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APA 3 - Wolfe > Organ Donation/Transplant > Flashcards

Organ Donation/Transplant Flashcards

1
Q

Maximum ischemic cold times
Heart and Lungs
Liver
Kidneys

A

Heart and Lungs 4-6 hrs
Liver 12-24 hrs
Kidneys 72 hrs

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2
Q

What is the most common method for donation?

A

Brain death organ donors

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3
Q

What is the definition of brain death

A

irreversible cessation of circulatory and respiratory functions, or of all functions of the entire brain, including the brain stem.

d/t lack of blood supply and O2

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4
Q

T/F: An individual’s signature on a driver’s license or donor card indicating their desire to donate their organs is legally binding and does not require family permission.

A

TRUE

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5
Q

Criteria for the diagnosis of brain death

A

Loss of cerebral cortical function

  • no spontaneous movement
  • unresponsive to external stimuli

Loss of brainstem function

  • apnea
  • absent CN reflexes (papillary, corneal, oculocephalic, oculovestibular)

Supporting documentation

  • EEG
  • cerebral blood flow studies
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6
Q

Common physiological derangements after brain death

A

Hypotension (DI, hemorrhage, neurogenic shock), arterial hypoxemia, hypothermia, cardiac dysrhythmias

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7
Q 
Donation after cardiac death (DCD):
Non-heart-beating donors
Severe whole brain \_\_\_\_\_\_
Have \_\_\_\_\_\_ in the brain
Death is defined by cessation of \_\_\_\_\_
A

dysfunction
electrical activity
circulation and respiration.

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8
Q

T/F: DCD –> Life support measures are used to control the timing of death, organ procurement, and to maximize function of organs from these donors.

A

TRUE

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9
Q

in DCD, after the patient’s heart stops beating, the physician declares death. The transplant
team waits no less than 5 minutes following
pulselessness before starting organ recovery.
Which organs can often be recovered?

A

The lungs, liver, pancreas and kidneys often

can be recovered.

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10
Q

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

Anesthesia management _____ for organ donation after cardiac death. (DCD)

A

required

MAY NOT be required

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11
Q

in organ recovery, how many surgeons will scrub in?

A

2

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12
Q

Anesthesia support of donor organ systems is necessary until

A

the proximal aorta is clamped, after which the ventilator, IV’s, and cardiac monitors may be discontinued.

after cross-clamp, you will be dismissed

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13
Q

If lungs are being transplants, anesthesia support will be required after cross-clamp. Why?

A

The purpose is to hyperventilate the lungs to insure that the perfusion is delivered at the cellular level. At this point you may be asked to extubate so the lungs and trachea may be recovered

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14
Q

The recovery of viable organs is dependent upon adequate respiratory support and organ perfusion as indicated by a:
BP ____ systolic and/or CVP ____
Maintain O2 sat ____ and urine output ____

A

SBP >100 and/or CVP 8-10
O2 sats >96%
UOP > 100 cc/hr

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15
Q

Vigorous volume expansion with crystalloid and colloid is usually necessary to avoid hypotension. What is the goal?

A

Euvolemia should be goal.

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16
Q

Anesthesia for organ procurement:

No anesthesia is necessary but a muscle relaxant may be required, why?

A

to neutralize spinal reflexes and relax the abdomen

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17
Q

Living donors account for ___% of all donors. They are frequently _____ to the recipient. Between the ages of ____. With no hx of…

A

44%
related
18-60
HTN, DM, CA, kidney or heart disease

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18
Q

Frequently required drugs and fluids for organ recovery

A 
6-8 Lactated Ringers
Heparin 30,000 units
Thyroxin drip may be required in certain cases 
Pancuronium/Vecuronium
dopamine, NEO, LEVO, or vasopressin
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19
Q

What is on hold for extra renal donors

A

PRBCs

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20
Q

What must be available if the liver is being split?

A

two (or more) units of PRBC’s are REQUIRED in the OR

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21
Q

Absolute contraindications to organ transplant

A 
Active uncontrolled infection
AIDS
Inability to tolerate immune suppression
Severe cardiopulmonary/medical condition - (patient unfit for surgery)
Continued drug or alcohol abuse
Extrahepatic Malignancy
Inability to comply with medical regimen
Lack of psychosocial support
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22
Q

What has caused the dramatic increase in the success of organ transplantation?

