Organ Transplant Flashcards
What are the recommended cold ischemia time for heart/lungs, livers, kidneys?
- Cold ischemia times (Barash), unos.org gives shorter times: preferably not as long (cold ischemia starts when arterial supply gets clamped)
- less than 6 hours for heart or lung grafts
- 12 to 24 hours for livers
- up to 72 hours for kidneys
What are some methods that increase the donor pool?
- Donation after cardiac death donors (DCD) previously called “non-beating heart”
- as opposed to brain dead
- Acceptance of “marginal donors”
- generally get paired with marginal recipients
- older people with comorbidities
- Paired kidney donations (kidney swaps)
- Some of the increase in deceased donation is d/t increased usage of donors w/ a broader set of medical criteria than considered in past.
- Nearly 20% of donors in 2018 donated after circulatory death as opposed to brain death.
- 9% of deceased donor kidney transplants involved organs with a kidney donor profile index (KDPI) score of 86 or higher, which may function less time compared to low KDPI kidney offers but may also shorten the waiting time for transplant candidates.
- Other donor characteristics setting all-time records in 2018 included age of 50 or older and/or being identified as having increased risk for blood-borne disease
What is the organ procurement and transplantation network? united network for organ sharing?
- Organ Procurement and Transplantation Network [OPTN]
- Established by Congress in 1984
- Facilitates organ matching/allocation process
- Collects and manages data about organ donation and transplantation
- Professional and public education
- United Network for Organ Sharing [UNOS]-administers the OPTN under contract with Health Resources & Services Admin of the U.S. Dept. of Health & Human Services
- Develop policy
- Monitor/Enforce processes of OPTN
- Maintain OPTN membership and review applications
- 2006: DonorNet- how they match donors to recipients
- Electronic resource for matching and distribution of organs around the United States
- Regional databases based on feasibility of achieving optimal cold ischemia times
What was the medication that changed survival rates in transplants?
cyclosporine
What are some wait time factors for the organ recipient?
- blood type; always confirm ABO compatibility of donor and recipient prior to surgery (HLA and ABO compatibility)
- tissue type
- not as many heart/lung vs kidney
- height and weight of transplant candidate
- ie lungs need to be optimally sized for best outcomes
- size of donated organ
- medical urgency
- time on the waiting list (not as important now—look more at regional and survivability)
- the distance between the donor’s hospital and the potential donor organ
- how many donors there are in the local area over a period of time (trauma center versus not, more organs high trauma area)
- the transplant center’s criteria for accepting organ offers – some only get high quality and others are volume-based
- need social, psychosocial support. Cant charge for organ but the rest cost $. Stay at hotel nearby for up to 6 mos. $$. Can be on multiple regional lists.
- Right to self-determination w/ donors, beneficence, maleficence, and equity. Huge ethical criteria.
- Use of marginal donors has expanded pool- ”marginal donor status” hepatitis, LV dysfunction, CAD, advanced age, DCD
- Marginal donors are used for patients who do not meet standard criteria
- 16% DCD in 2015
- DCD kidneys do well although longer time to graft function; DCD livers have poorer survival
Major indication for transplant? (don’t think she’ll actually test on this)
- Lung
- # 1 idiopathic pulmonary fibrsois
- Obstructive lung disease
- Heart
- CMP
- Intestinal
- primarily in kids (short gut syndrome)
- Pancreas
- T1DM
What are some considerations before transplant after brain death?
What patient criteria need to be met before clinical tests for brain death can be performed?
- Definitions will very state to state
- Cessation of cerebral and brain stem function
- death from a physiologic standpoint, does not mean that the patient will die a cardiac death
- Cessation of cerebral and brain stem function
- Physicians involved in the transplant process may not be involved in the declaratory process
-
First- potentially reversible causes are ruled out
- Hypothermia ( _>_36 C), hypotension ( > SBP 100 mmHg) even w/ pressors, drugs, toxins
- Achieve normal core temperature.
