Anesthesia for Organ Surgery & Transplantation Flashcards
Transplantation is expanding. We are now transplanting organs in:
- advanced age
- HIV
- drug addicts such as _______ patients
- alcoholics
methadone
**there may be some specifications to be able to get transplant - i.e. alcoholics may have to be 1 year sober
_____ donor grafts have greater success and survival rates than ______ donor grafts.
Living > deceased
FYI: Stats 2010 vs. 2015
122,071 vs 110,375 awaiting organs
22 vs. 18 die every day while waiting
1 organ donor can save up to __ lives
2011: 60% of transplant cases were people 50+
8 lives
Review graphs on slides 5-8.
Slide 5: WAY more patients on waiting list than there are donors (*donors fall very short of people on the waiting list and actual transplant)
Slide 6: Transplants by Organ - kidney (most common) > liver > heart > lung > kidney/pancreas, etc.
Slide 7: Transplants by Ethnicity - White > black > Hispanic > Asian, etc.
Slide 8: Transplantations by State (more in larger states w/ higher populations i.e. California)
Kidney and pancreas transplants are typically performed by ______ anesthetists.
Liver transplants are usually performed using a highly specialized team trained in liver transplantation.
Heart transplantation also utilizes a specialized team.
non-specialized
Kidney Transplantation:
Better survival rate than ______ at 3 years.
_____ effects on other organ systems make for a challenging anesthetic - patients are very sick.
High incidence of _____ disease, ____, and ______.
hemodialysis
ESRD
cardiac, HTN, diabetes
Kidney transplant indications:
- ______ disease
- ______ kidney disease
- ______
- ____
- ______ disease
glomerular polycystic diabetes HTN congenital
Characteristics of ESRD Patients:
1) _____ disease is most common cause of death.
2) _____-induced myocardial depression (normalizes after transplant)
3) _______
4) _______ (60% have LVH or RVH)
5) _______
6) Electrolyte abnormalities - esp. elevated ___
cardiac uremia-induced pericarditis cardiomyopathies dysrhythmias K+
ESRD & Cardiomyopathy:
1) Chronic ____ state d/t increasing circulating ___ ____, ____ _____, and ___ _____.
2) LVH and ______ cardiomyopathy related to increased ______.
3) _____ cardiomyopathy related to increased _____ ______.
1 - HTN - fluid volume, renin levels, Na+ retention
2 - concentric - afterload
3 - dilated - fluid volume
**These patients have poor heart function
Effect of Uremic Toxins w/ ESRD:
1) ______ disease
2) Altered _____ metabolism
3) ______
4) Small vessel ______ (esp. ______)
5) Decreased ____ ____*
6) _____ defects (hypercoagulation)
7) _____
1 - pericardial
2 - lipid
3 - dysrhythmias
4 - atherosclerosis - coronaries **BIG risk for MI
5 - gastric emptying (>0.4 mL/kg = FULL STOMACH)
6 - platelet
7 - anemia **kidneys not helping to produce RBCS - their bodies have adapted though so we don’t transfuse
Kidney transplantation surgical outcomes is based on 3 variables:
1) _____ management
2) harvested organ ______
3) Perioperative care of organ ______
donor management
harvested organ preservation
organ recipient
Anesthesia Implications for LIVING DONOR management for kidney transplantation:
Adequate ____ access and _____ availability:
- Greatest risk is ______
- Hydration ensures ______
- Offsets a reduced ____ ____ r/t flank position
IV, blood
hemorrhage
diuresis
venous return
*patients are in weird positions (can see more in reading on Access Anesthesiology)
Anesthesia implications for BRAIN DEAD DONOR for kidney transplantation:
1) _____ preservation is highest priority - the loss of sympathetic tone can cause ______. It can occur regardless of volume replacement. Ischemic insult can result in inability to transplant.
2) Maintain renal ______ of graft. Use low dose _____ (__-__mcg/kg/min) and AVOID high dose _______ which can lead to ischemia.
