Heart transplant recipient for appendicectomy52-year-old man, 80 kg, for urgent laparoscopic appendicectomy (acute appendicitis)

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 52-year-old heart transplant recipient on tacrolimus, for urgent laparoscopic appendicectomy. Patient
   • Urgency: urgent appendicitis, so hours to prepare, not days. Stem trigger
   • Active cardiac conditions? None on history, but graft vasculopathy can cause ischaemia without chest pain. Disease
   • Risk score: intraperitoneal surgery; creatinine 1.8 is under 2.0. RCRI 1.
   • Functional capacity: two flights without symptoms, over 4 METs.
   • Decision: proceed today, with his transplant team involved.
   • Denervated graft: his rate cannot rise by reflex, so his output depends on preload.

2. Prepare

   How do you prepare him?

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   • Call his transplant team; tacrolimus level and renal function checked today. (Disease)
   • Recent echo for graft function, and his latest rejection and vasculopathy screening.
   • Tacrolimus and mycophenolate continue without missed doses; fluid shifts can drop levels.
   • Tacrolimus is CYP3A4-metabolised; azoles and macrolides can raise calcineurin inhibitor levels.
   • No NSAIDs for him; they add to calcineurin inhibitor kidney injury.
   • Prednisolone 7.5 mg daily: hydrocortisone 50–75 mg IV at induction, tapering over 1–2 days.
   • Strict asepsis for every line; he is immunosuppressed.

3. Plan

   What is your anaesthetic plan?

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   • Arterial line; keep him well filled before induction and insufflation. Disease
   • Isoprenaline and adrenaline ready; atropine won't speed this heart.
   • Direct pressors such as phenylephrine or noradrenaline; avoid ephedrine.
   • Use relaxant only as needed; reverse with sugammadex 2 mg/kg rather than neostigmine.
   • HDU care; oral immunosuppression restarts early with the transplant team. After surgery

4. Crisis

   At insufflation BP falls to 76/48 and HR stays at 98. What do you do?

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   • No reflex tachycardia here; this is lost preload from the pneumoperitoneum. (Crisis)
   • Ask to deflate or lower pressure; give a fluid bolus.
   • Phenylephrine 50–100 mcg or a noradrenaline infusion, since direct agents work.
   • If he needs rate, isoprenaline 2–10 mcg/min, titrated to his heart rate.
   • Echo if no response, for graft dysfunction or ischaemia.

5. Crisis

   A colleague reversed him with neostigmine and glycopyrrolate; HR is now 38, BP 70/40. What now?

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   • Bradycardia algorithm: HR 38, BP 70/40 after neostigmine, in a transplanted heart. Crisis
   • Reversible cause: neostigmine, known to cause bradycardia and asystole after transplant.
   • His branch: atropine is the usual first drug, but his denervated heart won't respond.
   • So isoprenaline 2–10 mcg/min; adrenaline 2–10 mcg/min if still slow.
   • Drugs failing: pads on and transcutaneous pacing, while transvenous pacing is arranged.
   • Pulseless at any point: CPR, with adrenaline 1 mg every 3–5 minutes.
   • ICU, transplant team informed, and no neostigmine for him in future. After surgery