Organ Donation, Procurement And Transplantion Flashcards
1
Q
What organs can be transplanted?
A
- Kidney
- Liver
- Lung
- Heart
- Heart and Lung
- Pancreas
- Small Intestine
- Cornea
- Skin
- Bone
2
Q
What are the maximum cold ischemic times of heart and lungs, liver, and kidneys?
A
Heart and lungs——4-6hrs
Liver—— 12-24 hrs
Kidneys—— 72 hrs
3
Q
What are the 3 classifications of donors?
A
- Brain Death Donors
- Donation after Cardiac Death (DCD)
- Living Donors
4
Q
How does the US Uniform Determination of Death Act (1980) define death?
A
-Irreversible cessation of circulatory and respiratory functions, or of all functions of the entire brain, including the brain stem.
5
Q
T/F An individual’s signature on a driver’s license or donor card indicating their desire to donate their organs is NOT legally binding and does require family permission.
A
FALSE
-An individual’s signature on their driver’s license or donor card IS legally binding and DOESN’T require family permission.
6
Q
What are the criteria for diagnosis of Brain Death?
A
-Loss of cerebral cortical function
>No spontaneous movement
>Unresponsive to external stimuli
-Loss of Brainstem Function
>Apnea
>Absent cranial nerve reflexes (papillary, corneal, oculocephalic, oculovestibular)
-Supporting Documentation
>Electroencephalogram
>Cerebral blood flow studies (angiography, transcranial Doppler, xenon scan)
7
Q
What are the 4 common physiologic derangements after brain death?
A
- Hypotension
- Arterial Hypoxemia
- Hypothermia
- Cardiac dysrhythmias
8
Q
What causes hypotension after death?
A
- Hypovolemia (DI, hemorrhage
- Neurogenic shock
9
Q
What causes Arterial hypoxemia after death?
A
- Neurogenic pulmonary edema
- Aspiration
- Pneumonia
10
Q
What causes hypothermia after death?
A
-Hypothalamic infarction
11
Q
What cause Cardiac dysrhythmias after death?
A
- Hypothermia
- Arterial hypoxemia
- Electrolyte abnormality
- Myocardial ischemia
12
Q
Donations after Cardiac Death criteria:
A
- Non-heart-beating donors
- severe whole brain dysfunction
- have electrical activity in the brain
- death is defined by cessation of circulation and respiration
- Life support measures are used to control the timing of death, organ procurement, and to maximize function of organs from these donors
13
Q
What is the process for Donation after Cardiac Death (DCD)?
A
- doesn’t meet the criteria for brain death
- has no chance of survival and the family has decided to withdraw support
- support withdrawn in OR or in the ICU
- after heart stops beating, TOD declared
- organ recovery begins within 5 mins.
14
Q
Anesthesia management is ____________ for organ donation after brain death (DBD)
A
Required
15
Q
Anesthesia management ________ ________ be required for organ donation after cardiac death (DCD).
A
MAY NOT
16
Q
SLIDE 13 THE SURGERY
A
?
17
Q
What support is needed for the donor in CORE recovery?
A
- adequate respiratory support
- organ perfusion as indicated by SBP>100 and/or CVO 8-12
- O2 sat > 96%
- urine output > 100cc/hr
- vigorous volume expansion with crystalloids and colloids to avoid hypotension
- no anesthesia is necessary
- muscle relaxant may be required
18
Q
What are frequently required drugs and fluids for organ recovery?
A
- 6-8L LR
- Heparin 30,000 units
- Thyroxin drip may be required
- Pavulon/Vecuronium
- IV dopamine, Neo, Levo, or vasopressin
19
Q
What are additional medications CORE, or the Surgeon may request?
A
- PRBC’s (for renal donors if liver being split it is required in the OR
- 5% or 25% albumin
- 100 gm 25% Mannitol
- 100 mg Lasix
20
Q
T/F: 44% of organ donation come from living organ donors?
A
TRUE
Living donors
-Frequently related to the recipient
-between 18-60 yrs of age
-with NO history of
>HTN
>Diabetes
>CA
>Kidney Disease
>Heart Disease
21
Q
What are ABSOLUTE contraindications of organ implantation?
