**2. Components of perioperative care**

Perioperative care for organ transplant candidate/recipient is an exceedingly complex and multifaceted enterprise. It comprises three main components.

**A.** Preoperative care begins from selection of the proper candidate. In today's realm of organ transplantation, the current trend of performing combined, more complicated organ transplants on ever-increasing number of sick patients with severe cardiopulmonary, renal, endocrine co-morbidities, once considered as posing insurmountably high risk, prohibitive for surgery, is quickly becoming an everyday reality. At this stage, a person's medical and surgical history and current disease status, treatment progress, success or lack thereof, and compliance with numerous medication regimes are being reviewed. The critical portion of the selection includes a great deal of current functional status assessment, ability to tolerate multiple challenges of organ transplant surgery and postoperative period, and, most importantly, prediction of outcome, immediate and long-term. There are numerous prediction algorithms and systems, such as MELD score for liver transplant candidates, for example. The degree of functional impairment (after all, majority of patients suffer from end-stage organ failure, sometimes severe multi-organ insufficiency) is a matter of continuous re-assessment and optimization, whenever appropriate and feasible, in preparation to actual organ transplantation surgery. Numerous diagnostic studies, some of which invasive, are employed at this stage to pinpoint the problem and track the treatment progress.

This stage also includes an assessment of patient's mental status, habits, lifestyle, social and financial aspects, geographical factors, housing and transportation particulars, availability of family support in the posttransplant period, coping skills and intellectual capacity, illicit drug use and alcohol consumption, and many other pieces of the information, necessary to make an initial selection, and keep the candidacy active.

The organ transplant surgery is a culmination of the transplantation process, the central and most important part of the whole enterprise. The very possibility of the surgery is contingent on availability, oftentimes immediate, and proper quality of the donor organ. Current policies and practices of organ donation and sharing,

**5**

*Introductory Chapter: Tour De Force of Transplantation Science*

procurement and conservation techniques comprise a huge field of scientific and practical knowledge, and their discussion is beyond the scope of this book.

**B.** Intraoperative care for organ transplant recipient, even in the relatively straightforward cases, is by far one of the most challenging tasks the anesthesiologist ever encounters in his/her practice. The spectrum of problems and challenges include choice of particular anesthesia technique (that depends on organ failure involved and other patient-related factors), significant, sometimes life-threatening hemodynamic disturbances and acid-base/electrolytes disbalance, major ongoing blood loss, massive blood products administration, coagulation deficit correction, necessity of temporary organ replacement techniques (such as intraoperative dialysis), use of case- and organ-specific technologies and modalities, such as use of vasoactive agents for hemodynamic optimization, TEE, ECMO, total circulatory arrest, and plenty more. Some of the most challenging aspects of anesthesia care for transplant recipient include unpredictability of the timing (it is literally 24/7, no exclusions) and length of procedures, and, with evergrowing body of practical experience, incidence of unanticipated, rare complications, such as stress cardiomyopathy or intraoperative myocardial infarction. For all these reasons, and more, transplant anesthesiology has been established as one of the major independent subspecialties in the field of anesthesiology. Immediate postoperative care is an inseparable part of this stage. The challenges here, albeit quite similar to those encountered in the operating room, are different in many ways (time resolution, for one). The reasons of major morbidity and mortality of freshly transplanted patient include variety of cardiovascular complications; primary transplanted organ dis- and non-function; super-acute rejection; and numerous surgery-specific complications, such as hemorrhage, vascular thrombosis, dehiscence, bronchial anastomosis leaks, biliary leaks, wound infections/septic state, and also plenty of seemingly trivial, matter-of-everyday-practice problems, such as hemodynamic instability, blood glucose fluctuations, acid-base disturbances, ventilator-associated problems, pulmonary complications (pulmonary edema, ARDS, pneumonias, atelectasis), and early cognitive dysfunctions—all of which require immediate and apt attention and incessant efforts directed on

*DOI: http://dx.doi.org/10.5772/intechopen.87078*

correction, as soon and as complete as possible.

patient and organ survival and well-being.

**C.** Later, posttransplant care encompasses the time period from recipient's discharge form critical care unit until discharge from the hospital. The time frame for this stage varies (the range is from days to months), due to transplanted organ-, surgery-, related specifics, early complications and other medical conditions. At this stage, clinicians face quite different and very specific set of challenges, which includes choice and maintenance of immunosuppressive therapy; early, late, sub-acute, and chronic rejections; late organ dysfunctions; transition from pretransplant organ-specific hemodynamic profile to normalized one; wide variety of infectious complications (opportunistic bacterial, viral, and fungal infections); exacerbations of chronic diseases; early malignancies; PTSD and other mental, mood, and memory problems, and more. Albeit already not as acute and severe as major immediate perioperative problems, these conditions nevertheless remain as important and, oftentimes, as deadly, and certainly bear an enormous weight on the short- and long-term

Deep understanding and detailed knowledge of these components, their mutual influences, connections, and interactions are necessary conditions for any further

progress in this particular field, both in scientific and practical aspects.

*Perioperative Care for Organ Transplant Recipient*

probably only by cancer and heart research funding.

cated to at least some of the under-covered problems.