- Prior use of hypothermia (e.g., after cardiopulmonary resuscitation for cardiac arrest) may delay drug metabolism.
- In most pts, warming blanket needed to raise body temp and maintain a normal or near-normal temperature (36°C)
- Exclude presence of CNS-depressant drug effect by history, drug screen, or plasma levels below the therapeutic range.
- Legal alcohol limit for driving (BAC 0.08%) is a practical threshold below which brain death exam could reasonably proceed.
- No recent admin or continued presence of NMBDs (presence of a train of 4 twitches w/ maximal ulnar nerve stimulation).
- There should be no severe electrolyte, acid-base, or endocrine disturbance
-
Clinical exams completed once above has been met
- Apnea test
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Validated with diagnostics
- EEG, transcranial doppler, angiography
Clinical exams for brain stem reflexes?
-
Brainstem Reflexes: combination of tests, not just ONE!
- Absence of pupillary response to a bright light is documented in both eyes
- Absence of ocular movements using oculocephalic testing and oculovestibular reflex testing
- Oculocephalic reflex: Movement of eyes should be absent during 1 min of observation. Both sides tested, w/ an interval of several mins.
- Absence of corneal reflex— many don’t have if wear contacts
- Corneal reflex: Absent corneal reflex is demonstrated by touching the cornea with a piece of tissue paper, a cotton swab, or squirts of water. No eyelid movement should be seen.
- Absence of facial muscle movement to noxious stimulus
- Absence of the pharyngeal and tracheal reflexes
- pharyngeal or gag reflex is tested after stimulation of the posterior pharynx with a tongue blade or suction device.
- tracheal reflex is most reliably tested by examining the cough response to tracheal suctioning. The catheter should be inserted into the trachea and advanced to the level of the carina followed by 1 or 2 suctioning passes
- Brain death is not perfect: bodies of some patients who meet all criteria for brain death can survive for many years with all bodily functions intact except for consciousness and brain stem reflexes
- *
What is the apnea test?
- 100% FiO2 for 10 minutes (preoxygenate)
- Normalized PaCO2
- Confirmed by ABG
- T-piece: 7-10 minutes after disconnecting vent (want no ventilatory effort for 10 min)
- Repeat ABG
- PaCO2 >60mmHg
- Absence of spontaneous ventilation
if become hypotensive, if start to decompensate, they are placed back on vent and then retest
What are some aberrations that occur after brain death?
- Hemodynamic instability, wide swings in hormone levels, systemic inflammation, and oxidant stress
- Just after brain death = adrenergic surges= ischemia and ischemia-reperfusion injuries
- Transient period of hypotension with increased cardiac index and tissue perfusion
- precedes the autonomic storm associated with herniation of the brain
- bradycardia after brain herniation is often unresponsive to atropine
- catecholamine storm is often followed quickly by pituitary failure
- Transient period of hypotension with increased cardiac index and tissue perfusion
- Pituitary failure: hormone therapy; specifics vary widely
- triiodothyronine (thyroid hormone infusions)—**helps w/ response to pressors
- Desmopressin to maintain SVR at 800 to 1,200 dyne/s/cm5 (and for DI secondary to loss of pituitary function) good HD status
- Low-dose vasopressin also can be used for DI and to reduce catecholamine requirements- get ADH and pressor effect, w/ hypotensive
- Methylprednisolone (vs hydrocortisone)
- High doses of catecholamines avoided. If use pressor—use dopamine w/ as low of a rate as possible
- Insulin infusion to maintain blood glucose at 120 to 180 mg/dL to maintain function of all organs
- Coagulopathies may require correction
What is uncontrolled DCD? Controlled DCD?
