Organ Donation Flashcards
DBD
Donation after brain death
DCD
Donation after cardiac death
Non-beating donor heart
Status post cardiac death
Death anticipated w/in 1-2hrs after life support withdrawn
What is the most commonly performed transplant?
Kidney
Followed by liver, heart, & lungs
Allograft/Homograft
Tissue for transplant derived from non-twin donor same species
Human → human
Autograft
Tissue for transplant derived from the recipient (self)
Orthotopic
Implanting an organ in the anatomic position after the native organ removed
Heterotopic
Implanting an organ leaving the native organ in place
Xenograft/Heterograft
Tissue grafted from one species to another
Porcine valves
Major Histocompatibility Complex (MHC) Antigens
Cell surface glycoproteins that establish immunologic identify
Class I HLA
Human leukocyte antigen
Classic transplant antigens
Class II HLA
More difficult to match
Present on activated T cells
Reversible Cerebral Dysfunction
Hypothermia
Hypotension
Metabolic/endocrine instability
Drug overdose
Brain Death
Comatose - unresponsive to stimuli
Absence cerebral cortical function - non-responsive to painful stimulus & absence spontaneous movement
Loss brain stem function - no reflexes present
Supporting studies - EEG & cerebral flow
Brain Stem Function
No pupillary response to light (fixed & dilated)
Corneal reflex absent
Oculocephalic reflex absent
Oculovestibular reflex absent
No cough or gag reflex
Apnea test - absence spontaneous ventilation
Oculocephalic Reflex
Doll’s eye response
Eye fixed when head rotated indicates the brain stem not intact
Normal response = rotate head to L eyes more to the R
Oculovestibular Reflex
Cold caloric test
Irrigate auditory canal w/ ice water
Normal response = nystagmus then eyes deviate toward the stimulated ear
Corneal Reflex
Blink or eyelid reflex
Orbicularis oculi contraction in response to light cornea touch
Involuntary blinking elicited by cornea stimulation
Apnea Test
Pre-oxygenate 100% FiO2 10min Normalize PaCO2 Place T-piece 7-10min & assess respiratory effort Repeat ABG PaCO2 > 60mmHg Absence any spontaneous ventilation
Unable to complete apnea test in sick or critically ill patients w/ lung disease
Other diagnostics necessary
Organ Preservation Time
Heart & Lungs
4-6 hours
Organ Preservation Time
Liver
8-12 hours
Up to 24 hours
Organ Preservation Time
Pancreas
12-18 hours
Organ Preservation Time
Kidney
24-36 hours
Living Kidney Donors
Advantages as donors are generally healthy ASA 1 or 2
↓cold ischemic time
Less time on waiting list
Open or laparoscopic
Typically L kidney chosen d/t more readily accessible & longer vascular access
Maintain UOP w/ Mannitol or Lasix
Heparin prior to clamp (may need to reverse w/ Protamine)
Living Liver Donors
Partial liver hepatectomy
Adult R side 5-8 segments
Pediatric 2 or 3rd lobes L side (smaller therefore easier surgical technique to retrieve)
Donor liver regenerates 1-6mos back to original size
Living Lung Donors
Not common Cystic fibrosis Immediate family member Size & match Multi-donor resection ↑donor morbidity
Organ Preservation
Hypothermia ↓metabolism
Preservation solutions - maintain cellular integrity, prevent swelling or metabolite build-up, provide an energy source
Ex vivo - rapid cooling 4°C
Organs removed in susceptibility to ischemia order
Heart → lungs → liver → kidney
Implantation & reperfusion
Donor Anesthesia
Goal = preserve organ perfusion & oxygenation MAP 60-100 UOP 0.5-3mL/kg/hr Hgb > 10g/dL Glucose 120-180 CVP 5-10mmHg FiO2 < 40% PEEP < 10 SaO2 > 95% PaO2 > 100mmHg Temp > 35°C
Donor
Anesthetic Management
Fluid 1st crystalloid or colloid Vasopressors - Dopamine, Vasopressin, Dobutamine, Epinephrine Bradycardia resistant to Atropine - Isoproterenol (direct acting) Diabetes insipidus - Vasopressin or DDAVP - Monitor electrolytes - UOP replacement
Donor Anesthesia
Monitoring & Medications
A-line CVP or Swan Pressors Sodium nitroprusside, Nitroglycerin, β blocker PRBCs/FFP Heparin Mannitol or Lasix Methylprednisolone PGE1 Long-acting non-depolarizing muscle relaxant
Donor Anesthesia
Special Considerations
Confirm ETT placement
Midline incision from neck to pubis
Know organs to be retrieved
Sternal saw → drop lungs
Organs mobilized & dissected
Aorta cross-clamped & ventilator turned off
Heart/lung procurement → continue to manually ventilate at 4bpm until told to stop by surgical team
ESRD Etiology
Diabetes 30-40% Glomerulonephritis Polycystic kidney disease Hypertensive kidney disease Chronic pyelonephritis Obstructive uropathy Lupus (SLE) Alport's syndrome
ESRD Physiology
↓GFR < 30mL/min
↓UOP < 400mL/day
Nitrogenous waste build-up
Fluid & electrolyte retention
Renal Transplant
Preop
Organ matching & allocation - ABO compatibility, HLA profile, & patient specific crossmatch (reactive antibodies) EKG, stress ECHO, cardiac cath β blockade Autonomic neuropathy CBC Electrolytes Coagulation Dialysis - volume & electrolyte correction Immunosuppression & antibiotic protocol
Renal Transplant
Intraop
A-line GETA Plasmalyte > 0.9 NaCl CVP 10-15mmHg Systolic > 90 MAP > 60 Ensure adequate renal perfusion
Renal Transplant
Postop
Analgesia - narcotics, PCA, or regional
Intercostal or TAP blocks
Renal Transplant Recipient
Monitor reperfusion
Anticipate hypotension d/t clamping, metabolites, & acidosis
Monitor UOP
- Obstruction/irrigation
- U/S monitor thrombosis in anastomosis
- Pharmacologic therapy
Rejection - hyper-acute biopsy to diagnose