A
- Active uncontrolled infection
- AIDS
- Inability to tolerate immune suppression
- Severe cardiopulmonary/medical condition
- Continued drug or alcohol abuse
- Extrahepatic Malignancy
- Inability to comply with medial regimen
- Lack of psychosocial support
22
Q
What has lead to the dramatic increase in the success of Organ transplantation?
A
- Immunosuppressive regimens
>Cyclosporine 1980’s-decreased host rejection
>Azathioprine (Imuran)
>OKT3
> Steroids-prednisone and methylprednisolone - Improved donor
/recipient tissue typing
23
Q
What factors play a role in post-transplantation organ function?
A
- Donor demographic
- Organ ischemic time
- Mechanism of death of donor
- Medical condition of recipient
24
Q
What is the graft survival rate of living donors kidneys at 5 years?
A
81%
25
What is the graft survival rate for cadaveric donors at 5 years?
72% -nonextended criteria
| 57%-extended criteria
26
T/F: More than 85,000 people await a kidney transplant.
FALSE -more than 75,000
27
What are the major indication for Kidney Transplantation?
* **1. DM
* **2. Hypertension- induced nephropathty
3. Glomerulonephritis
4. Polycystic Kidney Disease
*** most common reasons***
28
What is emphasized in the pre-op work-up for a kidney transplant?
- Cardio-pulmonary system
- Extent of renal failure and associated conditions
- Normalization of electrolyte imbalance
- Normalization of volume status
- Pre-op renal dialysis if necessary
29
What are the physiologic disturbances often present before renal transplantation?
- peripheral neuropathy
- lethargy
- anemia
- platelet dysfunction
- pericarditis
- systemic hypertension
- depressed ejection fraction
- pleural effusions
- skeletal muscle weakness
- ileus
- glucose intolerance
30
T/F: HTN and DM are the most common causes of ESRD.
TRUE
31
What else could HTN lead to in these pts?
- LVH
- cardiac chamber dilatation
- increase Lt. ventricular wall tension
- redistribution of coronary blood flow
- myocardial fibrosis
- heart failure
- arrhythmias
32
What pre-op evaluation of cardiac risk factors do kidney transplant pts need to have?
- EKG
- Holger Monitoring
- Stress testing
Pts may be
- volume overloaded
- hypovolemic
- anemic
- hyperkalemic
33
T/F: Diabetic autonomic neuropathy can make intra-op BP control difficult.
TRUE
34
What increases risk of aspiration during induction of GETA?
Gastroparesis- it is a complication of autonomic neuropathy
35
CRF is characterized with ____________.
ANEMIA (hgb 6-8)
36
A hgb of ___% or greater is needed for adequate O2 delivery to the heart and transplanted graft.
8%
37
T/F: There is no need to evaluate the acid-base, electrolyte, and volume status of kidney transplant pts who are receiving hemodialysis or peritoneal dialysis since they are getting a new kidney.
FALSE- it is important to evaluate their acid-base, electrolyte and volume status pre-operatively.
38
Why is pre-op airway evaluation so important for pts with type 1 IDDM?
-they often manifest with stiff joint syndrome characterized by a fixation of the atlantooccipital joint along with limited head extension
39
What is pulmonary function impairment related to and how is it characterized in pts with IDDM?
- it is related to the loss of lung elastic properties
| - it is characterized by a decrease in cough reactivity and a significant restriction of lung volumes
40
There is a reduced ______ ______ and ______ _____ ______ in IDDM pts.
- Tidal volume
| - Forced Expired Ventilation (FEV)
41
With a Living Donor Kidney transplant what is the fluid protocol?
- 10mL/kg/hr above calculated losses
| - maintain UO>100mL/hr
42
Why can’t you use Nitrous Oxide for kidney transplantation?
-distended bowel can get in surgeons way(laparoscopic)
43
Cadaveric Kidney Transplant
Slide 31
44
What should most pt have for renal transplant surgery as far as monitoring and access?
