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Principles II > anesthesia for organ transplantation (liver, kidney, pancreas, heart) > Flashcards

anesthesia for organ transplantation (liver, kidney, pancreas, heart) Flashcards

1
Q

which type of donor grafts have greater success and survival rates?

A

living donor grafts

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2
Q

how many lives can one organ donor save?

A

up to 8 lives

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3
Q

what is the most common transplant performed?

A

kidney

-next is liver

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4
Q

which transplant procedure requires specialized CRNAs

A
  • liver

- heart

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5
Q

describe kidney transplantation considerations

A
  • better survival rate than hemodialysis at 3 yrs.
  • ESRD effects on other organ systems make for a challenging anesthetic: uremic conditions, fluid overload
  • high incidence of cardiac disease
  • high incidence of HTN and diabetes
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6
Q

what are kidney transplant indications?

A
  • glomerular disease
  • polycystic kidney disease
  • diabetes
  • HTN
  • congenital diseases
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7
Q

what are some characteristics of ESRD patients?

A
  • cardiac disease most common cause of death
  • uremia-induced myocardial depression (weaker heart, weaker pump; more challenging to put to sleep); normalizes after transplantation
  • pericarditis
  • cardiomyopathies (60% have either RVH or LVH)
  • dysrhythmias
  • electrolyte abnormalities, especially K+ increase
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8
Q

describe ESRD and cardiomyopathy

A
  • chronic HTN state: increased circulating fluid volume; increased circulating renin levels that vasoconstrict; increased Na+ retention)
  • LVH and concentric cardiomyopathy r/t increased afterload
  • dilated cardiomyopathy r/t increased fluid volume
  • increased afterload and preload
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9
Q

what are the effects of uremic toxins in ESRD?

A
  • pericardial disease
  • altered lipid metabolism
  • dysrhythmias
  • small vessel atherosclerosis (esp. coronaries); increased risk MI, ischemia
  • decreased gastric emptying ( >0.4 ml/kg; all are full stomach)
  • platelet defects; clots off grafts (hypercoagulation)
  • anemia
  • uremic frost on skin
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10
Q

what 3 variables determine the surgical outcome of kidney transplant?

A
  • donor management; live vs. deceased
  • harvested organ preservation
  • perioperative care of organ recipient
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11
Q

what are anesthesia implications for the living donor?

A
  • adequate IV access
  • blood availability (**greatest risk is hemorrhage)
  • use of balanced salt solution (ensures diuresis; offsets a reduced venous return r/t flank position)
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12
Q

what are anesthesia implications for the brain dead donor?

A
  • graft preservation is highest priority (ensure undamaged)
  • loss of sympathetic tone can cause hypotension
  • hypotension regardless of volume replacement
  • maintain renal perfusion of graft
  • use low dose dopamine (1-3 mcg/kg/min)
  • avoid high dose vasopressors which can lead to ischemia
  • maintain urinary output with diuretic use
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13
Q

what are contraindications to kidney transplant?

A
  • absolute: active infection

- relative: non-compliant drug or ETOH; malignancy; hepatocellular carcinoma with cirrhosis

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14
Q

describe the pre op assessment for kidney transplant

A
  • determine the cause of renal failure (DM #1 cause, HTN #2)
  • determine comorbid conditions: ESRD, CAD, DM, HTN, autonomic neuropathy, coagulopathy
  • labs/testing: metabolic profile with glucose
  • EKG and Echocardiogram with ejection fraction
  • CBC with platelet count
  • treat patient from renal failure perspective
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15
Q

describe anesthesia implications for kidney transplant

A

*expect hemodynamic instability
-volume overload, cardiomyopathy, weak pump
-hypotension, bradycardia upon induction if diabetic r/t autonomic neuropathy (inability to compensate for drop in SVR)
have patient hold ACE inhibitor; drops BP
*Type and crossmatch several units (although usu. little blood loss)
*dialyze prior to surgery to optimize fluid volume and electrolyte status

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16
Q

describe intra op considerations for kidney transplants

A

Large 8-10 inch incision

  • GA preferred with excellent muscle paralysis
  • regional has been used successfully
  • normal saline preferred crystalloid (LR contains K+)
  • caution with nondepolarizing NMBA (*Cisatracurium good since Hoffman elimination, organ independent)
  • A line for optimal hemodynamic control and frequent blood sampling
  • CVL for fluid vol. management and monitoring (*keep CVP b/w 10-15 mmHG)
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17
Q

what commonly happens after unclamping the iliac vessels?

