*3.3.3.4. Neuromuscular blockade*

The decision to use neuromuscular blockade should be based on the type of surgery and actual need for muscle relaxation during the procedure or the need to optimize intubating conditions. The choice of specific neuromuscular blocking agent should be dictated by length of surgery, underlying medical illnesses (i.e. myasthenia or other neuromuscular disorders), history of malignant hyperthermia, and the functional state of the patient's kidney and liver.

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].

Although the risk of infectious complications is very low, it is important to be highly vigilant when monitoring these patients after a neuraxial anesthesia as the attenuated inflammatory response may diminish the typical signs and symptoms of infection [59]. Again, aseptic tech-

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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 microcir-

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

Transplanted heart is completely denervated, meaning it lacks neural regulating mechanisms [65]. Even though, it has the ability to adjust with compensatory mechanisms to the increased demands in stress returning the recipients to an active life. Transplanted heart has no sensory sympathetic and parasympathetic innervation. Therefore, it has a higher resting heart rate of 90–110 bpm secondary to the loss of vagal tone. The resting ECG is commonly altered showing two P waves: one is from the recipients' own SA node and the other is the donors' SA node. Patients are at higher risk of developing atrial flutter or atrial fibrillation. The transplanted heart is "preload dependent." Cardiac output becomes dependent on venous return. Therefore, it is

Although the cardiac index of the transplanted heart is lower than that of normally innervated control hearts, it remains in the normal range. The catecholamine response is different from

important to maintain a sufficient systolic pressure and prevent hypovolemia [66].

preload status, renal function, and prevention of infection.

**4. Specific anesthetic considerations**

**4.1. Heart transplant recipients**

nique and a mask should be considered essential when performing these procedures.

*3.3.5. Postoperative care management*

culation [62, 63].

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 of malignant hyperthermia [53].