- CVP monitoring
- good peripheral IV access
- A-line
- if pt has significant cardiopulmonary disease- PAC is necessary to monitor CO, SVO2 and PA and capillary pressures.
45
What should be avoided during anesthetic management of Renal transplant pts?
- Hypotension (reperfusion of donor kidney is critically dependent on perfusion pressure)
- Hypertention
- Tachycardia
- Alpha adrenergic drugs (transplanted kidney is sensitive to sympathomimetics)
46
Why is it important to know K+ level before going into the OR?
- in normokalemic pts. Succs is safe
| - if K abnormal cisatracurium or mivacrium is preferable (there is no kidney involvement in their metabolism)
47
___________ muscle relaxant is preferred in pt with ESRD d/t autonomic gastropathy, obesity, or If pts on peritoneal dialysis with significant volume of dialysate fluid left in.
Depolarizing
48
Is reversal safe in pts with ESRD?
Yes, Neostigmine and Robinul are safe.
49
What is administered immediately prior to induction of anesthesia to decreases gastric acid content?
Sodium citrate and Citric acids oral solution 30ml
*Controversial because it adds volume.
50
What can be used to increase gastric emptying and lower esophageal sphincter tone?
Metoclopromide 30mg PO
51
T/F: Administration of an H2 blocker immediately before induction can decreases gastric acid production.
False
| -administration 6-12 hrs before induction can decrease gastric acid production
52
Can continuous epidural analgesia be used for intra-op and post-op pain control?
Yes, low dose local anesthetics and narcotics can be injected continuously to decrease intra-op dosage of narcotics and inhalation agents.
53
__________ and _________ function have to be acceptable for epidural analgesia to be an option.
- Coagulation
| - platelet
54
What may be needed during renal transplant surgery to increase cardiac output and renal perfusion pressure?
Vasopressors or positive inotropic agents such as
- dopamine
- fenoldopam
- norepinephrine
- vasopressin
*the goal is to have the newly grafted kidney produce urine immediately
55
What other options are available to maintain renal perfusion pressure and enhance urine production?
- mannitol
- loop diuretic
-used before unclamping vascular supply to transplanted kidney
56
T/F: Reperfusion of the kidney graft may be associated with hypertension.
FALSE-
Reperfusion of the kidney graft may be associated with hypotension.
-this is most often related to a reduction in the preload as a consequence of unclamping the iliac artery
-treat with crystalloids, colloid or low-dose dopamine
57
Prompt urine production is desired, with living donor transplant there is prompt urine production __% Vs. __% with deceased donor transplant.
- 90%
| - 40-70%
58
Why is decreased urine output significant?
- may indicate mechanical impingement of graft, anastamosing vessel, or ureter.
- intra-op ultrasound may be used to assess flow through arterial and venous anastamosis
59
How should you treat moderate to severe hypertension accompanying emergence from anesthesia for renal transplant?
- short-acting anti-hypertensive (in the OR and ICU)
| - avoid longer acting beta-blockers b/c they may increase K+ levels
60
What are anesthetic consideration for the pt with prior renal transplant?
-renal excretion of drugs is usually decreased
-pts still suffer from primary systemic disease
>DM
>HTN
-anesthetic care should be adjusted
>avoid muscle relaxants with renal elimination for excretion
>provide adequate hydration
>avoid hypotension
-consequences of long term immunosuppressive therapy
61
What is the 10 year survival rate of liver transplantation?
60%
62
What are the indications for liver transplant?
- End stage liver disease with life threatening complications
- acute hepatic necrosis
- chronic hepatitis
- post necrotic non alcoholic cirrhosis
- sclerosis’s cholangitis
- cholestatic disease
- alcoholic cirrhosis
- metabolic diseases
- malignant disease of liver
63
What are causes of acute hepatic necrosis?
- viral hepatitis
- drug toxicity
- toxins
- Wilson’s disease
64
What can lead to chronic hepatitis?
- hepatitis B,C,D
- autoimmune hepatitis
- chronic drug toxicity
- cryptogenic cirrhosis
65
What leads to Cholestatic disease?
