BACKGROUND
Anaesthesia influences patient safety and outcome during renal transplant (RT) surgery. Departmental policies accentuate specifics of RT anaesthesia and may improve anaesthetic quality.

GOAL OF STUDY
Compare specific aspects of intra- and early postoperative anaesthetic practice in the UK centres. Assess departmental policies, adherence to them, view on their usefulness.

MATERIALS AND METHODS
Service evaluation between Sept 2014 and Feb 2015. SurveyMonkey questionnaire distributed to all UK centres for adult RT, with request to share departmental policy for adult RT anaesthesia.
122 anaesthetists from 20 centres responded. 3 centres have not returned any data.
Individual tactics for premedication, monitoring, fluid management, use of specific anaesthetic and graft survival related drugs, and post-operative management were studied. 
11 centres shared their policy for RT anaesthesia with us.
Individual and policy data analyzed against current evidence.

RESULTS

Intraoperative monitoring
* cardiac output / GDFA: 21%; non-invasive (ODM, ClearSight) 17%, pulse contour analysis (LidcoRAPID, Vigileo) 4%
* ART/invasive BP 14%, CVP 84%
* miscellaneous: temperature 99%, NMT 77%, ST segment 62%, 

Intraoperative analgesia
* fentanyl boluses 47%, fentanyl + morphine boluses 25%,
 remifentanil infusion followed by fentanyl or morphine bolus 29%
* routine paracetamol IV 46%

Intraoperative muscle relaxation and anaesthesia maintenance
* atracurium / cisatracurium 95%, rocuronium 5% (mainly for RSI in hyperkalaemic patients);     * DES 49%, SEVO 33%, ISO 14%

Specific medication use to improve graft function
* mannitol 57%, furosemide 33%, low-dose dopamine infusion 20%
* mainly determined by local policy and/or surgeon’s preference

Hemodynamic targets for reperfusion stage (equivocal / variable)
* CVP: 10-12 mmHg – 50%, surgeon’s opinion / graft appearance 25%, also: “trend rather than sole number”, “particular increase from initial”
* some respondents not relying on CVP, but rather cardiac output monitor
* MAP: 70-80 mmHg – 23%, surgeon’s opinion / graft appearance 37%, depending on patient’s baseline 73% 

Fluid choice for maintenance and volume loading
* Hartmann’s/Ringer lactate 54%, NaCl 0.9% - 53%, starch solution 0%

Postoperative analgesia
* Recovery: fentanyl 70%, morphine 26%, IV paracetamol 43%
* Ward: IV/PO paracetamol 100% (94% - regular), “usual” NSAIDs 0%, nefopam - 1 response;
• opioid PCA 98%, mainly fentanyl 20mcg / 5min - 49%
* Regional / local:   • LA wound infiltration by surgeons 42%,
• single shot TAP block 43%: by anaesthetists - 34% (mainly postoperatively under US guidance), by surgeons (direct vision) - 9%
* catheters used rarely – TAP 3%, wound 7%

Departmental policies
* policy known to be available - 77% of respondents
* adhered to – completely 48%, partially 25% 
* opinion on policy quality: adequate 59%, improvement potential 15%, poorly written / not research driven / misleading – 3%
* useful guidance for all anaesthetic grades 83%, aids trainee adaptation / increases confidence / aids setting standards of training 20%

DISCUSSION
Along with similarities, numerous differences exist, both between centres and between specialists of the same centre. 
* Neuromuscular transmission monitored only by 77% and not highlighted in all policies. To avoid inadequate relaxation (with risk of graft expulsion, anastomotic rupture) and end-of-anaesthesia neuromuscular blockade reversal, 100% inclusion of NMT monitoring in policies and compliance advisable.
* CVP / MAP targets for reperfusion are equivocal, and approached to in combination with graft appearance, surgeon's opinion, etc., not as sole numbers.
* There is also a notable trend to use cardiac output monitoring / GDFA.
* Rocuronium used by 5% of respondents in view of reversibility with sugammadex, mostly for hyperkalaemic patients’ RSI. Recommendation to date for RT patients is equivocal. Evidence of safety for rocuronium in ESRD when reversed with sugammadex has been growing recently.

CONCLUSION
* RT anaesthetic management in the UK is in line with current evidence.
* Departmental policies to date are welcomed by the majority of anaesthetists, found to be helpful and adhered to, however potential for their development and standardization exists.
* Lack of solid evidence for all domains of perioperative renal transplant management is complicating creation of an “ideal” policy.

Anaesthesia for adult renal transplant surgery: survey of current practice in the United Kingdom