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Principles 2** > Anesthesia for Organ Surgery & Transplantation > Flashcards

Anesthesia for Organ Surgery & Transplantation Flashcards

1
Q

Transplantation is expanding. We are now transplanting organs in:

  • advanced age
  • HIV
  • drug addicts such as _______ patients
  • alcoholics
A

methadone

**there may be some specifications to be able to get transplant - i.e. alcoholics may have to be 1 year sober

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2
Q

_____ donor grafts have greater success and survival rates than ______ donor grafts.

A

Living > deceased

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3
Q

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+

A

8 lives

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4
Q

Review graphs on slides 5-8.

A

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)

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5
Q

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.

A

non-specialized

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6
Q

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 ______.

A

hemodialysis

ESRD

cardiac, HTN, diabetes

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7
Q

Kidney transplant indications:

  • ______ disease
  • ______ kidney disease
  • ______
  • ____
  • ______ disease
A 
glomerular
polycystic 
diabetes
HTN
congenital
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8
Q

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 ___

A 
cardiac 
uremia-induced
pericarditis
cardiomyopathies
dysrhythmias 
K+
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9
Q

ESRD & Cardiomyopathy:

1) Chronic ____ state d/t increasing circulating ___ ____, ____ _____, and ___ _____.
2) LVH and ______ cardiomyopathy related to increased ______.
3) _____ cardiomyopathy related to increased _____ ______.

A

1 - HTN - fluid volume, renin levels, Na+ retention
2 - concentric - afterload
3 - dilated - fluid volume

**These patients have poor heart function

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10
Q

Effect of Uremic Toxins w/ ESRD:

1) ______ disease
2) Altered _____ metabolism
3) ______
4) Small vessel ______ (esp. ______)
5) Decreased ____ ____*
6) _____ defects (hypercoagulation)
7) _____

A

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

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11
Q

Kidney transplantation surgical outcomes is based on 3 variables:

1) _____ management
2) harvested organ ______
3) Perioperative care of organ ______

A

donor management
harvested organ preservation
organ recipient

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12
Q

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
A

IV, blood

hemorrhage
diuresis
venous return

*patients are in weird positions (can see more in reading on Access Anesthesiology)

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13
Q

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 _______

A

1 - graft - hypotension

2 - perfusion - dopamine (1-3 mcg/kg/min) - vasopressors
dopamine opens renal afferents to increase perfusion

3 - urinary output - diuretics

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14
Q

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
A

infection

drug or ETOH
malignancy
carcinoma

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15
Q

Kidney Transplant Preop Assessment:

  1. What is the ______ of the renal failure? _____ is #1 cause followed by _____.
  2. Evaluate comorbid conditions: ESRD, CAD, DM, HTN, autonomic ______, ________
  3. Labs & Testing:
    - Metabolic profile w/ glucose
    - EKG & Echo w/ EF
    - CBC w/ platelet count
    - Type & Crossmatch (LOTS of blood loss expected)
A
  1. CAUSE - DM, HTN

2. neuropathy, coagulopathy

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16
Q

Anesthesia Implications for Kidney Transplantation:

  1. EXPECT hemodynamic ______
    - volume overload (when did they get dialyzed last?), cardiomyopathy, weak pump
    - ______, _______ upon induction if diabetic r/t autonomic _______
  2. Have patient hold _____ - shown to _____ BP
  3. Type and crossmatch SEVERAL units
  4. Dialyze prior to surgery to optimize fluid ____ and ____ status.
A
  1. INSTABILITY - always w/ ESRD; hypotensive, bradycardia, neuropathy
    * Often HTN pre-op but have HUGE swings and drops in cardiac system once anesthesia is given
  2. hold ACEI (“prils”) *detrimental in trying to control BP when they take this
  3. volume, electrolytes *want them as optimized as possible preop
17
Q

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.

A

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

18
Q

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

A

2 - hypotension

3 - perfusion
hypotension
sympathomimetics (easy to overshoot w/ giving pressors)
alpha 1 agonists 
dopamine

4 - urine production

19
Q

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

A

1 - reverse
2 - extubation
3 - ICU
4 - easily

20
Q

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
A

diabetes mellitus
nephropathy - kidney
neuropathy, gastroparesis

21
Q

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

A

1 - LONG
2 - large, painful
3 - dissection - NMBA - needs to be very paralyzed
4 - immunosuppression

22
Q

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 _____ _____

A 
2 - colloids, crystalloids
4 - electrolytes
glucose
hourly before, Q30 min after 
5 - glucose levels *glycemic reduction indicates successful transplant
23
Q

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.

A

re-transplanting

24
Q

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 ______

A

1 - HTN - cirrhotic - >12 mmHg

2 - hyperdynamic - vasodilation, volume expansion

3 - ICP

4 - ammonia

5 - varicosities

25
Q

Liver Transplantation Indications:

1) Post-necrotic (non-alcoholic) ______ (portal HTN, hyperdynamic status)
2) Biliary _____
3) Sclerosing cholangitis
4) Primary hepatic ______
5) _____ cirrhosis

A

1 - cirrhosis
2 - cirrhosis
4 - neoplasia
5 - alcoholic

26
Q

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 _______.

A

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)

27
Q

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

A

1 - hematology-coagulation

3 - 10 units PRBCs, 10 units FFP

  • want to have a lot of product ready & available
  • also lots of blood draws
28
Q

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 ____ ____

A

1 - coagulopathy
2 - fluids, blood products
7 - pulmonary HTN

29
Q

Name the 3 stages of the liver transplantation procedure:

A

1 - Dissection
2 - anhepatic
3 - reperfusion

30
Q

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)

A

1 - lysis of adhesions
2 - removal, implanting
3 - restore, reperfusion

31
Q

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

A

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

32
Q

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

A

1 - hypotension; venous return; hypotension; reduction
*need pressors at beginning of case (very significant reduction)

2 - NMBA; beta blockers

3 - liver; bleeding

33
Q

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

A

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?)

34
Q

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.

A

dilated cardiomyopathy

ischemic heart

35
Q

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)

A 
1 - coronary filling
2 - preload 
3 - afterload, EF
4 - pulmonary vasoconstriction (failure easy to do if good pulmonary function)
5 - contractility
36
Q

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 _____.

A

3 - IJ, excision
4 - volume, air, contractility, valve fx, thrombus
**TEE is VERY valuable

37
Q

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 _______

A

1 - denervated - eliminated; NOT; pacing, isoproterenol

2 - nitrous oxide - inotropic support - contractility

Principles 2** (14 decks)

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