**3.2. Preoperative assessment and premedication**

The transplant team as well as the attending anesthesiologist and surgeon should have a good coordination during perioperative period, especially if a major surgical procedure is planned. A comprehensive preoperative evaluation by the anesthesiologist should include: evaluation of the graft function, presence of infection, function of other organ systems, the presence of concomitant diseases as well as the preoperative performance or functional status. Adherence to the fundamental principles of preoperative evaluation along with a high level of vigilance is required. Information and medical history should be gathered from the medical records, interview with the patient and/or next of kin or guardian. If medical information is unavailable, attempts should be made to contact the transplant center for pertinent history. Other useful information from the transplant center includes their most recent evaluations and recent data on graft function and general health of the patient. Close communication with the transplant team may be the single most important step in preparing the patient for surgery and developing a perioperative anesthetic plan.

the risk of a perioperative cardiovascular event a legitimate concern. Many transplant recipients have undergone complete cardiac testing and in some cases, interventions, before their transplant surgery. Records of the testing and interventions can be easily obtained from the transplant center to be used for comparison and consideration before the upcoming surgery. We must also bear in mind that many of these patients may have asymptomatic coronary dis-

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If unexpected abnormal findings are identified on physical examination or laboratory testing, symptomatic changes outside the patient's baseline are documented, or suspicion for rejection or infection exists during the preoperative evaluation, it should be considered to postpone any surgery that is non-urgent or elective. The patient should also be expeditiously referred back to the transplant center, cardiologist, or other consulting physician as indicated. Standard premedication may be used, as in non-transplant patients. However, dose adjustment for some drugs is needed (**Table 3**). Antibiotic, stress ulcer and VTE prophylaxis administration is recommended (as mentioned above). Supplemental steroids are not necessary for stress coverage except in post-transplant recipients in whom steroids are recently withdrawn [37].

Post-transplantation diabetes mellitus is a common metabolic consequence of the agents of immunosuppressive therapy agents [38]. It is imperative to institute a glycemic control plan before the surgery with closely managing intraoperative and postoperative glucose

The dose of immunosuppressive drugs should not be altered and should be continued postoperatively to reduce the risk of rejection. Daily monitoring of the steady-state blood level is recommended. Oral cyclosporine should be administered 4–6 h before surgery to maintain therapeutic blood levels. The alteration of dose of other immunosuppressive drugs dose is not required unless the route of administration needs to be changed from oral to intravenous [39].

There is no ideal anesthetic plan that can be used for all transplant recipients undergoing nontransplant surgery. A variety of anesthetic techniques have been successfully used in patients with a transplant history including general (inhalational, balanced, and total intravenous),

Generally, invasive monitoring is not mandatory and anesthesia should be performed using standard European Society of Anesthesiology's monitoring guidelines [40]. The decision to use invasive hemodynamic monitors, placement of central venous access, pulmonary artery catheters, or other procedures such as transesophageal echocardiography should be made on a case-by-case basis. It should be guided by consideration of the patient's comorbidities, hemodynamic stability, the expertise of the anesthesiologist in placing the invasive devices, and by the type of surgery and anesthesia planned. Aseptic technique is of utmost importance to minimize exposure to infectious organisms and bacteremia when attempting any invasive

ease as a result of diabetes or the transplant itself [36].

control.

**3.3. General anesthetic considerations**

neuraxial, and regional anesthesia.

procedures in this population [41].

*3.3.1. Monitoring*

A thorough review of systems along with a physical examination is essential in this population. Findings such as recent weight gain, edema, dyspnea, sweats, malaise, fever, rashes, abdominal pain, abnormal breath sounds on auscultation, and changes in stool or urine output are some of the potential signs and symptoms of infection or rejection.

The following investigations should be available preoperatively.

	- **a.** Complete blood count (to rule out bone marrow suppression)
	- **b.** Electrolytes
	- **c.** Renal function tests
	- **d.** Liver function tests
	- **e.** Coagulation tests
	- **f.** Biomarkers (i.e. brain natriuretic peptide)

Each preoperative evaluation and testing should be considered individually based on the target organ system(s) to be evaluated, the patient's medical history, and the inherent risks of the upcoming surgical procedure.

Cardiovascular disease is a major cause of mortality and morbidity among organ transplant recipients, especially in those with chronic kidney disease or previous heart transplant, making the risk of a perioperative cardiovascular event a legitimate concern. Many transplant recipients have undergone complete cardiac testing and in some cases, interventions, before their transplant surgery. Records of the testing and interventions can be easily obtained from the transplant center to be used for comparison and consideration before the upcoming surgery. We must also bear in mind that many of these patients may have asymptomatic coronary disease as a result of diabetes or the transplant itself [36].

If unexpected abnormal findings are identified on physical examination or laboratory testing, symptomatic changes outside the patient's baseline are documented, or suspicion for rejection or infection exists during the preoperative evaluation, it should be considered to postpone any surgery that is non-urgent or elective. The patient should also be expeditiously referred back to the transplant center, cardiologist, or other consulting physician as indicated.

Standard premedication may be used, as in non-transplant patients. However, dose adjustment for some drugs is needed (**Table 3**). Antibiotic, stress ulcer and VTE prophylaxis administration is recommended (as mentioned above). Supplemental steroids are not necessary for stress coverage except in post-transplant recipients in whom steroids are recently withdrawn [37].

Post-transplantation diabetes mellitus is a common metabolic consequence of the agents of immunosuppressive therapy agents [38]. It is imperative to institute a glycemic control plan before the surgery with closely managing intraoperative and postoperative glucose control.

The dose of immunosuppressive drugs should not be altered and should be continued postoperatively to reduce the risk of rejection. Daily monitoring of the steady-state blood level is recommended. Oral cyclosporine should be administered 4–6 h before surgery to maintain therapeutic blood levels. The alteration of dose of other immunosuppressive drugs dose is not required unless the route of administration needs to be changed from oral to intravenous [39].
