprine and cyclosporine) can prolong the action of the neuromuscular blocking agents [22]. Succinylcholine, the only depolarizing agent available, can be used in organ transplant recipients in the need for rapid sequence intubation and rapid airway control. It should be avoided only if there are other clinical reasons, such as hyperkalemia, muscular dystrophy, or history

Most of the cholinesterase inhibitor drugs are eliminated through the kidneys (neostigmine, edrophonium, and pyridostigmine). Caution is advised in renal failure. Several reports described that neostigmine may produce a dose-dependent life-threatening bradycardia in heart transplant recipients, whereas another publication described the safe use of neostigmine [54]. Reversal of neuromuscular block with sugammadex is another possibility, but limited

The decision to perform a regional or neuraxial anesthetic technique in a previously transplanted patient must be made on an individual basis. We must carefully consider potential benefit and risks of these techniques as well as the anesthetic alternatives when constructing the anesthetic plan in this population. There may be several advantages to choosing a neuraxial or regional technique in this population. Superior analgesia over systemic opioids, especially in patients who may have narcotics tolerance as a result of long-term opioid use, reduced pulmonary complications, and decreased incidence of graft occlusion are just a few of the benefits of regional and neuraxial anesthesia [56]. Clinically relevant doses of bupivacaine and ropivacaine, which are commonly used local anesthetics for neuraxial anesthesia, do not seem to result in toxic levels or increased risk of toxic effects in renal and liver transplant recipients. However, it is important to be prepared for the risk of hypotension because of pre-existing autonomic neuropathy and cardiac denervation in this population. Cautious correction of hypovolemia before epidural or spinal anesthesia may help to attenuate the hypotension. Concurrent hemodynamic monitoring is imperative during the procedure. Direct and indirect-acting adrenergic agonists

The consideration of spinal or epidural anesthesia is appropriate in this population as long as there is no increased risk for bleeding complications. It is necessary to perform a total blood count to exclude bone marrow suppression, especially thrombocytopenia, and coagulation tests (PT, INR, APTT, and fibrinogen). Peripheral nerve blocks became popular anesthetic option due to hemodynamic stability and better postoperative analgesia. Some studies show no difference in duration of peripheral nerve blocks in patients after transplantation compared to the general surgical population [57, 58]. Nevertheless, large prospective randomized trials are still lacking.

should be readily available along with emergency airway supplies.

of malignant hyperthermia [53].

240 Organ Donation and Transplantation - Current Status and Future Challenges

*3.3.3.5. Anticholinesterase drugs*

data exist in literature [55].

*3.3.4. Regional and neuraxial anesthesia*

Regardless of the procedure performed, successful outcomes also depend on optimal postoperative care. Depending on the type of surgery, patients' comorbidities, and preoperative condition, patient is after surgery transferred either to intensive care unit (ICU) or postanesthesia care unit (PACU). Adequate monitoring is tailored accordingly [60]. We reduce the delirium incidence by minimizing sedation, speed up extubation, and facilitate early ambulation and physical rehabilitation. Appropriate analgesia is essential component of postoperative surgical care. Opioids are the mainstay of analgesia in the early postoperative phase after major surgery. Parenteral paracetamol is an effective analgesic agent and may spare narcotics. There is no evidence of an increased risk of hepatotoxicity [61]. Once extubated, patient-controlled analgesia (PCA) devices are effective and well received by patients and nurses. Non-steroidal anti-inflammatory drugs should be avoided because of the risk of adverse interactions (e.g., gastrointestinal hemorrhage, nephrotoxicity, hepatic dysfunction). They augment nephrotoxicity of cyclosporine, as both drugs affect the renal microcirculation [62, 63].

Immunosuppressive therapy should be continued during the perioperative period and daily monitoring of steady-state cyclosporine or tacrolimus blood levels is recommended [64]. The dose of other immunosuppressive drugs should not be altered perioperatively unless the route of administration needs to be changed from oral to intravenous. In addition to the routine care as those for non-transplant recipients, increased attention should be paid to the preload status, renal function, and prevention of infection.
