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BackgroundThere is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. MethodsA 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. ResultsA 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. ConclusionsThis questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

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The technique of early extubation after coronary artery bypass grafting is increasing in popularity, but its safety and effect on myocardial ischaemia remain to be established. In a randomized, prospective study, patients undergoing routine elective coronary artery bypass grafting were managed with either early or late tracheal extubation. The incidence and severity of electrocardiographic myocardial ischaemia were compared. Data were analysed from 85 patients (43 early extubation; 42 late extubation). Median time to extubation was 110 min in the early extubation patients and 757 min in the late extubation patients. After correction for randomization bias, there were no significant differences between groups in ischaemic burden, maximal ST-segment deviation, incidence of ischaemia and area under the ST deviation-time curve (integral of ST deviation and time). Similarly, there were no differences between groups in postoperative creatine kinase MB-isoenzyme concentrations and duration of stay in the ICU or hospital. Therefore, this study provides evidence for the safety of early extubation after routine coronary artery bypass grafting.

SummaryA randomised double-blind clinical trial was conducted on 106 patients scheduled for pulmonary resection. Patients received an epidural infusion containing 0.1%, 0.2% bupivacaine or saline in combination with fentanyl 10 mg.ml ¹1 . Adequacy of analgesia was assessed at rest and during movement over 24 h. Analgesic efficacy was assessed using visual analogue scores and an observer/ verbal ranking scale. Pain scores were higher in the fentanyl-only group at the 2 h assessment (p < 0.05). Otherwise, there were no between-group differences in pain scores or in the total amounts of epidural solution used. All patients received continuous haemodynamic monitoring. There were no between-group differences in the number of episodes of hypotension or in the number of interventions for hypotension. However, the use of intra-operative vasopressor and the incidence of temporary neurological complications was higher in the 0.2% bupivacaine group (p < 0.05). We conclude that, in the early postoperative period, the addition of bupivacaine 0.1% improves fentanyl epidural analgesia in patients undergoing lung resection and is not associated with the disadvantages seen with the addition of bupivacaine 0.2%.