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Levi 3 > Organ Donation, Procurement And Transplantion > Flashcards

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
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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

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3
Q

What are the 3 classifications of donors?

A
  • Brain Death Donors
  • Donation after Cardiac Death (DCD)
  • Living Donors
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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.

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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.

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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)

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7
Q

What are the 4 common physiologic derangements after brain death?

A
  1. Hypotension
  2. Arterial Hypoxemia
  3. Hypothermia
  4. Cardiac dysrhythmias
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8
Q

What causes hypotension after death?

A
  • Hypovolemia (DI, hemorrhage

- Neurogenic shock

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9
Q

What causes Arterial hypoxemia after death?

A
  • Neurogenic pulmonary edema
  • Aspiration
  • Pneumonia
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10
Q

What causes hypothermia after death?

A

-Hypothalamic infarction

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11
Q

What cause Cardiac dysrhythmias after death?

A
  • Hypothermia
  • Arterial hypoxemia
  • Electrolyte abnormality
  • Myocardial ischemia
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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
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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.
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14
Q

Anesthesia management is ____________ for organ donation after brain death (DBD)

A

Required

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15
Q

Anesthesia management ________ ________ be required for organ donation after cardiac death (DCD).

A

MAY NOT

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16
Q

SLIDE 13 THE SURGERY

A

?

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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
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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
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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
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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

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21
Q

What are ABSOLUTE contraindications of organ implantation?

A
  1. Active uncontrolled infection
  2. AIDS
  3. Inability to tolerate immune suppression
  4. Severe cardiopulmonary/medical condition
  5. Continued drug or alcohol abuse
  6. Extrahepatic Malignancy
  7. Inability to comply with medial regimen
  8. Lack of psychosocial support
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22
Q

What has lead to the dramatic increase in the success of Organ transplantation?

A
  1. Immunosuppressive regimens
    >Cyclosporine 1980’s-decreased host rejection
    >Azathioprine (Imuran)
    >OKT3
    > Steroids-prednisone and methylprednisolone
  2. Improved donor
    /recipient tissue typing
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23
Q

What factors play a role in post-transplantation organ function?

A
  1. Donor demographic
  2. Organ ischemic time
  3. Mechanism of death of donor
  4. Medical condition of recipient
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24
Q

What is the graft survival rate of living donors kidneys at 5 years?

A

81%

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25
Q

What is the graft survival rate for cadaveric donors at 5 years?

A

72% -nonextended criteria

57%-extended criteria

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26
Q

T/F: More than 85,000 people await a kidney transplant.

A

FALSE -more than 75,000

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27
Q

What are the major indication for Kidney Transplantation?

A
  • **1. DM
  • **2. Hypertension- induced nephropathty
    3. Glomerulonephritis
    4. Polycystic Kidney Disease

* most common reasons*

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28
Q

What is emphasized in the pre-op work-up for a kidney transplant?

A
  • Cardio-pulmonary system
  • Extent of renal failure and associated conditions
  • Normalization of electrolyte imbalance
  • Normalization of volume status
  • Pre-op renal dialysis if necessary
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29
Q

What are the physiologic disturbances often present before renal transplantation?

A
  • peripheral neuropathy
  • lethargy
  • anemia
  • platelet dysfunction
  • pericarditis
  • systemic hypertension
  • depressed ejection fraction
  • pleural effusions
  • skeletal muscle weakness
  • ileus
  • glucose intolerance
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30
Q

T/F: HTN and DM are the most common causes of ESRD.

A

TRUE

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31
Q

What else could HTN lead to in these pts?

A
  • LVH
  • cardiac chamber dilatation
  • increase Lt. ventricular wall tension
  • redistribution of coronary blood flow
  • myocardial fibrosis
  • heart failure
  • arrhythmias
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32
Q

What pre-op evaluation of cardiac risk factors do kidney transplant pts need to have?