**2. Components of perioperative care**

treatment progress.

candidacy active.

of countless research works from all over the world. PubMed search alone returns about 800,000 titles of the indexed publications, pertinent to the field of transplantation, which covers approximately 70% of the total published works on the transplantation-related topics worldwide. There are also numerous books, book chapters, and other publications on these topics, that find their readers every year. Ongoing research is funded by tens of millions dollars and euros; these funds are coming from various government organizations and private investors, surpassed

And yet, among countless publications, covering most areas in this particular field, such a specific segment of key importance as perioperative care for the organ recipient remains underrepresented, and many topics of it still uncovered. The resulting lack of big, prospective studies, along with relative scarcity of conceptual level review articles, has prompted us to choose the main topic of this book, with the true intention to fill in the gap by collecting and presenting the articles dedi-

Perioperative care for organ transplant candidate/recipient is an exceedingly

**A.** Preoperative care begins from selection of the proper candidate. In today's realm of organ transplantation, the current trend of performing combined, more complicated organ transplants on ever-increasing number of sick patients with severe cardiopulmonary, renal, endocrine co-morbidities, once considered as posing insurmountably high risk, prohibitive for surgery, is quickly becoming an everyday reality. At this stage, a person's medical and surgical history and current disease status, treatment progress, success or lack thereof, and compliance with numerous medication regimes are being reviewed. The critical portion of the selection includes a great deal of current functional status assessment, ability to tolerate multiple challenges of organ transplant surgery and postoperative period, and, most importantly, prediction of outcome, immediate and long-term. There are numerous prediction algorithms and systems, such as MELD score for liver transplant candidates, for example. The degree of functional impairment (after all, majority of patients suffer from end-stage organ failure, sometimes severe multi-organ insufficiency) is a matter of continuous re-assessment and optimization, whenever appropriate and feasible, in preparation to actual organ transplantation surgery. Numerous diagnostic studies, some of which invasive, are employed at this stage to pinpoint the problem and track the

This stage also includes an assessment of patient's mental status, habits, lifestyle,

The organ transplant surgery is a culmination of the transplantation process, the

social and financial aspects, geographical factors, housing and transportation particulars, availability of family support in the posttransplant period, coping skills and intellectual capacity, illicit drug use and alcohol consumption, and many other pieces of the information, necessary to make an initial selection, and keep the

central and most important part of the whole enterprise. The very possibility of the surgery is contingent on availability, oftentimes immediate, and proper quality of the donor organ. Current policies and practices of organ donation and sharing,

complex and multifaceted enterprise. It comprises three main components.

**4**

procurement and conservation techniques comprise a huge field of scientific and practical knowledge, and their discussion is beyond the scope of this book.

**B.** Intraoperative care for organ transplant recipient, even in the relatively straightforward cases, is by far one of the most challenging tasks the anesthesiologist ever encounters in his/her practice. The spectrum of problems and challenges include choice of particular anesthesia technique (that depends on organ failure involved and other patient-related factors), significant, sometimes life-threatening hemodynamic disturbances and acid-base/electrolytes disbalance, major ongoing blood loss, massive blood products administration, coagulation deficit correction, necessity of temporary organ replacement techniques (such as intraoperative dialysis), use of case- and organ-specific technologies and modalities, such as use of vasoactive agents for hemodynamic optimization, TEE, ECMO, total circulatory arrest, and plenty more. Some of the most challenging aspects of anesthesia care for transplant recipient include unpredictability of the timing (it is literally 24/7, no exclusions) and length of procedures, and, with evergrowing body of practical experience, incidence of unanticipated, rare complications, such as stress cardiomyopathy or intraoperative myocardial infarction. For all these reasons, and more, transplant anesthesiology has been established as one of the major independent subspecialties in the field of anesthesiology.

Immediate postoperative care is an inseparable part of this stage. The challenges here, albeit quite similar to those encountered in the operating room, are different in many ways (time resolution, for one). The reasons of major morbidity and mortality of freshly transplanted patient include variety of cardiovascular complications; primary transplanted organ dis- and non-function; super-acute rejection; and numerous surgery-specific complications, such as hemorrhage, vascular thrombosis, dehiscence, bronchial anastomosis leaks, biliary leaks, wound infections/septic state, and also plenty of seemingly trivial, matter-of-everyday-practice problems, such as hemodynamic instability, blood glucose fluctuations, acid-base disturbances, ventilator-associated problems, pulmonary complications (pulmonary edema, ARDS, pneumonias, atelectasis), and early cognitive dysfunctions—all of which require immediate and apt attention and incessant efforts directed on correction, as soon and as complete as possible.

**C.** Later, posttransplant care encompasses the time period from recipient's discharge form critical care unit until discharge from the hospital. The time frame for this stage varies (the range is from days to months), due to transplanted organ-, surgery-, related specifics, early complications and other medical conditions. At this stage, clinicians face quite different and very specific set of challenges, which includes choice and maintenance of immunosuppressive therapy; early, late, sub-acute, and chronic rejections; late organ dysfunctions; transition from pretransplant organ-specific hemodynamic profile to normalized one; wide variety of infectious complications (opportunistic bacterial, viral, and fungal infections); exacerbations of chronic diseases; early malignancies; PTSD and other mental, mood, and memory problems, and more. Albeit already not as acute and severe as major immediate perioperative problems, these conditions nevertheless remain as important and, oftentimes, as deadly, and certainly bear an enormous weight on the short- and long-term patient and organ survival and well-being.

Deep understanding and detailed knowledge of these components, their mutual influences, connections, and interactions are necessary conditions for any further progress in this particular field, both in scientific and practical aspects.