Uncontrolled DCD refers to organ retrieval after a cardiac arrest that is unexpected and from which the patient cannot or should not be resuscitated (not brain dead)
Controlled DCD: planned withdrawal of life-sustaining treatments that have been considered to be of no overall benefit to a critically ill patient
- The patient is brought to the OR, life support is withdrawn – fam had time to say goodbye and going to OR is the finale vs in ICU
- Wait up to 1 hour without ventilation or other support
- Patient is observed for 2-5 minutes to ensure that the heart does not start beating again spontaneously
- If there continues to be no circulation for 2–5 minutes, the physician pronounces the patient dead.
- At this point, the transplant team enters the operating room and removes organs, usually the kidneys and liver, from the now dead patient.
What are some criteria for controlled DCD?
- Death likely within 1 hour of withdrawing support per ICU team; family willing to discuss withdrawal of care
- Characteristics
- Ventilator dependent for respiratory insufficiency: apneic or severe hypopneic; tachypnea ≥ 30 breaths /min after DC ventilator
- Dependent on mechanical circulatory support (LVAD; RVAD; V-A ECMO; Pacemaker w/ HR < 30 beats per minute without support)
- Severe disruption in oxygenation: PEEP≥ 10 and SaO2 ≤ 92%; FiO2 ≥ .50 and SaO2 ≤ 92%; V-V ECMO requirement
- Dependent upon pharmacologic circulatory assist: Norepinephrine, epinephrine, or phenylephrine ≥ 0.2 ug/kg/min; Dopamine ≥ 15 ug/kg/min
- IABP and inotropic support: IABP 1:1 and dobutamine or dopamine ≥10 ug/kg /min and CI ≤ 2.2 L/min/M2; IABP 1:1 & CI ≤ 1.5 L/min/M2
- Circulation and respiration absent for a minimum of 2 minutes before procurement started
Donor anesthesia setup for OR?
- Goal: optimizing organ perfusion and oxygenation
- Pressors on hand (vasopressin, epi, norepi, ephedrine, neo, dopamine, dobutamine)
- Response to pressors can be variable and difficult to manage
- Mainstay for BP—-FLUIDS (more for kidneys, less for lungs)—know goals of transplant team
- Lung protective ventilatory strategies; transport to OR with PEEP valve; may need ICU vent
- don’t disconnect vent: clamp ETT; disconnect and attach to bag w/ high PEEP valve and then un-clamp. if disconnected, de-recruit lungs
- Thromboprophylaxis—high risk for blood clots. Hep right before they take organs .
- Maintain normothermia (warming vs. cooling mechanisms). High fevers w/ loss of brainstem reflexes. Once die or DCD- get v cold!
- Available: draw bunch of labs HLA typing, serology, virology of pt
- As directed by procurement team: Steroids, N-acetylcysteine, Povidone-Iodine (per NGT); prostaglandin E1
- Broad spectrum antibiotics, mannitol, loop diuretics, heparin (usually 30-50,000 units of heparin)
- Procedure about 1-5hours (sterile): anesthesia present to support organ systems until prox aorta is clamped: once aorta clamped and cooling has started= anesthesia services no longer needed (usually remove PA cath if take the heart), want to d/c vent, fluids off, monitors
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All about communication w/ the team
- Want Fi02 100% and PEEP to maintain oxygen sats
- >100 SBP
- UO 2ml/kg/hr (want 4-6 L of crystalloid and 2 L albumin available for resuscitation)
- Don’t want a lot of vasopressors usually. When use dopamine- want <20mcg/kg/min
- T4 usually running- improves HD stability in BD pts- converts from anaerobic to aerobic metabolism, controls acidosis, and controls cardiac contractility (dec pt’s need for pressors)
Hemodynamic/ lab goals for donor OR?
Control of spinal reflexes?