A
  • hypotension

* be prepared to hang vasopressors if needed

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18
Q

what does the graft kidney’s health depend on and how is it maintained?

A
  • perfusion
  • avoid hypotension
  • studies show vessels of transplanted organs are highly sensitive to sympathomimetics so don’t use high dose vasopressor that can lead to ischemia
  • avoid high doses of alpha 1 agonists
  • renal dose dopamine is beneficial (D1 receptor; 1-3 mcg/kg)
19
Q

what determines success of kidney transplant?

A

urine production

*immediate in most recipients

20
Q

describe post op considerations for kidney transplant

A
  • completely reverse muscle relaxant
  • goal is extubation immediately after surgery
  • rarely admit to ICU post op
  • post op pain is usually easily controlled
21
Q

describe pancreatic transplantation

A
  • primarily to cure DM
  • nephropathy is present in 50-60% of diabetics causing many to receive kidney and pancreas
  • comorbid conditions r/t long term diabetes typically present: autonomic neuropathy, CAD, HTN, ESRD
  • usually more of an immunosuppressant challenge; require more immunosuppressant therapy
22
Q

what are intra op considerations with pancreatic transplants?

A
  • long surgery time
  • large, painful incision
  • extensive dissection to pancreas (pre op epidurals have shown promise with pain management)
  • immunosuppression increased
23
Q

describe intra op management for pancreatic transplant

A
  • a line to optimize hemodynamic status
  • colloids swell the pancreas LESS than crystalloid
  • CVL to optimize fluid vol. management and CVP measurements
  • frequent blood sampling: electrolytes, serial glucose
  • serial glucose checked hourly prior to unclamping and every 30 minutes after
  • *success of graft is measured by glucose levels
24
Q

describe liver transplantation outcomes

A
  • increased discrepancy between organ supply and recipient waiting list (more extensive surgery; all organs may be effected by end stage liver disease)
  • 3 yr. survival rate > 75%
  • hepatitis C recipients may need retransplanting in the future, causing greater demand for livers
25
Q

describe end-stage liver disease and pathophysiology

A
  • portal HTN develops: cirrhotic changes increase portal resistance and portal venous pressure > 12 mmHg
  • hyperdynamic circulatory state r/t vasodilation and volume expansion
  • increased ICP can occur
  • ammonia levels lead to encephalopathy
  • upper GI bleeding r/t varicosities
26
Q

what are indications for liver transplant?

A
  • post necrotic (non-alcoholic) cirrhosis (portal HTN, hyperdynamic circulatory status
  • biliary cirrhosis
  • sclerosing cholangitis
  • primary hepatic neoplasia
  • alcoholic cirrhosis (usu. must abstain from for > 2 yrs.)
27
Q

what medical issues usually present with patients requiring liver transplant?

A
  • hepato and porto-pulmonary syndrome: results in decreased PaO2 and shunting; resolves after transplantation
  • cardiac status: hyperdynamic state (ascites, SVR low, BP normal to low); HR increased
  • coagulation disorders (most challenging): decreased factors II, V, VII, IX, X, protein C, S, antithrombin III; thrombocytopenia lead to increased bleeding
  • *require frequent transfusions
  • accompanying renal disease common: hepatorenal syndrome (r/t liver decreased vasodilators and increased vasoconstrictor factors; perfusion deficit to kidney)
28
Q

describe liver transplant pre op

A
  • extensive multi-specialty workup: hematology-coagulation studies; pulmonology; cardiology; nephrology
  • cardiac eval: EKG; echo (EF, cardiomyopathy, portal HTN, pulmonary HTN); arteriogram (assess vascular issues); right heart cath (assess pulm. vascular status)
  • type and crossmatch and blood product preparation
  • 10 units PRBCs, 10 units FFP, Platelets, cryoprecipitate
29
Q

describe liver transplant monitoring

A
  • correct coagulopathy prior to line placement
  • need dependable large bore IV access for fluid and blood administration
  • a line for hemodynamic instability and frequent bloodwork
  • CVL- CVP measurement (used in 50% of centers)
  • telemetry
  • TEE (used in 11% of centers)
  • PA catheter (used in 30%): assess pulmonary HTN
30
Q

what are the three stages of liver transplant procedure?

