Organ Donation/Transplant Flashcards
Max cold ischemic times–heart and lungs = ___-___ hours; liver = ___-___ hours; kidneys = ___ hours
Heart and lungs = 4-6 hours; liver = 12-24 hours; kidneys = 72 hours
What are (3) types of organ donors?
- Brain death donors
- Donation after cardiac death (DCD)
- Living donors
What law is this describing?–defines death as the “irreversible cessation of circulatory and respiratory functions, or of all functions of the entire brain, including the brain stem”
US Uniform Determination of Death Act (1980)
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–T/F?
True
What are the criteria for the diagnosis of brain death?
- Loss of cerebral cortical function
- Loss of brainstem function
- Supporting documentation
Criteria for the Diagnosis of Brain Death–loss of cerebral cortical function = no ___, unresponsive to ___
Loss of cerebral cortical function = no spontaneous movement, unresponsive to external stimuli
Criteria for the Diagnosis of Brain Death–loss of brainstem function = ___, absent ___ reflexes
Loss of brainstem function = apnea, absent cranial nerve reflexes (papillary, corneal, oculocephalic, oculovestibular)
Criteria for the Diagnosis of Brain Death–supporting documentation = ___, ___ studies
Supporting documentation = EEG, cerebral blood flow studies (angiography, transcranial doppler, xenon scan)
Common physiologic derangements after brain death include ___tension, arterial ___emia, ___thermia, and cardiac ___
Common physiologic derangements after brain death include hypotension, arterial hypoxemia, hypothermia, and cardiac dysrhythmias
What is donation after cardiac death?–non-___ donors; severe ___ dysfunction; have ___ activity in the brain; death is defined by cessation of ___ and ___
- Non-heart-beating donors
- Severe whole brain dysfunction
- Have electrical activity in the brain
- Death is defined by cessation of circulation and respiration
For donation after cardiac death, life support measures are used to control the timing of death, organ procurement, and to maximize function of organs from these donors–T/F?
True
DCD donors meet the criteria for brain death–T/F?
False–DCD donors do NOT meet the complete criteria for brain death
For DCD, after the patient’s heart stops beating and the physician declares death, the transplant team waits no less than ___ minutes following pulselessness before starting organ recovery
The transplant team waits no less than 5 minutes following pulselessness before starting organ recovery
Anesthesia management ___ (is/is not) required for organ donation after brain death (DBD)
Anesthesia management IS required for organ donation after brain death
Anesthesia management ___ (is/is not) required for organ donation after cardiac death (DCD)
Anesthesia management IS NOT required for organ donation after cardiac death
Anesthesia for organ recovery–anesthesia support of donor organ systems is necessary until the ___
until the proximal aorta is clamped (after which the ventilator, IVs, and cardiac monitors may be discontinued)
Anesthesia for organ recovery–if the lungs are to be recovered for transplantation, anesthesia support ___ (will/will not) be required post cross-clamp
if the lungs are to be recovered for transplantation, anesthesia support will be required post cross-clamp
Why is anesthesia needed post cross-clamp if the lungs are to be recovered?
Anesthesia will hyperventilate the lungs to ensure that the perfusion is delivered at the cellular level
Anesthesia for organ recovery–goal is SBP > ___; CVP ___-___; O2 sat > ___%; urine output > ___cc/hr
goal is SBP > 100; CVP 8-12; O2 sat > 96%; urine output > 100 cc/hr
Anesthesia is required for organ recovery–T/F?
FALSE–no anesthesia is required
What might be needed to neutralize spinal reflexes and relax the abdomen during organ recovery surgery?
Muscle relaxant
Living organ donors are frequently related to the recipient, healthy individual between ___-___
18-60
Living organ donors must have no history of what (5) things?
- HTN
- Diabetes
- Cancer
- Kidney disease
- Heart disease
Absolute contraindications to organ implantation–active uncontrolled ___; ___; inability to tolerate ___ suppression; severe ___/___ condition (pt unfit for surgery); continued ___ or ___ abuse; ___ malignancy; inability to comply with ___ regimen; lack of ___ support
active uncontrolled infection; AIDS; inability to tolerate immune suppression; severe cardiopulmonary/medical condition (pt unfit for surgery); continued drug or alcohol abuse; extrahepatic malignancy; inability to comply with medical regimen; lack of psychosocial support
There has been a dramatic increase in the success of organ transplantation–T/F?
True
D/t immunosuppressive regimens and improved donor:recipient tissue typing
What is the most frequent solid organ transplant (order from greatest to least)?
Kidney > Liver > Heart > Lung > Heart/Lung
What are (4) major indications for kidney transplantation?
