**7. Perioperative management**

Recipients of pancreas transplantation are diabetic patients most often with a disease vintage over 10 years and frequently with secondary macro- and microvascular complications. The cardiovascular risk is superior to those of general population or recipients of kidney transplant alone. The perioperative management is of crucial importance not only to avoid the risk of hemodynamic instability and periods of low perfusion of the graft, but is also vital for organs such as brain and heart.

#### **7.1. Volume, acid-base and electrolyte, and hemodynamic stability**

Volume and electrolytes should be monitored closely during the first 48 h and fluids administered accordingly to avoid hypovolemia or acid-base and electrolyte inbalances. Although an individualized assessment should be performed in each case, it is considered appropriate to maintain a central venous pressure between 5 and 10 mmHG. The administration of fluids with dextrose should be avoided, as it may prolong the need for insulin.

Since most patients are also recipients of a kidney transplant, close monitoring of urinary output must be performed simultaneously. In the event of polyuria (urinary output >150 ml/h), aggressive volume reposition should be perfomed, usually at a rate of 1:1 during the first 24 h, and thereafter at a rate of 0.7:1 to avoind prolonging the polyuria. Fluid solution should be selected according to acid–base and electrolyte homeostasis, with 0.9% or 0.45% sodium chloride often being the first line of treatment.

In the event of delayed graft function and oliguria (urinary output <50 ml/day), fluids should be restricted to those needed for the minimum daily calories and electrolyte intake to avoid hastening the need for dialysis intended for volume management. When needed, dialysis modality (continuous vs. intermittent) should be discussed with the nephrologist and risk benefits must be weighed—intermittent dialysis may be performed with the need for anticoagulation, and with low ultrafiltration volumes, reducing the risk of surgical complications, while continous dialysis reduces hemodynamic instability and therefore decreases the risk of reducing organ perfusion.

Anemia is frequent among patients with ESRD. It is important to maintain adequate levels of hemoglobin (Hgb >10 mg/dl), especially in the case of postoperative bleeding. Controversy exists regarding the need for immediate anticoagulation (vide Section 8—prophylaxis).

Both hypotension and hypertension should be avoided. A systolic blood pressure < 100 mmHG increases the risk of arterial and venous thrombosis of the graft, especially in the immediate postoperative period. On the other hand, prolonged severe hypertension can lead to a stroke or myocardial infarction and may increase the risk of intra-abdominal hemorrhage. It is advisable to maintain the systolic pressure between 120 and 160 mmHg during the first 24 h post-transplant to ensure adequate perfusion of the graft and minimize the risk of adverse effects.
