Mod13: Lung & Corneal Transplantations Flashcards

1
Q

Lung Transplantation - Overview

What are common indications for Lung Transplantation?

A

End-stage Parenchymal disease

Severe Pulmonary hypertension

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2
Q

Lung Transplantation - Overview

Candidates for lung Tpx have a poor prognosis. What are they functionally incapacitate by?

A

Dyspnea

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3
Q

Lung Transplantation - Overview

Which factor is responsible for varying management criteria in lung transplantation?

A

Primary disease process

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4
Q

Lung Transplantation - Overview

General indications to having a lung Tpx from Barash anesthesia:

A

End-stage lung dz

Failed maximal medical treatment of lung dz

Age within limits for planned transplant

Life expectancy < 2-3 yrs

Ability to walk and undergo rehabilitation

Sound nutritional status (70%-130% of IBW)

Stable psychosocial profile

No significant comorbid disease

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5
Q

Lung Transplantation - Overview

From Barrish, what are COPD-specific indications for lung Tpx?

A

FEV1 < 25% of predicted value after bronchodilators and/or

PaCO2 = 55 mmHg and/or

Pulmonary Hypertension (especially with Cor Pulmonale)

Chronic O2 therapy

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6
Q

Lung Transplantation - Overview

From Barrish, what are Cystic Fibrosis-specific indications for lung Tpx?

A

FEV1 < 30% of predicted

Hypoxemia, hypercarbia, or rapidly declining lung function

Weight loss and hemoptyis

Frequent exacerbations, especially young females

Absence of antibiotic-resistant organisms

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7
Q

Lung Transplantation - Overview

From Barrish, what are Idiopathic pulmonary fibrosis-specific indications for lung Tpx?

A

Vital capacity <60%-65% of predicted

Resting hypoxemia

Progression of disease despite therapy (steroids)

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8
Q

Lung Transplantation - Overview

From Barrish, what are Pulmonary-hypertension-specific indications for lung Tpx?

A

NYHA functional status class III or IV,

despite Prostacyclin therapy

Mean right atrial pressure < 15 mmHg

Mean pulmonary artery pressure < 55 mmHg

Cardiac Index < 2L/min/m2

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9
Q

Lung Transplantation - Overview

From Barrish, what are Einsenmenger-syndrome-specific indications for lung Tpx?

A

NYHA class III or IV, despite optimal therapy

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10
Q

Lung Transplantation - Overview

From Barrish, what are Pediatric-specific indications for lung Tpx?

A

NYHA class III or IV

Disease unresponsive to maximal therapy

Cor pulmonale, cyanosis, low CO

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11
Q

Single vs. Double Lung Transplant

Single-lung transplantation may be performed for selected patients with which medical condition?

A

COPD

Chronic obstructive pulmonary disease

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12
Q

Single vs. Double Lung Transplant

Double-lung transplantation is typically performed for patients with which medical conditions?

A

Cystic fibrosis

Bullous emphysema

Vascular diseases

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13
Q

Single vs. Double Lung Transplant

Why are younger patients more likely to receive bilateral lung transplants?

A

Disease process tyically involve full lungs

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14
Q

Single Lung Transplantation

Why is Single Lung Transplantation often attempted without CPB?

A

Can ventilate the other lung (down lung) that is not being transplanted

Double-lumen tube must be used for one-lung (down lung) ventilation

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15
Q

Single Lung Transplantation

Which type of incision is used for Single Lung Transplantation?

A

Posterior thoracotomy

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16
Q

Single Lung Transplantation

Which clinical signs would indicate the need for CPB during transplantation of one lung?

A

Arterial hypoxemia (spO2 <88%)

Sudden increase in PA pressures

17
Q

CPB for One Lung Transplantation

When CPB is necessary, where would pt be cannulated during a Left thoracotomy?

A

Femoral-vein-to-Femoral-artery bypass

18
Q

CPB for One Lung Transplantation

When CPB is necessary, where would pt be cannulated during a Right thoracotomy?

A

Right-atrium-to-Aorta bypass

This is the typical approach for open heart surgery

19
Q

Double-Lung Transplantation

Which type of incision is used for Double-Lung Transplantation?

A

Clamshell” transverse sternotomy

20
Q

Double-Lung Transplantation

True or False: Double-Lung Transplantation is occasionally performed with normothermic CPB

A

True

As opposed to traditional hypothermic CPB

21
Q

Double-Lung Transplantation

Why is Sequential bilateral thoracotomies for double-lung transplantation now the preferred approach over the sequential unilateral (one lung at the time) approach?

A

Sequential bilateral thoracotomies associated with:

Decrease bleeding

Decrease need for tracheal anastomosis

22
Q

Double-Lung Transplantation

What’s a disadvantage of sequential bilateral thoracotomies

A

One-lung ventilation not feasable

Henced the need for CPB

23
Q

Lung Transplantation - Induction of Anesthesia

Which induction technique is appropriate for lung Tpx?

A

RSI with aspiration prophylaxis

24
Q

Lung Transplantation - Induction of Anesthesia

Which induction technique would you employ to avoid precipitous drops in blood pressure?

A

Slow induction with:

Ketamine - Etomidate - Opioids

25
Lung Transplantation - Induction of Anesthesia Which muscle relaxant will you use to facilitate laryngoscopy?
Succinylcholine or a nondepolarizing NMBA
26
Lung Transplantation - Induction of Anesthesia Which must be avoided to prevent further increases in pulmonary artery pressure?
**Hypoxemia** and **Hypercarbia**
27
Lung Transplantation - Induction of Anesthesia Why should you treat hypotension with pressors rather than fluid?
Fluid will cause further increase in PA pressures
28
Lung Transplantation - Post-transplantation Management True or False: After anastomosis ventilation to both lungs is delayed to allow the anastomosis to heal.
**False** After anastomosis _ventilation to both lungs is resumed_
29
Lung Transplantation - Post-transplantation Management Why should you keep Peak inspiratory pressures as low as possible?
To maintained minimum pressure compatible with good lung expansion Avoid placing any additional stress and pressure on the anastamosis
30
Lung Transplantation - Post-transplantation Management Why must you maintain inspired oxygen concentration close to room air?
To keep **PaO2 \>60 mm Hg** May go up on your FiO2 if PaO2 is inadequate
31
Lung Transplantation - Post-transplantation Management Why are **Methylprednisolone** and **mannitol** usually given prior to release of vascular clamps?
Must anticipate the fact that the tpx will _interupt neural innervation_ Will affect _lymphatic drainage_, and bronchial circulation Respiratory patterns once the pt is awake should go back to normal, but the **cough reflex** below the carina will be _abolished_ This will result in **bronchial hyperactivity** _Absence of lymphatic drainage_ will increase the risk of **pulmonary edema**_,_ **pneumonia** Another reason to be conservative with intraop fluid replacement
32
Corneal Transplant Corneal Transplant is the most common transplant. How many are done per year?
**\>40,000**
33
Corneal Transplant Which anesthetic techniques are appropriate for Corneal Transplant?
Local, MAC or general anesthesia appropriate Typically a combination of _Local + IV sedation_
34
Corneal Transplant If using General Anesthesia, why should Succinylcholine be avoided?
Succinylcholine will increase IOP The goal is to keep IOP low
35
Corneal Transplant True or False: Most recipients are elderly pts
True
36
Corneal Transplant What's the most common cause of graft loss in the 1st year
Rejection of allograft