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
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
3
Q
criteria for diagnosis of brain death
A
- loss of cerebral cortical function
- loss of brainstem function
- supporting documentation
4
Q
what is loss of cerebral cortical function
A
- no spontaneous movement
- unresponsive to external stimuli
5
Q
what is loss of brainstem function
A
- apnea
- absent cranial nerve reflexes
6
Q
what is supporting documentation to brain death
A
- ECG
- cerebral blood flow studies
7
Q
vital sign requirements for donor support
A
- BP > 100 systolic
- CVP 8-12
- O2 sat > 96%
- UO > 100 cc/hr
8
Q
paralytic for donors during surgery
A
- no anesthesia required by may require paralytic to neutralize spinal reflexes and relax the abdomen
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
10
Q
major indications for kidney transplant
A
- DM
- HTN induced nephropathy
- glomerulonephritis
- polycystic kidney disease
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
12
Q
hyperphosphatemia in renal pts
A
- leads to hypocalcemia which = inability to activate vitamin D = increased risk for fractures
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)
14
Q
living donor fluid protocol for kidneys
A
- 10ml/kg above calculated loss
- maintain UO > 100 ml/hr
- no NO2 (distends bowel)
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
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
anesthesia management during pre-anhepatic stage
- risk of hemorrhage
- coagulation problems occur
- impaired venous return from surgical retraction and IVC clamping
- hypocalcemia, hyperkalemia, metabolic acidosis
26
ascites management
- 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
anhepatic phase
-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
vena cava clamping techniques
- 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
anesthesia management of anhepatic phase
- 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
neohepatic phase
- begins with unclamping of portal vein, hepatic artery, and vena cava, and reperfusion of donor liver
- may experience great hemodynamic instability
31
anesthesia management of neohepatic phase
- severe hemodynamic instability (reperfusion syndrome)
- ionized Ca should be normal, acidosis corrected, K < 4.5
32
reperfusion syndrome
- 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
initial signs of functioning graft
- intraop bile production, correction of negative base excess, improvement of coagulation
34
HGb in liver transplants
- keep between 7 and 8 to keep blood from clotting
35
eisenmenger's syndrome
- 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
indications for lung transplant
- COPD
- pulmonary fibrosis
- cystic fibrosis
- alpha-1 antitrypsin deficiency
- sarcoidosis