A

Immunosuppressive regimens

  • Cyclosporine 1980s ~ decreased host rejection
  • Azathioprine (Imuran)
  • OKT3 (Muromonab-CD3)
  • Steroids ~prednisone and methylprednisolone

Improved donor:recipient tissue typing

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23
Q

Post-transplantation organ function is dependent on multiple factors…

A

Donor demographics
Organ ischemic time
Mechanism of death of donor
Medical condition of recipient

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24
Q

Most frequent solid organ transplants

A 
Kidney –25,500
Liver – 6,291
Heart – 3,000
Lung – 1,000
Heart-lung - 40
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25
7000 kidney transplants are from _____ | what is the 5 year survival rate?
cadavers 72% - nonextended criteria 57% - extended criteria
26
What is the remaining kidney donors from? | What is the 5 year survival rate?
living donors | 81%
27
What is the 5 year survival on dialysis?
30%
28
What are the common indications for kidney transplant?
DM & HTN (most common) Glomerulinephritis Polycystic kidney disease
29
Physiologic disturbance often present before renal transplant
``` Peripheral neuropathy lethargy anemia platelet dysfunction pericarditis HTN Depressed EF Pleaural effusions skeletal muscle weakness ileus Glucose intolerance ```
30
What does HTN lead to?
LVH, cardiac chamber dilatation, increased Lt ventricular wall tension, redistribution of coronary blood flow, myocardial fibrosis, heart failure and arrhythmias.
31
What is anemia r/t in renal transplant patients? how does the body compensate?
decreased erythropoietin production and hemolysis compensates by increasing CO --> ischemia
32
What may the HGB be in a renal transplant patient?
Hgb may be 5-8 g/dL. May need transfusion ahead of time, coagulopathies are prevalent, may need desmopressin or cryo.
33
For renal patients, a hgb of ____ is needed for adequate O2 delivery to the heart and transplanted graft
8% or greater
34
In renal patients, what is caused by diabetic autonomic neuropathy?
Can make intra-op BP control difficult | Gastroporesis - increasing risk for aspiration
35
What electrolyte abnormalities are common in renal patients?
Hyperphosphatemia is common, leads to hypocalcemia due to lack of calcium absorption due to inability to activate Vit. D = risk for fractures. Hyperkalemia is most hazardous.
36
Why is airway assessment of pts with type 1 DM extra important?
These patients often manifest with stiff joint syndrom characterized by a fixation of the atlantooccipital joint along with limited head extension
37
What respiratory issues may type 1 diabetics have?
Pulmonary function impairment is related to a loss of lung elastic properties and is characterized by a decrease in cough reactivity, a significant restriction of lung volumes with a reduced tidal volume and forced expired ventilation (FEV)
38
What is the fluid protocol for a living kidney donor
10mL/kg/hr ABOVE calculated losses Maintain UO > 100mL/hr. Titrate to a specific CVP (can be inaccurate)
39
Why should you NOT use nitrous during kidney transplant
distended bowel can get in surgeons way (laparoscopic)
40
Cadeveric kidney transplant: Patient is positioned supine. After induction of anesthesia, a _____ is placed. Incision in the right or left lower quadrant. The retroperitoneal space is developed by retracting the peritoneum. The _____ are identified. The vein is clamped and anastomosed first followed by the artery, then clamps are released. ____ should be given by this point. The bladder is filled with ____ to facilitate implantation of the ureter.
3-way Foley retracting the peritoneum external iliac vein and artery Mannitol or Lasix antibiotic solution
41
What lines should the renal transplant patient have?
- 2nd IV - Aline - CVP (The accuracy of CVP to monitor Lt ventricle pre-load status is still debatable) - PAC is necessary to monitor CO, SVO2 and pulmonary arterial and capillary pressures.
42
Be attentive to hypotension after reperfusion of donor kidney because graft function is critically dependent on perfusion pressure.
!!!
43
What drugs should be AVOIDED in the kidney recipient?
alpha adrenergic drugs because transplanted kidney is sensitive to sympathomimetics. (this will compromise blood flow to the kidney)
