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Advanced anesthesia 2 > organ procurement > Flashcards

organ procurement Flashcards

1
Q

maximum cold ischemic times for organs

A
  • heart and lungs = 4-6 hrs
  • liver = 12-24 hrs
  • kidneys = 72 hrs
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2
Q

definition of 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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3
Q

criteria for diagnosis of brain death

A
  • loss of cerebral cortical function
  • loss of brainstem function
  • supporting documentation
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4
Q

what is loss of cerebral cortical function

A
  • no spontaneous movement
  • unresponsive to external stimuli
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5
Q

what is loss of brainstem function

A
  • apnea
  • absent cranial nerve reflexes
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6
Q

what is supporting documentation to brain death

A
  • ECG
  • cerebral blood flow studies
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7
Q

vital sign requirements for donor support

A
  • BP > 100 systolic
  • CVP 8-12
  • O2 sat > 96%
  • UO > 100 cc/hr
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8
Q

paralytic for donors during surgery

A
  • no anesthesia required by may require paralytic to neutralize spinal reflexes and relax the abdomen
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9
Q

frequently required meds/gtts for organ recovery

A
  • 6-8 LR
  • 30,000 units of heparin
  • thyroxin gtt
  • vec or pan
  • vasopressors
  • possibly PRBCs, albumin, mannitol, lasix
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10
Q

major indications for kidney transplant

A
  • DM
  • HTN induced nephropathy
  • glomerulonephritis
  • polycystic kidney disease
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11
Q

anemia in renal transplant pts

A
  • anemia related to decreased erythropoietin and hemolysis
  • body compensates by increasing CO
  • Hgb may be 5-8
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12
Q

hyperphosphatemia in renal pts

A
  • leads to hypocalcemia which = inability to activate vitamin D = increased risk for fractures
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13
Q

pre-op problems with renal transplant patients

A

-anemia, LVH, hyperkalemia
- gastroparesis
- stiff joint syndrome (fixed AO and head extension)
- pulmonary impairment (loss of lung elasticity)

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14
Q

living donor fluid protocol for kidneys

A
  • 10ml/kg above calculated loss
  • maintain UO > 100 ml/hr
  • no NO2 (distends bowel)
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15
Q

anesthetic management of renal transplant pt

A
  • CVP (LV pre-load)
  • A-line
  • avoid tachycardia, hypotension, and HTN
  • avoid alpha adrenergic medications and LR
  • neostigmine and robinul are safe
  • Na citrate and citric acid decrease gastric acid content
  • metoclopramide may increase gastric emptying
  • H2 blockers 6-12 hrs before induction decrease gastric acid production
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16
Q

vasopressors for kidney transplant

A
  • dopamine
  • fenoldopam
  • norepinephrine
  • vasopressin
17
Q

diuretics for renal transplant

A
  • mannitol and loop diuretics
  • give before unclamping vascular supply to the kidney
18
Q

hypotension associated to reperfusion of kidney graft

A
  • due to reduction of preload from unclamping iliac artery
  • treat with crystalloid or low-dose dopamine
19
Q

emergence with renal transplants

A
  • HTN occurs
  • treat with short acting antihypertensives
  • avoid long acting beta blockers as they may raise K+ levels
20
Q

indications for liver transplant

A
  • cholestatic disease
  • alcoholic cirrhosis
  • metabolic diseases
  • malignant diseases of the liver
  • maple syrup disease is common (amino acids)
  • end stage liver disease
  • hepatic cirrhosis
  • hepatitis
  • sclerosing cholangitis
21
Q

physiologic presentation of liver pts

A
  • hyperdynamic circulation (low peripheral vascular resistance and increased CI)
  • hepatic encephalopathy
  • hepatopulmonary syndrome
  • portal HTN, ascites
22
Q

orthotopic

A
  • native liver is removed and replaced by the organ donor in the same anatomical position as the original liver
23
Q

pre-anhepatic phase

A
  • lysis of adhesions and exploration of abdomen
  • mobilization of lover and careful dissection of hepatic artery, common bile duct, supra and infra hepatic vena cava and portal vein
  • shunting vs non-shunting procedure
24
Q

shunting vs non-shunting procedure, liver transplant

A
  • shunt placed if portal HTN is severe and there is a high risk of hemorrhage due to varices
25
Q

anesthesia management during pre-anhepatic stage

A
  • risk of hemorrhage
  • coagulation problems occur
  • impaired venous return from surgical retraction and IVC clamping
  • hypocalcemia, hyperkalemia, metabolic acidosis
26
Q

ascites management

A
  • when drained pt can experience large fluid shifts
  • use 5% albumin
  • maintain low to normal CVP to decrease blood loss
  • TEG is gold standard for guiding transfusions
27
Q

anhepatic phase

A

-begins with clamping of hepatic blood flow
- removal of native liver
- vena cava is removed with liver
- implantation of donor liver
- period of no drug metabolism and massive blood loss

28
Q

vena cava clamping techniques

A
  • bicaval clamping (clamp above and below liver = drop in preload and profound hypotension and tachycardia)
  • piggyback technique (side-clamp the inferior vena cava = preserve some caval flow and preload)
29
Q

anesthesia management of anhepatic phase

A
  • hemorrhage, fibrinolysis, coagulation, acidosis, hypothermia, decrease in renal function
  • support CO and BP
  • citrate intoxication from large infusions of blood
  • Ca administration
  • aggressively treat hypotension with fluids to CVP 10-20 cmH2O
30
Q

neohepatic phase

A
  • begins with unclamping of portal vein, hepatic artery, and vena cava, and reperfusion of donor liver
  • may experience great hemodynamic instability
31
Q

anesthesia management of neohepatic phase

A
  • severe hemodynamic instability (reperfusion syndrome)
  • ionized Ca should be normal, acidosis corrected, K < 4.5
32
Q

reperfusion syndrome

A
  • characterized by decreased CO, HR, BP, conduction defects, pulm HTN, decreased SVR
  • rapid increase in K
  • severe coagulopathies (fibrinolysis, release of heparin, and hypothermia)
  • defined by a decrease in MAP > 30% for 1 min during first 5 min of reperfusion
  • may need to lower CVP
33
Q

initial signs of functioning graft

A
  • intraop bile production, correction of negative base excess, improvement of coagulation
34
Q

HGb in liver transplants

A
  • keep between 7 and 8 to keep blood from clotting
35
Q

eisenmenger’s syndrome

A
  • pressure in the PA becomes so high that is causes O2 poor blood to flow from RV to LV causing cyanosis
  • indication for lung transplants
36
Q

indications for lung transplant

A
  • COPD
  • pulmonary fibrosis
  • cystic fibrosis
  • alpha-1 antitrypsin deficiency
  • sarcoidosis

Advanced anesthesia 2 (10 decks)

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