A
  • dissection: extensive lysis of adhesions
  • anhepatic: removal of native liver and implanting donor
  • reperfusion (neohepatic): anastomosis, restore hemostasis , reperfusion
  • *complex and challenging management (fluid shifts, electrolytes up and down, and severe hypotension)
31
Q

what are intra op considerations during liver transplant?

A

1) liver failure and drug metabolism
- decreased biotransformation
- hypoalbuminemia causes altered protein binding
- altered volume of distribution (fluid overload)
2) hemodynamic fluctuations
- clamping and unclamping the portal vein and vena cava
- veno-venous bypass (VVB) used in 50% instead of clamp
3) venous air embolism upon reperfusion of the hepatic graft, reperfusion syndrome
4) significant coagulopathy (anticipate significant blood loss)
5) encephalopathy (increased ammonia levels)

32
Q

describe intra op management of liver transplant

A
  • varies between institutions
  • extensive blood and fluid status management
  • challenge to pharmacologically manage
  • oral gastric tube
  • keep normothermic: ice cold donor liver; worsens coagulopathy and drug metabolism
  • avoid N2O: intestinal distention
  • impaired insulin-mediated glucose uptake: hyperglycemia
  • renal alterations hyperkalemia, hyponatremia (no rapid replacement with 3% saline, cause pontine myelinolysis)
  • *severe coagulopathy and blood most significant issue with liver transplantation: marked acidosis and hypocalcemia occur
33
Q

what causes the need for extensive blood and fluid status management with liver transplant?

A
  • ascites decompression upon incision causes hypotension
  • manipulation of liver impedes venous return decreasing preload and CO
  • inferior vena cava occluded causes severe hypotension and > 50% reduction in CO
34
Q

what causes a pharmacologic challenge with liver transplant?

A
  • removal of one liver, implanting another
  • NMBA used to gauge function of new liver (is it biodegrading NMB?)
  • beta blockers for varices bleeding (decreased bleeding)
35
Q

what is considered with oral gastric tube insertion during liver transplant?

A
  • decompress gastric cavity to increase liver exposure
  • expect bleeding r/t varices and coagulopathy
  • *insert delicately
36
Q

what actions can be taken to keep the pt. normothermic with liver transplant?

A
  • run all fluid through warmer

- used forced warm air and heating blankets

37
Q

describe heart transplantation

A
  • definitive treatment for terminal heart disease
  • 90% are for idiopathic dilated cardiomyopathy and ischemic heart disease
  • remaining 10% for congenital, valvular heart disease, cardiac tumor, life-threatening arrhythmias, and repeat transplant
38
Q

what are goals of heart transplant?

A
  • maintain coronary filling by optimizing DBP
  • ensure optimal preload
  • afterload reduction with the goal of increasing ejection fraction
  • avoid pulmonary vasoconstriction: oxygenate, normocapnic, normal Vt, normal pH
  • promote contractility: drugs, assist devices and balloon pumps
39
Q

describe heart transplant monitoring

A
  • a line
  • CVL- CVP
  • PA catheter pulled back to IJ prior to excision of heart
  • TEE assesses volume, air, contractility, valve functioning and thrombus; also assesses wall motion of new heart
40
Q

what is a good agent to induce cardiac transplant pts. with?

A

etomidate

-know for its cardiovascular stability, avoiding instability and preventing collapse on induction

41
Q

why should induction of anesthesia and monitoring be rapid?

A

-keep the period of ischemia of the donor heart as short as possible to reduce ischemia reperfusion injury

42
Q

what benefit does fentanyl have in cardiac anesthesia?

A

-prevent increases in systemic afterload during periods of intense surgical stimulation

43
Q

what NMB was more commonly used in cardiac transplantation?

A

rocuronium d/t its fast-acting onset and intermediate effects

44
Q

what can be done to help donor heart adapt to increased pulmonary artery pressure and pulmonary vascular resistance of recipient?

A
  • use strategies to reduce pulmonary artery pressure and resistance and augment right ventricular contractility
  • nitric oxide: vasodilates; effective to reduce pulmonary artery pressure but avoids systemic vasodilation and hypotension since inhaled
  • dobutamine (5-10 mcg/kg/min), epi (0.05-0.3 mcg/kg/min), or dopamine (5-7.5 mcg/kg/min) provide inotropic support of right ventricle

Principles II (18 decks)

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