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N934 Advanced Principles of Anesthesia II > Organ Donation > Flashcards

Organ Donation Flashcards

1
Q

Organ Procurement and Transplantation Network (OPTN)

A
  • established by congress in 1984
  • facilitates organ matching/allocation process
  • collects and manages data about organ donation and transplantation
  • professional and public education
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2
Q

United Network for Organ Sharing (UNOS)

A
  • administers the OPTN under contract with health resources and services admin of the US department of health and human services
  • develop policy
  • monitor and enforce processes of OPTN
  • maintain OPTN membership and review application
  • organ transplant centers HAVE to be members of this
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3
Q

organ most transplanted as of 2020

A

kidney

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4
Q

organs transplanted from most to least frequent

A
  • kidney
  • liver
  • pancreas
  • kidney/pancreas
  • heart
  • lung
  • heart/lung
  • intestine
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5
Q

current waiting list for all organs

A

117,204

demand is HIGH

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6
Q

allograft/homograft

A

-tissue for transplant derived from a non-twin donor of the same species

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7
Q

autograft

A
  • tissue for transplant derived from the recipient

- example = burn patient skin graft

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8
Q

orthotopic

A

-implanting an organ in the anatomic position after the native organ is removed

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9
Q

heterotopic

A

-implanting an organ leaving the native organ in place

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10
Q

xenograft/heterograft

A
  • tissue grafted from one species to another
  • example is using pig valve for valve replacements
  • also some full organ transplant from animal to human
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11
Q

Major Histocompatibility Complex (MHC) antigens

A
  • cell surface glycoproteins that establish immunologic identity
  • class I human leukocyte antigen (HLA) A-B-C classic transplant antigens
  • class II HLA DR-DQ-DP on activated t cells are antibodies that will attack foreign objects
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12
Q

major blood group antigens

A

ABO potent transplant antigens

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13
Q

Kidney HLA tissue typing

A
  • ABO and HLA matching, T-Cell cross match and PRA (panel reactive antibody profile)
  • also pancreas and ideally lung (but sometimes not lung because time is of the essence)
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14
Q

heart/liver HLA tissue typing

A

-ABO and other factors such as size/urgency

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15
Q

types of organ donors

A
  • cadaveric; donation after brain death (DBD)
  • non-heart beating donor; donation after cardiac death (DCD)
  • living donor - kidney paired donation (sometimes liver too)
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16
Q

cadaveric or donation after brain death

A
  • previously healthy
  • brain death established
  • negative for extracranial malignancy
  • absence of untreatable infection
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17
Q

donor mechanism of injury in DBD

A

usually violent in some way - MVC, GSW, asphyxiation

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18
Q

determination of brain death history

A
  • first talked about in mid 1950s
  • Harvard med school published criteria for brain death in 1968 because this is when 1st heart transplant occurred
  • president commission for the study of ethical problems in medicine 1981; defined brain as primary organ
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19
Q

what must be done to determine brain death

A
  • r/o reversible cerebral dysfunction
  • nothing else that could be masking as brain death
  • hypothermia
  • hypotension
  • metabolic/endocrine instability
  • drug OD
  • R/O and like that for 12-14 hours then can proceed with brain death testing
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20
Q

criteria on brain death exam

A
  • comatose - unresponsive to verbal stimuli
  • absence of cerebral cortical function - non-responsive to painful stimulus; absence of spontaneous movement
  • loss of brain stem function - reflexes
  • supporting studies - EEG and cerebral flow studies; sometimes HAVE to do this
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21
Q

neurological absence of brain stem function (also part of brain death exam)

A
  • pupillary response to light
  • corneal reflex
  • oculocephalic reflex absent, dolls eye response
  • oculovestibular reflex absent, cold caloric test
  • gag and cough reflex
  • absent respiratory reflex (apnea test)
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22
Q

occulcephalic reflex absent

A
  • eyes fixed when head rotated sideways - BAD

- normal for eyes to move the opposite way

23
Q

oculovestibular reflex absent

A
  • irrigate ear with cold water

- eyes have nystagmus toward stimulated ear

24
Q

apnea test

A
  • 100% FiO2 for 10 min
  • normalized PaCO2 - confirmed by ABG
  • T-piece for 7-10 minutes
  • repeat ABG
  • PaCO2 on repeat > 60 mmHg
  • absence of spontaneous ventilation
  • sometimes unable to complete due to patient stability - may need EEG or flow study
25
Q

non-heart beating organ donor (or donation after cardiac death)