- Diabetes mellitus
- Hypertension-induced nephropathy
- Glomerulonephritis
- Polycystic kidney disease
What are (2) most common causes of ESRD?
- HTN
- DM
Patients receiving kidney transplant must have cardiac workup preoperatively–T/F
?
True–need EKG, Holter monitor, stress test
Diabetic autonomic neuropathy can make intraoperative ___ control difficult
BP control
Gastroparesis, another complication of autonomic neuropathy, increases the risk of ___ during induction of GETA
increases the risk of aspiration during induction of GETA
CRF is characterized by Hgb ___-___; Hgb of ___% or greater is needed for adequate O2 delivery to the heart and transplanted graft
CRF is characterized by Hgb 6-8%; Hgb of 8% or greater is needed for adequate O2 delivery to the heart and transplanted graft
In pts receiving hemodialysis or peritoneal dialysis, it is important to evaluate their ___, ___, and ___ status
acid-base, electrolyte, and volume status
___ evaluation is very important for patients with type 1 insulin dependent diabetes mellitus (IDDM); why?
Airway evaluation because these patients often manifest with stiff joint syndrome, characterized by a fixation of the AO joint, along with limited head extension
What is another problem in patients with type 1 IDDM?–impairment of ___ function r/t loss of lung ___ properties
impairment of pulmonary function
Pulmonary function impairment (for patients with type 1 IDDM) is characterized by a decrease in ___ reactivity, a significant restriction of lung volumes, with reduced ___ volume and forced ___ ventilation
Pulmonary function impairment (for patients with type 1 IDDM) is characterized by a decrease in cough reactivity, a significant restriction of lung volumes, with reduced tidal volume and forced expired ventilation
Fluid protocol for living kidney donor–___ ml/kg/hr above calculated losses; maintain UO > ___ ml/hr
10 ml/kg/hr above calculated losses; maintain UO > 100 ml/hr
What gas should NOT be used for living kidney donors? Why?
Nitrous oxide–can distend the bowel which can get in surgeons way (because it is done laparoscopically)
What (2) vessels are identified during cadaveric kidney transplantation?
External iliac vein and artery
Which is clamped/anastomosed first–the external iliac vein or artery?
External iliac vein is clamped/anastomosed first
What med(s) should be given when the clamps are released from the external iliac vein/artery?
Mannitol or lasix
Be attentive to ___tension after reperfusion of donor kidney because graft function is critically dependent on ___
Be attentive to hypotension after reperfusion of donor kidney because graft function is critically dependent on perfusion pressure
What drugs should be avoided in kidney transplant patients? Why?
Avoid alpha adrenergic drugs b/c transplanted kidney is sensitive to sympathomimetics
Alpha adrenergic drugs enhance blood flow to transplanted organs–T/F?
FALSE–alpha adrenergic drugs compromise blood flow to transplanted organs
Choice of muscle relaxant in kidney transplant patients depends on what electrolyte?
K+ level
In normokalemic patients, ___ (what muscle relaxant?) is safe
Succs– 1-1.5 mg/kg
What are (2) other muscle relaxants that can be used in kidney transplant patients?
- Cisatracurium (Hoffman elimination) (0.1 mg/kg)
- Mivacurium (0.15-0.2 mg/kg)
___ (depolarizing/nondepolarizing) muscle relaxant is preferred in patients who are at high risk of pulmonary aspiration in ESRD d/t autonomic gastropathy, obesity, or on peritoneal dialysis with significant volume of dialysate fluid left in
Depolarizing–succs
Reversal of muscle relaxants with neostigmine and robinul is safe in patients with ESRD–T/F?
True–but sugammadex is even better
If diabetic gastroparesis is a concern, what can be administered immediately prior to the induction of anesthesia to decrease the gastric acid content?
Sodium citrate/citric acid oral solution
What drug can be given to increase gastric emptying and lower esophageal sphincter tone?
Metoclopramide
What drug can be given 6-12 hours prior to induction to decrease gastric acid production?
H2 blocker
Anesthetic goals for kidney transplant = maintain renal ___ and enhance ___ production
maintain renal perfusion pressure and enhance urine production
What (2) drugs should be given before unclamping vascular supply to transplanted kidney?
- Mannitol
- Loop diuretics
Reperfusion of kidney graft may be associated with ___tension; this is most often related to a reduction in the ___load as a consequence of unclamping the ___; how should you treat?
Reperfusion of 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 crystalloid, colloid, or low-dose dopamine
Moderate to severe ___tension may accompany emergence from anesthesia for renal transplant; treat with ___ (short/long) acting antihypertensives
hypertension; treat with short acting antihypertensives
Should long acting beta-blockers be used to treat hypertension on emergence from anesthesia for renal transplant?
