**3.1. Preoperative assessment of transplant recipients**

Many transplant recipients live relatively normal and productive lives, but often have limited physical reserves. A successful transplant abolishes the symptoms and replaces function of the failed organ, but often there are persistent abnormalities from the underlying or preexisting illness that may have caused the organ failure or chronic physiologic abnormalities resulting from the organ failure itself. The preoperative evaluation of transplant recipients undergoing non-transplant surgery should include graft function, signs of rejection, presence of infection, and function of other organs.

Allograft rejection may occur at any time during the post-transplant period, especially when discontinuing the use of immunosuppressants. Chronic rejection is the most significant medical obstacle to long-term morbidity-free allograft survival. The incidence is thought to progressively increase with time after transplantation, but after a period of 5 years, it affects about 10% of liver to around 60% of lung allograft recipients [26]. Chronic organ rejection results in a progressive deterioration of organ function (assessed trough laboratory tests) and is the main cause of late mortality in the transplant recipients. Mortality rate is high if rejection remains untreated before surgery [27]. Therefore, the presence of any degree of rejection should be ruled out and urgently managed preoperatively with increased immunosuppression.

Immunosuppressed patients are at risk of infections that may be bacterial, viral, fungal, or protozoan. Infection is a significant cause of morbidity and mortality after transplantation [28]. Its presence should also always be preoperatively ruled out (by obtaining laboratory, radiologic, and microbiology tests). It is imperative to emphasize that the immunosuppressed patient may not present the typical signs and symptoms of infection (i.e. fever, leukocytosis). Microbiology advice should be strongly sought for prevention as well as strict control of infection. Any infection should be treated preoperatively [29].

Although transplant patients are considered as risk hosts for infection because of their immune status, there is no evidence to suggest different bacteriology of surgical site infections than for the general population. Antimicrobial coverage need not be expanded to include atypical or opportunistic organisms as long as active infection with such an organism is not present or suspected [30]. Prophylaxis with broad spectrum antibiotic should be administered 1 hour before surgical incision (depending on hospital protocol) (**Table 5**).

Transplanted patients may also suffer from diabetes, hypertension, epilepsy, renal dysfunction, bone marrow suppression, lymphoproliferative disorders, and adrenal insufficiency as the side effects of chronic immunosuppressive therapy [31]. Hepatobiliary and pancreatic diseases are relatively common after transplantation, as well as the upper gastrointestinal bleeding secondary to peptic ulcer disease. Surgical stress, corticosteroids, and mycophenolate may contribute to gastrointestinal ulcers [32]. So, it is absolutely necessary to provide stress ulcer prophylaxis for transplanted patients.

The transplant patient population is considered as high-risk group for developing venous thromboembolism (VTE) given the fact that most of these patients have multiple identifiable risk factors [33]. However, the exact risk of developing VTEs in these patients is not clearly defined in the literature, nor there are clear guidelines regarding the appropriate use of thromboprophylaxis in transplant recipients [34]. In our opinion, VTE prophylaxis should be tailored to the patient's specific needs in accordance with current guidelines [35].


**Table 5.** Antimicrobial prophylaxis for selected surgical procedures [30].

are preferred agents because their elimination is not affected by renal or hepatic function. Therefore, patients receiving cyclosporine as immunosuppressive therapy may require a smaller dose of nondepolarizing muscle relaxant and the recovery time may be prolonged [22]. Neostigmine can lead to bradycardia and cardiac arrest in patients with heart transplantation despite the concurrent use of an antimuscarinic agent [23]. Bupivacaine and ropiva-

Many transplant recipients live relatively normal and productive lives, but often have limited physical reserves. A successful transplant abolishes the symptoms and replaces function of the failed organ, but often there are persistent abnormalities from the underlying or preexisting illness that may have caused the organ failure or chronic physiologic abnormalities resulting from the organ failure itself. The preoperative evaluation of transplant recipients undergoing non-transplant surgery should include graft function, signs of rejection, presence

Allograft rejection may occur at any time during the post-transplant period, especially when discontinuing the use of immunosuppressants. Chronic rejection is the most significant medical obstacle to long-term morbidity-free allograft survival. The incidence is thought to progressively increase with time after transplantation, but after a period of 5 years, it affects about 10% of liver to around 60% of lung allograft recipients [26]. Chronic organ rejection results in a progressive deterioration of organ function (assessed trough laboratory tests) and is the main cause of late mortality in the transplant recipients. Mortality rate is high if rejection remains untreated before surgery [27]. Therefore, the presence of any degree of rejection should be

ruled out and urgently managed preoperatively with increased immunosuppression.

caine can be safely used through regional routes without any side effects [24, 25].

**3. Anesthesia and preoperative care**

of infection, and function of other organs.

**3.1. Preoperative assessment of transplant recipients**

**Anesthetic agent Effect with immunosuppressive drugs**

234 Organ Donation and Transplantation - Current Status and Future Challenges

Opioids CyA ↑ analgesic effect produced by fentanyl

Local anesthetics Bupivacaine and ropivacaine can be safely used

Muscle relaxants Prolonged neuromuscular blockade Neostigmine Caution in heart transplant patients

**Table 4.** Effect of specific anesthetic agent on immunosuppressive drugs.

Benzodiazepines ↑ Blood level of benzodiazepines

Isoflurane ↓ Clearance of oral CyA

Thiopental Nil

Propofol Nil Etomidate Nil