A
  • EKG
  • Holger Monitoring
  • Stress testing

Pts may be

  • volume overloaded
  • hypovolemic
  • anemic
  • hyperkalemic
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33
Q

T/F: Diabetic autonomic neuropathy can make intra-op BP control difficult.

A

TRUE

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34
Q

What increases risk of aspiration during induction of GETA?

A

Gastroparesis- it is a complication of autonomic neuropathy

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35
Q

CRF is characterized with ____________.

A

ANEMIA (hgb 6-8)

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36
Q

A hgb of ___% or greater is needed for adequate O2 delivery to the heart and transplanted graft.

A

8%

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37
Q

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.

A

FALSE- it is important to evaluate their acid-base, electrolyte and volume status pre-operatively.

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38
Q

Why is pre-op airway evaluation so important for pts with type 1 IDDM?

A

-they often manifest with stiff joint syndrome characterized by a fixation of the atlantooccipital joint along with limited head extension

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39
Q

What is pulmonary function impairment related to and how is it characterized in pts with IDDM?

A
  • 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

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40
Q

There is a reduced ______ ______ and ______ _____ ______ in IDDM pts.

A
  • Tidal volume

- Forced Expired Ventilation (FEV)

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41
Q

With a Living Donor Kidney transplant what is the fluid protocol?

A
  • 10mL/kg/hr above calculated losses

- maintain UO>100mL/hr

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42
Q

Why can’t you use Nitrous Oxide for kidney transplantation?

A

-distended bowel can get in surgeons way(laparoscopic)

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43
Q

Cadaveric Kidney Transplant

A

Slide 31

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44
Q

What should most pt have for renal transplant surgery as far as monitoring and access?

A
  • 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
Q

What should be avoided during anesthetic management of Renal transplant pts?

A
  • Hypotension (reperfusion of donor kidney is critically dependent on perfusion pressure)
  • Hypertention
  • Tachycardia
  • Alpha adrenergic drugs (transplanted kidney is sensitive to sympathomimetics)
46
Q

Why is it important to know K+ level before going into the OR?

A
  • in normokalemic pts. Succs is safe

- if K abnormal cisatracurium or mivacrium is preferable (there is no kidney involvement in their metabolism)

47
Q

___________ 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.

A

Depolarizing

48
Q

Is reversal safe in pts with ESRD?

A

Yes, Neostigmine and Robinul are safe.

49
Q

What is administered immediately prior to induction of anesthesia to decreases gastric acid content?

A

Sodium citrate and Citric acids oral solution 30ml

*Controversial because it adds volume.

50
Q

What can be used to increase gastric emptying and lower esophageal sphincter tone?

A

Metoclopromide 30mg PO

51
Q

T/F: Administration of an H2 blocker immediately before induction can decreases gastric acid production.

A

False

-administration 6-12 hrs before induction can decrease gastric acid production

52
Q

Can continuous epidural analgesia be used for intra-op and post-op pain control?

A

Yes, low dose local anesthetics and narcotics can be injected continuously to decrease intra-op dosage of narcotics and inhalation agents.

53
Q

__________ and _________ function have to be acceptable for epidural analgesia to be an option.

A
  • Coagulation

- platelet

54
Q

What may be needed during renal transplant surgery to increase cardiac output and renal perfusion pressure?

A

Vasopressors or positive inotropic agents such as

  • dopamine
  • fenoldopam
  • norepinephrine
  • vasopressin

*the goal is to have the newly grafted kidney produce urine immediately

55
Q

What other options are available to maintain renal perfusion pressure and enhance urine production?

A
  • mannitol
  • loop diuretic

-used before unclamping vascular supply to transplanted kidney

56
Q

T/F: Reperfusion of the kidney graft may be associated with hypertension.

A

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
Q

Prompt urine production is desired, with living donor transplant there is prompt urine production __% Vs. __% with deceased donor transplant.

A
  • 90%

- 40-70%

58
Q

Why is decreased urine output significant?

A
  • 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
Q

How should you treat moderate to severe hypertension accompanying emergence from anesthesia for renal transplant?