NO–because they can raise K+ levels
Use short-acting antihypertensives
How is the excretion of drugs affected by a prior renal transplant?
Renal excretion of drugs is usually decreased in patients with a prior renal transplant
Most livers available for transplantation come from heart-beating cadaveric donors–T/F?
True
Patients with chronic liver dysfunction and cirrhosis have a ___ (hyper/hypo) dynamic circulation with ___ (low/high) peripheral vascular resistance and a/an ___ (increased/decreased) cardiac index
Patients with chronic liver dysfunction and cirrhosis have a hyperdynamic circulation with low peripheral vascular resistance and an increased cardiac index
What are the (3) phases of liver transplantation surgery?
- Preanhepatic phase
- Anhepatic phase
- Neohepatic phase
Preanhepatic phase involves what?
- 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 and portal vein
Preanhepatic phase–if portal HTN is severe to the degree that mobilizing the liver may result in significant blood loss or the patient is unstable, then what (2) things may be instituted?
- Portocaval shunt
- Venous bypass
Preanhepatic phase–non-shunting procedures are aimed at controlling ___ from ___
non-shunting procedures are aimed at controlling hemorrhage from portosystemic varices
Preanhepatic phase–shunting procedures redirect the portal venous flow into the systemic ___ circulation via a ___ conduit, thus relieving ___, decompressing ___, and at the same time relieving ___
shunting procedures 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
Anesthesia management of preanhepatic phase–hemorrhage leads to ___ instability; ___ problems occur at this stage; impaired ___ from surgical retraction and IVC clamping; ___calcemia, ___kalemia, and metabolic ___osis
hemorrhage leads to CV instability; coagulation problems occur at this stage; impaired venous return from surgical retraction and IVC clamping; hypocalcemia, hyperkalemia, and metabolic acidosis
Anhepatic phase begins with ___
clamping of hepatic blood flow
What (2) big things occur during anhepatic phase?
removal of native liver, implantation of donor liver
Bicaval clamp used during the anhepatic phase clamps what?
Clamps vena cava above and below the liver
Bicaval clamp drops ___, leading to profound ___tension and ___cardia
Bicaval clamp drops preload, leading to profound hypotension and tachycardia
Piggyback technique for anhepatic phase ___ clamps the IVC; what is the benefit of this?
Piggyback technique for anhepatic phase side clamps the IVC; benefit is that it preserves some caval flow/preload
Venovenous bypass is not typically used today during the anhepatic phase–T/F?
True
Bicaval clamp or piggyback technique are typically done
Considerations during anhepatic phase–___, increasing ___lysis, ___pathy, ___osis, ___thermia, and decreased ___ function
hemorrhage, increasing fibrinolysis, coagulopathy, acidosis, hypothermia, and decreased renal function
Anhepatic phase–cardiac output and systemic blood pressure may need to be supported with ___ and ___
inotropes and vasopressors
Anhepatic phase–___ intoxication may occur from rapid infusion of large volumes of blood in absence of liver function
citrate intoxication
What electrolyte abnormality may occur during anhepatic phase? How should you treat?
Hypocalcemia–give calcium
Neohepatic phase begins with what?
Unclamping of the portal vein, hepatic artery, vena cava and reperfusion of the donor liver
What may occur with unclamping of portal vein?
Severe hemodynamic instability–post reperfusion syndrome
Neohepatic phase–before unclamping of portal vein, ___ should be normal, ___ should be corrected, and K+ should be ___
ionized calcium should be normal, acidosis should be corrected, and K+ should be < 4.5
What vasopressors should be used during neohepatic phase? What should be avoided?
Epi, norepi, or both
Avoid fluid overload prior to unclamping
Neohepatic phase–hemodynamics typically stabilize once ___
allograft begins to function
Reperfusion syndrome is characterized by decreased ___, ___, and ___; ___ defects (___arrhythmias, ___); ___ HTN; ___ (increased/decreased) SVR
decreased CO, HR, and BP; conduction defects (bradyarrhythmias, asystole); pulmonary HTN; decreased SVR
Reperfusion syndrome–a rapid increase in ___ can occur, ensure normal pH and electrolytes prior to unclamping
a rapid increase in K+
Reperfusion syndrome–severe coagulopathies occur d/t ___lysis, release of ___, and ___thermia
severe coagulopathies occur d/t fibrinolysis, release of heparin, and hypothermia
Initial indirect signs of a functioning graft = intraoperative ___ production; intraoperative spontaneous correction of ___; improvement in ___
intraoperative bile production; intraoperative spontaneous correction of negative base excess; improvement in coagulation