3) Maintain ____ _____: can use _______
1 - graft - hypotension
2 - perfusion - dopamine (1-3 mcg/kg/min) - vasopressors
dopamine opens renal afferents to increase perfusion
3 - urinary output - diuretics
The number of kidney transplant contraindications continue to DECLINE. Contraindications may vary by institution.
ABSOLUTE contraindications include:
- active ______
RELATIVE contraindications include: (vary by institution)
- non-compliant ___ or ____ use
- ________
- hepatocellular ______ w/ cirrhosis
infection
drug or ETOH
malignancy
carcinoma
Kidney Transplant Preop Assessment:
- What is the ______ of the renal failure? _____ is #1 cause followed by _____.
- Evaluate comorbid conditions: ESRD, CAD, DM, HTN, autonomic ______, ________
- Labs & Testing:
- Metabolic profile w/ glucose
- EKG & Echo w/ EF
- CBC w/ platelet count
- Type & Crossmatch (LOTS of blood loss expected)
- CAUSE - DM, HTN
2. neuropathy, coagulopathy
Anesthesia Implications for Kidney Transplantation:
- EXPECT hemodynamic ______
- volume overload (when did they get dialyzed last?), cardiomyopathy, weak pump
- ______, _______ upon induction if diabetic r/t autonomic _______ - Have patient hold _____ - shown to _____ BP
- Type and crossmatch SEVERAL units
- Dialyze prior to surgery to optimize fluid ____ and ____ status.
- INSTABILITY - always w/ ESRD; hypotensive, bradycardia, neuropathy
* Often HTN pre-op but have HUGE swings and drops in cardiac system once anesthesia is given - hold ACEI (“prils”) *detrimental in trying to control BP when they take this
- volume, electrolytes *want them as optimized as possible preop
Kidney Transplant: Intraop Considerations
1) A large __-__ inch incision - in the _______ fossa.
- GA is preferred w/ excellent ____ _____
- _____ has been used successfully
- ____ _____ is the preferred crystalloid
- Caution w/ non-depolarizing NMBA (using ______ may be beneficial)
- A-line for optimal hemodynamic control & frequent blood sampling
- CVL for ____ management & monitoring - keep CVP between ___-___ mmHg.
8-10 inch incision - extraperitoneal fossa
muscle paralysis
regional
normal saline (NO LR d/t K+)
cisatricurium (Hoffman elimination) *most others are eliminated renally & suggamadex is CI in ESRD
fluid - 10-15 mmHg
Kidney Transplant: Intraop Considerations
2) _____ is common after unclamping iliac vessels d/t metabolites being released.
3) Graft kidney DEPENDS on adequate ______
- avoid ______
- studies show vessels of transplanted organs are highly sensitive to _______
- avoid high doses of ___ _ agonists
- renal dose _____ is beneficial (D1 receptor)
4) Immediate ___ ____ in most recipients
2 - hypotension
3 - perfusion hypotension sympathomimetics (easy to overshoot w/ giving pressors) alpha 1 agonists dopamine
4 - urine production
Kidney Transplantation: Postop Considerations
1) completely _____ muscle relaxants
2) Goal is ______ immediately after surgery
3) Rarely (<1%) admit to ____ postop
4) Postop pain is usually _____ controlled
1 - reverse
2 - extubation
3 - ICU
4 - easily
Pancreatic transplantation is primarily to cure ____ _____.
______ is present in 50-60% of diabetics causing many to receive ____ AND pancreas.
All of the comorbid conditions that result from long-term diabetes are typically present:
- Autonomic ______ & ______
- IHD, CAD
- HTN
- ESRD
diabetes mellitus
nephropathy - kidney
neuropathy, gastroparesis
Pancreatic Transplant: Intraop Considerations
1) ____ surgery time
2) ____, _____ incision
3) Extensive _____ to pancreas requires LOTS of _____ (epidurals have shown promise w/ pain management)
4) _______ is increased
1 - LONG
2 - large, painful
3 - dissection - NMBA - needs to be very paralyzed
4 - immunosuppression
Pancreatic Transplantation: Intraop Management
1) A-line to optimize hemodynamic status
2) _____ swell pancreas LESS than ______
3) CVL to optimize fluid volume and monitoring (CVP)
4) Frequent blood sampling
- ______
- Serial ____ measurements: checked ____ prior to unclamping and checked every ____ minutes after unclamping.