- CVP monitoring (maintain 6-12 mmHg)
- Depends on organs procured
- Higher for kidneys and lower for lungs (fluid admin a/w acute graft failure for lung transplants).every addtl L given during procurement increases # of pts w/ acute graft failure
- Na+ <155
- PaCO2 30-35 mmHg
- Spinal reflexes may be intact and NMB’s may be needed
- Volatile anesthetics may help to blunt spinal reflexes, reduce the adrenergic storm (DCD will have storm after asystole for 2-5min) and provide some ischemic preconditioning to the vital organs (controversial 0.4 Iso—some give, some don’t)
- Opioids will also help with reduction in response to stimulation- most people don’t give opioids
- May need the ICU vent if complex vent settings being used
- Diuretics may be given prior to lung procurement
Potential complications during organ harvest?
-
Hypoxemia (atelectasis, pulmonary edema, aspiration, or pneumonia)
- FiO2 and minute ventilation to maintain a PaO2 ≤100 mm Hg, PaCO2 = ~35, & pH WNL, SBP >100, UO:2mL/kg/hr
- Follow ABG every 30 to 60 minutes
- Avoid High PEEP to preserve cardiac output and avoid barotrauma
- Avoid High FiO2 in potential lung donors to minimize possible oxygen toxicity. Most tx can use 100% tho
- Unable to regulate temperature: actively warm
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Hypertension transiently accompanies brain death and can be dramatic
- Reflex hypertensive responses to surgical stimulation may occur
- Tx with Short-acting agents such as nitroprusside or esmolol should be used bc acute hypotension & pituitary failure soon
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Hypotension follows due to hypovolemia & poor vasomotor control
- Tx with crystalloid, colloid solutions, and blood products (6 L of crystalloid and 2 L of albumin)
- Keep hct >30%
- Use pressors PRN—try to avoid, but as needed (dopamine is pressor of choice)
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Dysrhythmias (due to electrolyte imbalance, hypothermia, increased ICP, hypoxemia and acidosis, and derangement of brainstem cardiovascular control centers)
- Antiarrhythmics (use like normal. V tach- lido or amiodarone) – esmolol, pacing, replacing lytes
- Bradycardia resistant to atropine—may need pressors (epi available); have pacing available
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Polyuria(due to volume overload, osmotic diuresis, or DI from derangement of the HPA) common
- Maintain IV infusion of vasopressin or desmopressin may be titrated to treat severe diabetes insipidus (patients receiving vasopressin need fewer pressors)
- discontinue these infusions 1 hour before aortic cross-clamping to minimize the risk of ischemic injury (esp w/heart and lungs)
- need fewer pressors w/ vaso instead of other pressors
- Oliguria
- Use volume; good diuresis will be preferred if kidneys taken
- Use pressors
- Fluid & pressors not working? mannitol and/or furosemide
Care for the living kidney donor?
- Healthy; no renal disease; no history of proteinuria or renal stones
- Most often laparoscopic (hand assisted)
- small number of these robotically assisted (higher complication rate)
- rarely done open - position: lateral with bed flexed; high rate chronic pain post-op (up to 1/3)
- 2.4% of kidney donors experience anesthetic/surgical complications (unacceptably high!) 2.4/100 ppl
- Good ERAS candidate: pre-hydration CHO load (carb load); TAP blocks; multi-modal – preemptive analgesia, fluid mgmt., avoid ops
- Insufflation decreases renal blood flow: compensated with fluids to prevent pre-renal injury & mt renal perfusion
- Nitrous oxide is contraindicated (surgeon visualization impaired) bowel distention makes more diff to see retroperitoneal structures
- Not common to place CVL; CVP unreliable with lap retrieval in lateral position – 2 IV bc hard to place another w/ lateral
- Extubate in OR
- Anticipate post-op need for pain control (epidural, PCA)
Left vs right liver living donor considerations?
- Healthy donor, no risk for thromboembolic disease, no liver disease
-
Left lobe liver donation (segments II and III) is usually done in the context of parent-to-child donation with recipients smaller than 15 kg
- Major procedure but much lower risk vs. right , doesn’t have high comp rate
- Laparoscopic vs. open
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Right hepatectomy needed for adult-to-adult liver transplantation
- major procedure with significant risk!