- primary/secondary biliary cirrhosis
- sclerosis’s cholangitis
- biliary atresia
- cystic fibrosis
66
In order to be considered for a liver transplant pt must abstain from alcohol for _ months and be in ongoing therapy and evaluation.
- 6
67
What are some causes of malignant disease of the liver?
- hepatocellular carcinoma
- carcinoid tumor islet cell tumor
- epithelioid hemangioendothelioma
68
T/F: When caring for organ donors, the focus of care has shifted from preserving the pt to preserving the function of the graft organs.
TRUE
69
In living donor liver cases the primary concern is ________ safety.
Donor
70
Pts with chronic liver dysfunction and cirrhosis have _________ circulation, _____ PVR, and _______ cardiac index.
- hyperdynamic
- low
- increased
71
With chronic liver dysfunction these conditions are common:
- coagulopathies
- edema
- ascites
- renal dysfunction
- portopulmonary hypertension
- hepatopulmonary syndrom
- autonomic neuropathies
72
Hepatic encephalopathy is believed to be ____________.
Multifactorial
-it must be differentiated from many other nonfocal neurological conditions such as hypoglycemia, hyponatremia, intracranial hemorrhage or mass lesions and meningitis
73
Liver failure would cause what to the CNS?
- Hepatic encephalopathy
| - increased intracranial pressure (acute liver failure)
74
Liver failure would cause what to the cardiac system?
- hyperdynamic Circulation
| - cirrhotic cardiomyopathy
75
Liver failure would cause what to the respiratory system?
- hepatopulmonary syndrome (arterial hypoxemia)
| - portopulmonary hypertension
76
Liver failure would cause what to the gastrointestinal system?
- portal hypertension
- upper gastrointestinal bleeding
- ascites
77
Liver failure would cause what to the hematologic system?
- Anemia
- Thrombocytopenia
- Prolonged PT and PTT
- Decreased plasma fibrinogen concentration
- DIC
- Protein C and S deficiency
78
Liver failure would cause what to the Renal system?
- hepatorenal syndrome
| - acute tubular necrosis
79
Liver failure cause what miscellaneous problems?
- electrolyte disturbances (hypokalemia, hypocalcemia)
- malnutrition
- hypoglycemia
- metabolic acidosis
80
Post-op pain control should be considered because of a _______ subcostal incision.
Large
81
With liver transplantation there is the potential for massive __________ and ________ physiologic derangement during and after surgery.
- hemorrhage
| - severe
82
T/F: The focus of the cardiac assessment for liver transplantation includes functional and invasive test of cardiac performance that assess ischemic potential.
TRUE
83
Cardiac ________ anomalies that might compromise outcome from orthotopic liver transplantation must also be identified.
Structural
84
What is needed for intra-op management of a liver transplant pt.
- A-line
- CVP
- PAC or TEE per pt history
- Large board IV access(rapid infuser, heated fluids and blood)
**TEG is the gold standard when managing coagulopathies and blood replacement
85
What considerations need to be made for anesthetic drugs for liver transplantation?
- try to avoid drug that rely on hepatic metabolism and excretion
- use is safe due to implantation of functioning liver but it may be delayed
- avoid nitrous oxide
86
What are the phases of liver transplantation surgery?
- preanhepatic phase
- anhepatic phase
- neohepatic phase
87
What happens in the preanhepatic phase of liver transplantation?
- lysis of adhesion
- mobilization of liver and careful dissection of hepatic artery, common bile duct, Supra and infrahepatic vena cava and portal vein.
88
When would a portocaval shunt or venous bypass be instituted during a liver transplant?
- if portal HTN is severe to the degree that mobilizing the liver may result in significant blood loss
- pt is unstable
89
What do shunting procedures do?
- redirect the portal venous flow into the systemic venous circulation via a nonvariceal conduit, thus
- relieving portal hypertension
- decompressing varicose
- relieving ascites
90
What is the aim of nonshunting procedures during the preanhepatic phase?
-controlling hemorrhage from the portosystemic varices
91
What are problems that occur during the preanhepatic phase?
- hemorrhage>CV instability
- coagulation problems
- impaired venous return from surgical retraction and IVC clamping
- hypocalcemia, hyperkalemia and metabolic acidosis
92
What happens in the anhepatic phase of liver transplantation?