5) Success of graft is measured by _____ _____
2 - colloids, crystalloids 4 - electrolytes glucose hourly before, Q30 min after 5 - glucose levels *glycemic reduction indicates successful transplant
Liver transplantation has an increased discrepancy between organ supply and recipient waiting list. It is a more extensive surgery and ALL organs may be affected by end-stage liver disease.
The 3 year survival rate is >75%.
Hep C recipients may require _______ in the future.
re-transplanting
End-Stage Liver Disease & Pathophysiology:
1) Portal ____ develops: _____ changes increase portal resistance, portal venous pressures are > ___ mmHg
2) ______ circulatory state related: vaso_____ and volume ______
3) Increased ____ can occur.
4) Increased _____ levels can lead to encephalopathy (confusion)
5) Upper GI bleeding r/t ______
1 - HTN - cirrhotic - >12 mmHg
2 - hyperdynamic - vasodilation, volume expansion
3 - ICP
4 - ammonia
5 - varicosities
Liver Transplantation Indications:
1) Post-necrotic (non-alcoholic) ______ (portal HTN, hyperdynamic status)
2) Biliary _____
3) Sclerosing cholangitis
4) Primary hepatic ______
5) _____ cirrhosis
1 - cirrhosis
2 - cirrhosis
4 - neoplasia
5 - alcoholic
Liver Transplant Presenting Medical Issues:
1) Hepato- & Porto-pulmonary syndrome results in decreased ____ and ______ - it resolves after transplantation.
2) Cardiac status: the hyperdynamic state results in ____, ___ SVR, ___ HR, and ___-___ BP.
3) Coagulation disorders: _____ factors II, V, VII, IX, X, protein C, S, antithrombin III, and thrombocytopenia - all promote increased _____!
4) Accompanying renal disease is common d/t hepatorenal disease r/t liver releasing chemical mediators that _____ ___ but kidney responds by sensing low perfusion and increasing ____ secretion leading to _______.
1 - PaO2 and shunting
2 - ascites, low SVR, increased HR, normal-low BP (lots of fluid shifts w/ these pts.)
3 - decreased factors/platelets - increased bleeding (***can easily bleed out - BLEEDING is BIGGEST intraop concern)
4 - vasodilate SVR, renin, vasoconstriction (read chapter to learn more)
Liver Transplantation: Preop Preparation
1) Extensive multi-specialty workup required.
- _____ studies
- pulmonary, cardiology, nephrology
2) Cardiac evaluation
- EKG
- Echo: EF, cardiomyopathy, portal HTN
- Arteriogram - assess vascular issues
- Right heart cath - assess pulmonary vascular status
3) Type and crossmatch - blood product prep
- ___ units PRBCs, ___ units FFP, platelets, cryo
1 - hematology-coagulation
3 - 10 units PRBCs, 10 units FFP
- want to have a lot of product ready & available
- also lots of blood draws
Liver Transplant Monitoring:
1) Correct ______ prior to line placement.
2) Need dependable large bore IV access for ____ and _____ administration.
3) A-line to monitor hemodynamic instability and for frequent blood draws.
4) CVL: CVP measurements used in 50% of treatment centers
5) Telemetry
6) TEE: used in 11% of treatment centers
7) PA catheters: used in 30% of treatment centers to assess ____ ____
1 - coagulopathy
2 - fluids, blood products
7 - pulmonary HTN
Name the 3 stages of the liver transplantation procedure:
1 - Dissection
2 - anhepatic
3 - reperfusion
3 Stages of Liver Transplantation:
1) Dissection: extensive ____ of _____
2) Anhepatic: _____ of native liver and ______ donor
3) Reperfusion (neohepatic): anastomosis, _____ hemostasis, and ______ (*this stage is complex and very challenging)
1 - lysis of adhesions
2 - removal, implanting
3 - restore, reperfusion
Liver Transplantation: Intraop Considerations
1) Liver failure & drug metabolism: _____ biotransformation, hypo______ (_____ is altered), altered _______
2) Hemodynamic fluctuations: ____/_____ portal vein and vena cava (can cause significant BP jumps/drops) & veno-venous bypass (VVBP)
3) Venous ___ _____ upon reperfusion of the hepatic graft and _____ syndrome
4) Significant ______ - anticipate significant blood loss.