44
What IVF is contraindicated in RT patients
LR
45
Muscle relaxant based off K level: normokalemic: Hyperkalemic:
normokalemic --> Succs (1-1.5 mg.kg) otherwise --> cisatracurium (0.1 mg/kg) or mivacurium (0.15-0.2 mg/kg) is preferable.
46
When are DMR preferred to intubate a renal patient
pts who are at high risk of pulmonary aspiration as in ESRD d/t autonomic gastropathy, obesity, or on peritoneal dialysis with significant volume of dialysate fluid left in
47
What reversal meds do you use with kidney transplant
Neostigmine and robinul is safe in patients with ESRD
48
Is propofol safe in renal transplant?
yes, metabolized by the liver
49
If diabetic gastroporsis is a concern, what should you give?
(Sodium citrate and citric acid oral solution 30 mL) is administered immediately prior to the induction of anesthesia to decrease the gastric acid content Use of metoclopramide (30 mg PO) may increase gastric emptying and lower esophageal sphincter tone Administration of an H2 blocker 6-12 hours prior to induction can decrease gastric acid production
50
The use of continuous epidural analgesia may be considered for intraoperative as well as postoperative pain control. Low dose local anesthetics and narcotics (bupivacaine 0.125% and fentanyl 3mcg/ml). What needs to be considered
coagulopathies
51
Why should analgesics be used cautiously prior to surgery?
Active metabolites | Morphine:morphine-6-glucuronide, Meperidine:normeperidine
52
Vasopressors or positive inptropes may be needed to increase cardiac output and renal perfusion pressure. What are the meds?
Dopamine Fenoldopam Norepinephrine Vasopressin
53
When do you give mannitol and loop diuretics?
Before unclamping vascular supply to transplanted kidney
54
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. What should this be treated with?
Treat with crystalloid, colloid or low-dose dopamine
55
Significance of decreased urine output
May indicate mechanical impingement of graft, anastamosing vessel, or ureter. Intra-operative ultrasound may be used to assess flow through arterial and venous anastamosis.
56
Moderate to severe hypertension may accompany emergence from anesthesia for renal transplant. What meds should be used and avoided?
Short-acting anti-hypertensives may be considered The use of longer acting beta-blockers should be avoided as they may raise K+ levels
57
Anesthetic considerations for a patient with prior renal transplant surgery
Renal excretion of drugs is usually decreased compared to those with native kidneys. Patients still suffer from primary systemic disease –DM, HTN Avoid muscle relaxants that rely on renal excretion for elimination Provide adequate hydration Avoid hypotension
58
10 year survival rate for liver transplant
~60%
59
Indications for liver transplant
Cholestatic disease - Primary/secondary biliary cirrhosis - Sclerosing cholangitis - Biliary atresia - Cystic fibrosis Metabolic diseases Malignant disease of liver - Hepatocellular carcinoma - Carcinoid tumor islet cell tumor - Epithelioid hemangioendothelioma End stage liver disease Acute hepatic necrosis - Viral hepatitis - Drug toxicity - Toxins - Wilson’s disease Chronic Hepatitis - B, C, D - Autoimmune hepatitis - Chronic drug toxicity - Cryptogenic cirrhosis Post necrotic (non alcoholic) cirrhosis Sclerosing cholangitis
60
Alcoholic cirrhosis may be considered for transplant if abstinence of alcohol for
6 months
61
What is Wilsons disease?
rare genetic disorder that does not allow for the body to eliminate copper causing it to build up in key organs
62
Most livers available for transplantation come from _______ donors.
heart-beating cadaveric A heart-beating cadaver is kept alive in order to keep its organs from decaying before they can be transplanted…some donated organs are taken from non-heart-beating donors. Organs from brain deaths, however, have a better success rate, and currently most organ donation is from these deaths.
63
Pt’s. with chronic liver dysfunction and cirrhosis have a ________ circulation with low ________ and an increased _____
hyperdynamic peripheral vascular resistance cardiac index
64