A
  • S/P cardiac arrest
  • death anticipated within 1-2 hours (ideally sooner) after life support withdrawn
  • comatose, unresponsive; may have some brainstem activity but poor quality of life
  • warm ischemia time
  • controlled vs uncontrolled
26
Q

kidney living organ donor

A
  • donor is usually healthy
  • advantages = decreased cold ischemic time (organ will work better) and less time on waiting list
  • can be laparoscopic or open
  • selection of kidney = usually of L side bc easier to get to and longer vascular access
  • anesthetic = GA; standard monitors; maintain UOP with mannitol/lasix; heparin and protamine prior to clamping
27
Q

partial liver living organ donor

A
  • more common in peds vs adults
  • not done as much anymore
  • liver regenerates over time
  • adult usually R side = V, VI, VII, VIII
  • peds usually L side = II, III, IV
  • anesthetic technique is GA
  • monitoring - CVP, A line, Large bore IV
  • +/- epidural (controversial in literature)
  • drop CVP with transection to around 5 mmHg or less
  • NGT FO SURE!!! to evacuate the stomach
  • no N2O, dont want bowel expansion
  • cell saver or isovolemic hemodilution
  • clamp hepatic –> VR decrease 20% (good to volume load before this)
28
Q

organ preservation strategies

A
  • keep organ healthy so it will work for the recipient
  • hypothermia decrease metabolism
  • maintain cellular integrity
  • prevent cellular swelling, vasospasm and build up of toxic metabolism
  • provide source of energy
29
Q

Ex-vivo organ preservation

A
  • rapid cooling at 4 degrees celcius
  • preservative solutions
  • removed in order of susceptibility
30
Q

preservative solutions

A
  • UW - intrabdominal organs (hyperkalemia)

- celsior/cardioplegia (heart)

31
Q

order of susceptibility of removal

A
  • heart
  • lung
  • liver
  • kidney
32
Q

heart max preservation time

A

4-6 hours

33
Q

liver max preservation time

A

8-12 hours

*Barash used to say up to 24 hours

34
Q

pancreas max preservation time

A

12-18 hours

35
Q

kidney max preservation time

A

24-36 horus

36
Q

donor anesthesia

A
  • brain death = established prior to arrival in OR
  • goal = preserve organ perfusion and oxygenation
  • hypotension - loss of descending vasomotor control
  • decreased CO and SVR
  • decreased oxygenation = atelectasis, aspiration, pulmonary edema
  • DI = destruction of hypothalamic-pituitary axis
  • bradycardia = loss of vagal motor nucleus, increased ICP
  • visceral and somatic reflexes = will still have these
37
Q

visceral and somatic reflexes

A
  • still present after brain death
  • donor can still respond to pain and have some motor movements
  • may need opioids and muscle relaxant
38
Q

MAP for preserving organ function

A

60-100 mmHg

39
Q

UOP for preserving organ function

A

0.5-3 mL/kg/hr

40
Q

Hgb for preserving organ function

A

> 10 g/dL

41
Q

Glucose for preserving organ function

A

120-180 mg/dL

42
Q

CVP for preserving organ function

A

5-10 mmHg

43
Q

FiO2 for preserving organ function

A

<40% if tolerated for lung retrieval especially to minimize effects of O2 toxicity

44
Q

PEEP for preserving organ function

A

no more than 10 cm H2O; now more liberal though

45
Q

SaO2 for preserving organ function

A

> 95%

46
Q

PaO2 for preserving organ function

A

> 100 mmHg

47
Q

Core temp for preserving organ function

A

> 35 C

48
Q

fluids for organ donation

A

colloids first vs crystalloid, especially for lungs

49
Q

vasopressors in order of use

A

dopamine
vasopresson (recommended for heart)
dobutamine
epinephrine

50
Q

which vasopressor do you NOT use

A

phenylephrine; decreases splanchnic BF which is BAD for abdominal perfusion if those organs are being procured

51
Q

bradycardia for organ donation

A
  • resistant to atropine because no vasomotor control

- use a direct acting agent like isoproterenol

52
Q

DI in organ donation

A
  • vasopressin or DDAVP

- free water - D5W 0.45% NS = fluid type based on hourly serum electrolytes

53
Q

other things for donor anesthesia

A
  • standard monitors, A line, CVP, Swan
  • pressors and SNP/NTG/beta blocker
  • PRBCs/FFB
  • Heparin
  • mannitol/lasix
  • methylprednisolone (protects heart, lungs and kidneys from ischemia)
  • PGE1 (lung membrane stabilization)
  • long acting NDMR
54
Q

special considerations for donor anesthesia

A
  • confirm ETT placement with surgical team
  • midline incision from neck to pubis
  • ensure you know organs that are to be procured
  • sternal saw –> drop lungs
  • organs mobilized and dissected
  • aorta cross-clamped and vent turned off
  • heart lung procurement –> continue to manually ventilate at 4 breaths/min

N934 Advanced Principles of Anesthesia II (17 decks)

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