- Begins with clamping of hepatic blood flow
| - removal of native liver
93
During the Anhepatic phase what is the Bicaval Clamp?
-clamp venacava above and below liver
| >drops preload——>profound hypotension and tachycardia
94
What is the piggyback technique used during the anhepatic phase ?
-sideclamp the inferior vena cava
| >preserves some caval flow and preload
95
What anesthetic management is needed during the anhepatic phase of liver transplantation?
- hemorrhage, increased Fibrinolytics, coagulopathy, acidosis, hypothermia, and decrease renal function
- CO and systemic BP may need to be supported with inotropes and vasopressors
- citrate intoxication May occurs from rapid infusion of large volumes of blood in absence of liver function
- Calcium administration if hypocalcemic
96
What happens in the Neohepatic phase of liver transplantation surgery?
- begins with unclamping of the portal vein, hepatic artery and vena cava and Reperfusion of donor liver
- preparation for this phase is important b/c it may be a period of great hemodynamic instability
97
Severe _________ instability May occur with unclamping of portal vein (post Reperfusion syndrome)
“Hemodynamic”
-ionized CA++ should be normal, acidosis should be corrected and K+ would be <4.5
-may need potent vasopressors
>Epi, norepi
>fluid overload prior to unclamping should be avoided
-hemodynamics typically stabilizes one graft begins to function
98
What is Reperfusion syndrome characterized by?
- decreased CO, HR and BP
- conduction defects (bradyarrythmias, asystole)
- pulmonary HTN
- decreases SVR
- rapid increase in K+-ensure normal pH and electrolytes prior to unclamping
- severe coagulopathies occur d/t Fibrinolysis, release of heparin and hypothermia
99
What are the initial indirect signs of a functioning graft?
- intra-op bile production
- intra-op spontaneous correction of negative base excess
- improvement in coagulation
100
What occurs in the post-op care of liver transplant pt?
-extubation deferred
-ICU-direct admit
-Serial ultrasound assessments of hepatic artery and portal vein patency
>thrombosis may require re-transplantation
101
What are the 3 types of lung transplantation?
- single-lung transplantation
- bilateral sequential lung transplantation
- heart-lung transplatation
102
What are the most frequent indications for lung transplantation?
- COPD
- Idiopathic pulmonary fibrosis
- cystic fibrosis
- alpha 1-antitrypsin deficiency
- sarcoidosis
- congenital heart disease (Eisenmenger’s syndrome with concomitant cardiac repair)
104
What are the indications for heart transplants(end stage cardiac failure)?
- ischemic cardiomyopathy
- idiopathic dilated cardiomyopathy
- congenital defects
- valvular heart disease
- dysfunction of previous cardiac graft
- intra-cardiac tumors
105
What stabilizing measures are used while awaiting heart transplantation?
- IV inotropes
- Intra-aortic balloon pump
- ventricular assist device
- mechanical ventilation
106
What standard anesthesia and invasive hemodynamic monitoring is needed for pt with end-stage cardiac failure?
- Arterial BP
- PAC
- CVP
- TEE
- RV assist device
107
What is important to keep in mind when providing anesthesia for cardiac transplant pt?
- pts are typically on vasopressors and inotropes pre-induction
- pt are at the limit of hemodynamic compensatory mechanisms (ECMO, CPB)
- titrations all drugs to pt response
- hypotension my ensue regardless of drugs used and careful attention given
108
A post-heart transplant pt has no _______, __________, or __________ innervations.
- sensory
- sympathetic
- parasympathetic
-the HR should be high (90-110’s) because the parasympathetic innervation that normally lower the HR is not present
109
T/F: You must use atropine to treat bradycardia with post-heart transplant pt.
FALSE- you have to use EPI
Atropine won’t work because it works by blocking the parasympathetic response that decreases HR since there’s no parasympathetic innervation to block it won’t work.
110
The pre-op assessment of the lung transplant pt evaluates what?
Varying degrees of
- impairs gas exchange
- altered pulmonary mechanics
- right ventricular function