T/F: Coagulopathies, edema, ascites, renal dysfunction, portopulmonary hypertension, hepatopulmonary syndrome, and autonomic neuropathies are common in chronic liver dysfunction
True
65
Hepatic encephalopathy is thought to be multifactorial, resembles and must be differentiated from many other nonfocal neurologic conditions such as
hypoglycemia, hyponatremia, intracranial hemorrhage or mass lesions, and meningitis.
66
Co-morbid conditions associated with liver failure
``` look at slide 57! but some important ones are Increased ICP Anemia Thrombocytopenia Prolonged PT/PTT Decreased plasma fibrinogen DIC Protein C&S deficiency Hypokalemia and Hypocalcemia Metabolic acidosis ```
67
How is the incision for liver transplant?
Large subcostal incisoin | painful and large potential for hemorrhage
68
What does orthotopic mean?
the native liver is removed and replaced by the donor organ in the same anatomic position as the original liver
69
Considerations for anesthetic drugs for liver transplant
Rely on hepatic metabolism and excretion | Use is safe due to implantation of functioning liver
70
Do you use nitrous on a liver transplant?
NO
71
What is the pre-anhepatic phase?
Lysis of adhesions and exploration of abdomen Mobilization of liver and careful dissection of hepatic artery, common bile duct, supra and infra-hepatic vena cava & portal vein
72
What is a non-shunting procedure aimed at?
aimed at controlling hemorrhage from portosystemic varices.
73
What do shunting procedures do?
redirect the portal venous flow into the systemic venous circulation via a nonvariceal conduit, thus relieving portal hypertension, decompressing varices, and at the same time relieving ascites.
74
The pre-anhepatice phase is where what occurs
Coagulation problems ***
75
Why is there decreased venous return in the pre-anheptic phase?
from surgical retraction and IVC clamping
76
What are the electrolyte abnormalities in the pre-anhepatic phase?
Hypocalcemia, hyperkalemia, metabolic acidosis
77
Ascites is drained and patient can experience large fluid shifts. Decrease in intrabdominal pressure may show volume depletion. What do you use for volume expansion?
Volume expansion with 5% albumin
78
In the pre-anhepatic phase, what CVP should you maintain and why?
maintain low to low-normal CVP to decrease blood loss
79
What is the gold standard to guide transfusions?
TEG | takes 45 minutes
80
What is the anhepatic phase
Begins with clamping of hepatic blood flow Removal of native liver Implantation of donor liver
81
When a bicaval clamp (Clamp venacava above and below liver) is placed in the anheptic phase, what may you see?
Drop preload | Profound hypotension and tachycardia***
82
The piggyback technique side clamps the inferior vena cava, what is different compared to bicaval?
Preserves some caval flow and preload
83
T/F: In the anhepatic phase, Hemorrhage, increasing fibrinolysis, coagulopathy, acidosis, hypothermia and decreased renal function may occur
true
84
In the anhepatic phase, aggressively treat hypotension with fluids to CVP of
10-20 cm H20. No metabolism will lead to lactate build up and metabolic acidosis. Will worsen with reperfusion, so treat ahead of time. (Usually goal for higher CVP).
85
What does the neohepatic phase begin with?
Begins with unclamping of the portal vein, hepatic artery and vena cava and reperfusion of the donor liver
86
What is preparation for the neohepatic phase important
This is a period of great hemodynamic instability (post re-profusion syndrome) May need potent vasopressors. Epi, norepi, both Fluid overload prior to unclamping should be avoided Hemodynamics typically stabilize once allograft begins to function.
87
What is reprofusion syndrome?
Is characterized by decreased CO, HR and BP, conduction defects (bradyarrythmias, asystole), pulm HTN, and decreased SVR A rapid increase in K+ can occur, ensure normal pH and electrolytes prior to unclamping Severe coagulopathies occur d/t fibrinolysis, release of heparin and hypothermia
88
Initial indirect signs of functioning graft
- Intraoperative bile production - Intraoperative spontaneous correction of negative base excess - Improvement in coagulation - Temp, glucose improvement
89
Are liver transplants extubated after?
NO

APA 3 - Wolfe (11 decks)

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