A presentation to help new pediatric transplant nurses manage the post-operative kidney transplant patient

1. z
POST-OPERATIVE
NURSING CARE
Instructor: Joanne Landers,
BSN RN CPN CCTN
PEDIATRIC KIDNEY
TRANSPLANTATION

2. z
Assessment and Monitoring
 Assess respiratory status, vital signs and perfusion
 Assess neuro status
 Blow-by oxygen as needed
 Notify provider immediately for hypotension or severe hypertension
 Assess fluid balance – review fluid management orders
 Assess urine output via Foley catheter
 Check IV sites and IV fluid infusions
 Continuous cardiorespiratory and 02 saturation monitoring

3. z
Assess Surgical Sites & Skin
 Assess primary surgical site for bleeding and dressing condition
 Assess other surgical sites such as previous PD catheter site
(abdomen)
 Assess JP drain site and drainage in bulb
 Full skin survey for pressure areas and abnormalities

4. z
Review All Orders
 Review orders for IV fluids – urine replacement fluids and insensible
fluids
 Review all care orders – hourly VS and hourly fluid management
 Strict I & O’s – hourly calculations
 NPO (sometimes sips allowed but include in replacement fluids)
 Review all medication orders

5. z
Insensible Water Losses
Insensible water losses pertain to body water that is lost through
evaporation which occurs naturally through the skin and lungs. These
losses cannot be accurately calculated. Insensible losses increase during
and after surgery and are effected by environmental heat and humidity,
activity and complications such as fever and infection. In pediatrics,
insensible losses are calculated using a ratio of water to calorie
expenditure. The insensible water losses of hospitalized children varies
from 30 to 45 cc/100 Cal/day.

6. z
Hourly Fluid Management
 Measure urine and JP drain output on the hour
Example: from 12noon to 1pm, the patient had 100cc’s of urine out and
20cc’s of JP drainage for total of 120 cc’s out.
From 1pm to 2pm, run the IV normal saline (replacement fluid) at 120cc’s
per hour. Then measure urine and JP output from 1pm to 2pm and
repeat replacement via IV normal saline again.
Note: IV fluid will run continuously at the same time to replace insensible
losses at a steady rate.

7. z
It’s 2 O’Clock. What is the fluid balance?
 Using the hourly 1:1 IV fluid replacement process for urine and JP
drainage insures that you will have a precise measurement of your
patient’s fluid balance every hour.
 You will have strict control of your patient’s fluid balance so that it does
not become too negative risking impaired perfusion or too positive risking
fluid overload.
 The fluid balance each hour should always be +insensible loss hourly
rate because of the 1:1 adjustable replacement of urine and JP output.

8. z
Review Transplant Kidney Protocol
 Q 6 hr extended chemistry panel
 Q 12 hr CBC/diff
 Daily UA and urine electrolytes
 Renal Ultrasound performed immediately post-op
 MAG3 scan on POD #1
 Weight POD #0-1 (weight gain of 1 gram=+fluid balance of 100cc’s)
 Immunosuppression and anti-viral medications

9. z
Transplant Medications
Immunosuppression
 Pre-operative- IV altuzumab (Campath)
 Pre-op & post-op – IV methylprednisolone, IV or PO mycophenolate (Cellcept)
 PO Tacrolimus (Prograf) – not started until urine output is adequate &
BUN/creatinine are trending down (usually 2-7 days post-transplant)
Antibiotics
 Perioperative- IV Cefazolin
 Post-op- PO atovoquone (Mepron) for prophylaxis of PCP
Anti-virals
 Pre-op & Post-op- IV ganciclovir for prophylaxis of CMV infection

10. z
Complications
Bleeding Impaired renal perfusion
Fever/infection Electrolyte imbalance (hyperkalemia)
Hypotension or hypertension Acute pain
Hyperacute rejection Fluid overload
Anuria/delayed graft function (ATN) Hypovolemia

11. z
Clinical Signs &
Symptoms of Complications
Fever higher than 38.5c Severe chills or rigors
Severe abdominal or back pain Tachycardia or tachypnea
Persistent hypotension Severe hypertension
Urine output less than 1ml/kg/hr HCT/HGB drops
Urine output decreases/stops BUN/creatinine trend up

12. z
Education, Comfort and Support
 Explain nursing care to patient and family
 Provide reassurance about patient condition and graft function
 Provide comfort items such as stuffed animal and special blanket
 Review pain management plan with patient and family
 Encourage rest and nutrition for family
 Consult social worker for support and services
 Provide education for proper handwashing for all family and visitors
 No sick visitors

13. z
Responding to Complications
 Notify transplant team of concerns
 Maintain NPO status
 Increase frequency of VS
 Insure IV access and maintain infusions
 Insure patency of Foley catheter
 Assess pain management
 Accompany patient to diagnostics – emergency ultrasound or
Mag 3 scan
 Teaching and emotional support for patient and family

14. z
References
American Society of Transplantation. (2015). Pediatric kidney transplantation: A
guide for patients and families. Retrieved from
https://www.myast.org/sites/default/files/Pediatric%20Kidney%20Transplantatio
n%20BrochureAST%20%20-%20final%20copy%202015-06-27_0.pdf
Cruzado, J., Melilli, E. (2017). Looking for the needle in the kidney
transplantation haystack. Clinical Kidney Journal, 10(1), 95-96.
Richards, C. (2016). Pediatric renal transplantation. Nephrology Nursing
Journal, 43(1), 35-38.
Saeed, B. (2012). Pediatric renal transplantation. International Journal of Organ
Transplant Medicine, 3(2), 62-73.
Slota, P., Seward, L., O’Brien, P, Angeletti, C. (2001). Organ transplantation.
Critical Care Nursing of Infants and Children (2nd Ed.). Philadelphia, PA:
Saunders, 910-915.
Zilinska, Z. et al. (2010). Vascular complications after renal transplantation.
Bratisi Lek Listy (Slovakia), 111(11), 586-589.