Challenging the old traditions in renal transplantation: Enhanced recovery after renal transplantation

Abstract

Background: Despite recent evidence showing the benefit of multimodal care programmes in many surgical subspecialties, local practice in the renal transplant unit at Sheffield teaching hospitals is currently based on traditional perioperative care. Some of these included unnecessary delay in discharge planning and patient education. Also old traditions in anaesthetic techniques and leaving catheter and lines longer than necessary led to delayed recovery and subsequently longer length of stay. There is wrong belief among renal transplant surgeons and physicians that enhanced recovery can not be applied to these immunocompromised patients who are ASA III. Aim: To prove that the principle of enhanced recovery is applicable in renal transplant recipients with improvement in the patient care. Methods: We adopted a multidisciplinary team approach involving surgeons, anaesthetists, physicians and nurses. Patient education and discharge planning are commenced before transplantation. Goal-directed fluid management using Lithium Dilution Cardiac Output monitor (LIDCOrapid ) helped to achieve adequate fluid balance during the operation. Intrathecal diamorphine and TAP block with minimal use of intravenous morphine improved postoperative pain control without increase in PONV. Patients commenced fluid intake few hours after the operation and oral feeding next day morning. Urinary catheter and drains were removed 3 to 4 days after the operation. This allowed continuing patient education and early mobilization and subsequently early discharge without increase in the readmission rate. Results: patients were discharged within 5 to 7 days (mean 6) after surgery with enhanced recovery, compared to 6 and 23 days (mean 9.2) with traditional recovery. Conclusion: The principle of enhanced recovery is applicable in this category of immunocompromised high risk patients. When a standardised, multidisciplinary pathway is implemented and managed correctly, reductions in the length of stay can be achieved without compromising the patients' care.