A
  • short-acting anti-hypertensive (in the OR and ICU)

- avoid longer acting beta-blockers b/c they may increase K+ levels

60
Q

What are anesthetic consideration for the pt with prior renal transplant?

A

-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
Q

What is the 10 year survival rate of liver transplantation?

A

60%

62
Q

What are the indications for liver transplant?

A
  • 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
Q

What are causes of acute hepatic necrosis?

A
  • viral hepatitis
  • drug toxicity
  • toxins
  • Wilson’s disease
64
Q

What can lead to chronic hepatitis?

A
  • hepatitis B,C,D
  • autoimmune hepatitis
  • chronic drug toxicity
  • cryptogenic cirrhosis
65
Q

What leads to Cholestatic disease?

A
  • primary/secondary biliary cirrhosis
  • sclerosis’s cholangitis
  • biliary atresia
  • cystic fibrosis
66
Q

In order to be considered for a liver transplant pt must abstain from alcohol for _ months and be in ongoing therapy and evaluation.

A
  • 6
67
Q

What are some causes of malignant disease of the liver?

A
  • hepatocellular carcinoma
  • carcinoid tumor islet cell tumor
  • epithelioid hemangioendothelioma
68
Q

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.

A

TRUE

69
Q

In living donor liver cases the primary concern is ________ safety.

A

Donor

70
Q

Pts with chronic liver dysfunction and cirrhosis have _________ circulation, _____ PVR, and _______ cardiac index.

A
  • hyperdynamic
  • low
  • increased
71
Q

With chronic liver dysfunction these conditions are common:

A
  • coagulopathies
  • edema
  • ascites
  • renal dysfunction
  • portopulmonary hypertension
  • hepatopulmonary syndrom
  • autonomic neuropathies
72
Q

Hepatic encephalopathy is believed to be ____________.

A

Multifactorial

-it must be differentiated from many other nonfocal neurological conditions such as hypoglycemia, hyponatremia, intracranial hemorrhage or mass lesions and meningitis

73
Q

Liver failure would cause what to the CNS?

A
  • Hepatic encephalopathy

- increased intracranial pressure (acute liver failure)

74
Q

Liver failure would cause what to the cardiac system?

A
  • hyperdynamic Circulation

- cirrhotic cardiomyopathy

75
Q

Liver failure would cause what to the respiratory system?

A
  • hepatopulmonary syndrome (arterial hypoxemia)

- portopulmonary hypertension

76
Q

Liver failure would cause what to the gastrointestinal system?

A
  • portal hypertension
  • upper gastrointestinal bleeding
  • ascites
77
Q

Liver failure would cause what to the hematologic system?

A
  • Anemia
  • Thrombocytopenia
  • Prolonged PT and PTT
  • Decreased plasma fibrinogen concentration
  • DIC
  • Protein C and S deficiency
78
Q

Liver failure would cause what to the Renal system?

A
  • hepatorenal syndrome

- acute tubular necrosis

79
Q

Liver failure cause what miscellaneous problems?

A
  • electrolyte disturbances (hypokalemia, hypocalcemia)
  • malnutrition
  • hypoglycemia
  • metabolic acidosis
80
Q

Post-op pain control should be considered because of a _______ subcostal incision.

A

Large

81
Q

With liver transplantation there is the potential for massive __________ and ________ physiologic derangement during and after surgery.

A
  • hemorrhage

- severe

82
Q

T/F: The focus of the cardiac assessment for liver transplantation includes functional and invasive test of cardiac performance that assess ischemic potential.

A

TRUE

83
Q

Cardiac ________ anomalies that might compromise outcome from orthotopic liver transplantation must also be identified.

A

Structural

84
Q

What is needed for intra-op management of a liver transplant pt.

A
  • 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
Q

What considerations need to be made for anesthetic drugs for liver transplantation?

A
  • 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
Q

What are the phases of liver transplantation surgery?

A
  • preanhepatic phase
  • anhepatic phase
  • neohepatic phase
87
Q

What happens in the preanhepatic phase of liver transplantation?