5) ______ d/t increased ammonia levels
1 - decreased, hypoalbuminemia (protein-binding), altered volume of distribution
2- clamping/unclamping
3 - air embolism, reperfusion
4 - coagulopathy (*can just give PRBCs - they need coags too)
5 - encephalopathy
Liver Transplantation: Intraop Management
Management varies widely between institutions - there is no standard.
1) Extensive blood and fluid status management:
- ascites decompression results in ______
- manipulation of liver impedes ____ _____
- IVC occluded can cause severe ______ (>50% ____ in CO)
2) Challenge to pharmacologically manage:
- removal of one liver, implanting of another
- _____ used to gauge function of new liver
- ____ _____ for varices bleeding
3) Oral gastric tube: decompress gastric cavity to increase _____ exposure; expect _____ r/t varices an coagulopathy
1 - hypotension; venous return; hypotension; reduction
*need pressors at beginning of case (very significant reduction)
2 - NMBA; beta blockers
3 - liver; bleeding
Liver Transplantation: Intraop Management
4) Keep normothermic: ice cold donor liver - can worsen _____ and drug ______
5) Avoid ____ intestinal distention
6) Impaired insulin-mediated glucose uptake: _____ is common
7) Renal alterations: ______ and ______ (can cause pontine myelinolysis w/ rapid ____ replacement)
8) Severe coagulopathy and blood MOST SIGNIFICANT issue w/ liver transplantation:
- no standard, varies widely among centers
- extremely complex hemostasis management!!!
- marked ____ and _____ occur
4 - coagulopathy (cold reduces function) & metabolism (impairs enzymes)
5 - N2O
6 - hyperglycemia (will likely give insulin)
7 - hyperkalemia, hyponatremia (Na+)
8 - acidosis and hypocalcemia (from blood products?)
Heart transplant is the definitive treatment for terminal heart disease. 90% are for idiopathic _____ ______ and ____ ____ disease.
The remaining 10% are for congenital, valvular heart disease, cardiac tumor, life-threatening arrhythmias, and repeat transplants.
dilated cardiomyopathy
ischemic heart
Goals of Heart Transplant Surgery:
1) Maintain ____ _____ by optimizing SBP.
2) Ensure optimal _____
3) _____ reduction w/ goal of increasing ___
4) Avoid ____ _____ (oxygenate, normocapnic, normal Vt, and normal pH)
5) Promote ______ (drugs, assistive devices, balloon pumps)
1 - coronary filling 2 - preload 3 - afterload, EF 4 - pulmonary vasoconstriction (failure easy to do if good pulmonary function) 5 - contractility
Heart Transplant Monitoring:
1) A-line
2) CVL - CVP
3) PA catheter: pulled back to the ___ prior to ____ of heart.
4) TEE: assesses ____, ___, _____, ____ functioning, and presence of _____.
3 - IJ, excision
4 - volume, air, contractility, valve fx, thrombus
**TEE is VERY valuable
Heart Transplantation: Intraop Considerations
1) Heart is ______: the response to hemodynamic changes is _______. Indirect heart drugs are ___ effective. Use _____ and ______.
2) Right-sided heart failure r/t pulmonary HTN:
- can treat pulm. HTN w/ ___ ___ (vasodilator and reduces SVR)
- can use _____ support to increase RV _______
1 - denervated - eliminated; NOT; pacing, isoproterenol
2 - nitrous oxide - inotropic support - contractility