- residual liver volume of the donor must be greater than 35% of original volume
- Early death among live liver donors in the United States is estimated to be 1.7 per 1,000 donors
- Complication rates: up to 1/3 of donors:
- air embolism, atelectasis, pneumonia, respiratory depression, and biliary tract damage (then jaundice, ERCP, symptomatic, pain)
- Reserved for healthier recipients
- When lift/twist liver have no BP. When start bleeding usually parenchymal tissue of liver not big vessels, so very difficult to control bc a mill little bleeders not just 1 vessel to clamp & intrinsic/extrinsic clotting that’s impacted w/ coag status and functional ability of liver & vol status w/ hemodilution if do mass resus
Anesthesia consideratiosn with right liver living donor?
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Significant hypotension with cross-clamping hepatic pedicle
- Debate over volume loading (prevent renal compromise; decrease air embolism risk) vs. volume restriction (decreased blood loss) if hemodilute what you lose has less blood content in it vs hemoconc easier for surgical control. Surgeon pref
- Vasopressin and norepi will augment physiologic levels to compensate – talk to surgeon. If acute compromised HD tell them can manip liver and improve situation
- Right hepatectomy usually done open vs L can be lap
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CVL +/- (need for CVP monitoring is often surgeon preference).
- If no CVP, need ability for mass resuscitation, large bore IV; track CVP if trying to keep dry ~6
- EBL <1 Liter; good cell-saver case bc no malignancy, healthy pt. could be mass BL, just depends
- Avoid hypothermia
- Plan for OR extubation
- Pain control (epidural, TAP catheters, PCA) v painful bc big open abd procedure
- Postop:
- Hypophosphatemia is common
- Liver function tests including INR are abnormal
- usually return to baseline levels within 3 months; may persist up to 1 year
- some donors have chronic low platelet counts after hepatectomy
What is involved in the workup for the kidney recipient?
- Screened for tumors (mammography, Papanicolaou test, colonoscopy, prostate specific antigen) –all organ recipients go to r/o active malignancy- often CI d/t increased r/f further malignancy secondary to high dose anti-rejection medications)
- Screened for infection (dental evaluation, viral serologies) look at valves or bad dentition at r/f infection, do full mouth extraction ie bad AR, very sick, go to sleep for dental extraction before valve lot of local and only little anesth
- Optimize co-morbidities
- CV risk factor modification: control htn & hyperlipidemia
- Good control of diabetes before transplant
- Evaluation for psychiatric stability and social support, transportation, financial support
- Severe heart, lung, or liver disease; most malignancies; and active or untreatable infections such as tuberculosis are exclusion criteria for renal transplantation.
- latent infections (TB) + anti-rejection meds ^immunsupp**à infections will re-colonize and cause probs. i.e.: s/p heart tx 1st 5 yrs= high r/o dying from rejection. At 10 yrs- 27% will have a malignancy d/t high dose rejection meds
Preoperative considerations prior to kidney transplant?
NOT AS RUSHED (rushing time is d/t allowable ischemia time) – have time for w/u beforehand, good can get HD
- Commonly have hypertension and/or diabetes mellitus —2 leading causes for needing a transplant
- Increased risk for coronary artery disease and congestive heart failure
- Review CV workup (TEE, EKG, enzymes)
- Frequently hyperdynamic if they are fluid overloaded
- Evaluate electrolyte and acid-base abnormalities, anemia, and platelet dysfunction (uremic)
- PFTs are particularly important in type 1 diabetics (kidney-pancreas)
- Common issues with reduced lung volumes and diffusing capacity
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Preoperative dialysis is recommended when feasible – see how graft working, how much fluid off, any problems
- If HD pre-op: may be dry- if a lot of fluid off give ~250mL fluid in pre-op = smoother induction bc already contracted intravascular space bc of chronic HTN, don’t tolerate induction well but if also dry, tank @ induction
Preop/induction considerations for kidney transplant?