A
  • lysis of adhesion
  • mobilization of liver and careful dissection of hepatic artery, common bile duct, Supra and infrahepatic vena cava and portal vein.
88
Q

When would a portocaval shunt or venous bypass be instituted during a liver transplant?

A
  • if portal HTN is severe to the degree that mobilizing the liver may result in significant blood loss
  • pt is unstable
89
Q

What do shunting procedures do?

A
  • redirect the portal venous flow into the systemic venous circulation via a nonvariceal conduit, thus
  • relieving portal hypertension
  • decompressing varicose
  • relieving ascites
90
Q

What is the aim of nonshunting procedures during the preanhepatic phase?

A

-controlling hemorrhage from the portosystemic varices

91
Q

What are problems that occur during the preanhepatic phase?

A
  • hemorrhage>CV instability
  • coagulation problems
  • impaired venous return from surgical retraction and IVC clamping
  • hypocalcemia, hyperkalemia and metabolic acidosis
92
Q

What happens in the anhepatic phase of liver transplantation?

A
  • Begins with clamping of hepatic blood flow

- removal of native liver

93
Q

During the Anhepatic phase what is the Bicaval Clamp?

A

-clamp venacava above and below liver

>drops preload——>profound hypotension and tachycardia

94
Q

What is the piggyback technique used during the anhepatic phase ?

A

-sideclamp the inferior vena cava

>preserves some caval flow and preload

95
Q

What anesthetic management is needed during the anhepatic phase of liver transplantation?

A
  • 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
Q

What happens in the Neohepatic phase of liver transplantation surgery?

A
  • 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
Q

Severe _________ instability May occur with unclamping of portal vein (post Reperfusion syndrome)

A

“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
Q

What is Reperfusion syndrome characterized by?

A
  • 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
Q

What are the initial indirect signs of a functioning graft?

A
  • intra-op bile production
  • intra-op spontaneous correction of negative base excess
  • improvement in coagulation
100
Q

What occurs in the post-op care of liver transplant pt?

A

-extubation deferred
-ICU-direct admit
-Serial ultrasound assessments of hepatic artery and portal vein patency
>thrombosis may require re-transplantation

101
Q

What are the 3 types of lung transplantation?

A
  • single-lung transplantation
  • bilateral sequential lung transplantation
  • heart-lung transplatation
102
Q

What are the most frequent indications for lung transplantation?

A
  • COPD
  • Idiopathic pulmonary fibrosis
  • cystic fibrosis
  • alpha 1-antitrypsin deficiency
  • sarcoidosis
  • congenital heart disease (Eisenmenger’s syndrome with concomitant cardiac repair)
104
Q

What are the indications for heart transplants(end stage cardiac failure)?

A
  • ischemic cardiomyopathy
  • idiopathic dilated cardiomyopathy
  • congenital defects
  • valvular heart disease
  • dysfunction of previous cardiac graft
  • intra-cardiac tumors
105
Q

What stabilizing measures are used while awaiting heart transplantation?

A
  • IV inotropes
  • Intra-aortic balloon pump
  • ventricular assist device
  • mechanical ventilation
106
Q

What standard anesthesia and invasive hemodynamic monitoring is needed for pt with end-stage cardiac failure?

A
  • Arterial BP
  • PAC
  • CVP
  • TEE
  • RV assist device
107
Q

What is important to keep in mind when providing anesthesia for cardiac transplant pt?

A
  • 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
Q

A post-heart transplant pt has no _______, __________, or __________ innervations.

A
  • sensory
  • sympathetic
  • parasympathetic

-the HR should be high (90-110’s) because the parasympathetic innervation that normally lower the HR is not present

109
Q

T/F: You must use atropine to treat bradycardia with post-heart transplant pt.

A

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
Q

The pre-op assessment of the lung transplant pt evaluates what?

A

Varying degrees of

  • impairs gas exchange
  • altered pulmonary mechanics
  • right ventricular function

Levi 3 (2 decks)

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