- Usually GETA
- Epidural/ spinal concerns: uremic plt dysfunction and residual heparin after pre-op dialysis
- Case time 3 hours or less; supine; kidney will be placed in right iliac fossa (most common) or retroperitoneal space
- Pre-meds (Tylenol, H2 blocker to combat anaphylactoid rxn w/ 1st dose of immunosupp) especially if you will be starting the first immunosuppressant (ATG); Midazolam is commonly given
- RSI (diabetes, gastroparesis, uremia)—may or may not have met NPO criteria (uremia huge risk factor for inc resid vol and asp)
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Expect difficult IV & CVL access- CVP will likely be needed; have usg available
- bc had multiple access sites/rep vasc cath & vasculopathic bc DM & HTN. Look @ RIJ w/ US & clotted off or look ok but move US down and see cant thread. When thread wire, if meet resistance, take it out don’t try to pass it thru. If L bad too, can do fem or surgeon can help.
- Foley, NGT
- Give pre-incision antibiotic
- Give Benadryl 50 mg & Solumedrol 500 mg after induction if you will be starting ATG (immunosuppression)
Maintenance considerations for kidney transplant?
GOAL: PRESERVE RENAL BLOOD FLOW
- Volume loading and general avoidance of pressors: usually get ~3 liters in volume load before new kidney is in (crystalloid vs. albumin)- monitor CVP as guide (often give 1 L crystalloid and then switch to albumin)
- General goals: systolic pressure > 90 mmHg, mean systemic pressure > 60 mmHg, and CVP > 10 mmHg
- Blood products not usually needed; available- not just T&S, have T&C.
- Choice of inhalational agent does not impact outcome (Sevo, Des, Iso all fine), bal anesth
- Avoid Morphine and Demerol; Fentanyl is usually used (don’t want active metabolites)
- May want to use a NDNMB w/ Hoffman elimination (Atracurium/ Cisatracurium)- cis better bc no histamine release (already have antirejection drugs that cause histamine release). Int w/ sux for RSI, K prob ok if HD. Then switch to nimbex (cis)
- Transplant surgeons tend to REALLY like NMB’s; keep relaxed until fascia closed at least
- Use TOF monitor to guide & don’t try to get back breathing til very end of case
- Good glucose management; monitor electrolytes throughout
- Anticipate administration of furosemide (40 or 80mg) and mannitol (0.5gram/kg)
- Timed around first anastomosis (per Barash); usually give few mins b4 unclamp. When ask for tiny suture = anastomosis & pay attn to sx
- Monitor UOP after unclamping – make sure foley bag totally drained & start looking for urine
- Unclamp: organ has hyperkalemic, acidotic, preservative in it–may see lactic acidosis and K go to systemic circ– may need Ca (helps w/ hypotension and transient hyperk to dec effects of K on heart membrane)
Emergence considerations in kidney transplant?
- Expect to extubate: evaluate closely for fluid overload before making this decision bc of comorbs
- Tachypnea, diaphoresis, rales, hyperdynamic: caution; may have to stay on vent until fluid off. Don’t assume pain, ausc.
- Ensure NMB adequately reversed
- Increased risk for post-op respiratory depression with narcotics
- Pain control: consider TAP blocks or combo blocks ilioinguinal-iliohypogastric and intercostal nerve blocks; PCA
- NSAIDs & COX-2 contraindicated!
- Post-op pain is expected to be severe
- Post-op complications:
- ureteral obstruction and fistulae, vascular thromboses, lymphoceles, wound complications, and bleeding
Anesthesia considerations for pancreas transplant?
same stuff from kidney but + a line
- Pre-op: Evaluate Type I diabetes complications
- The main thing that is different on a Pancreatic TP (75% are getting a kidney too) is that they all get arterial lines because a kidney/pancreas TP is very long and we check blood sugars every 15- 30 minutes after the pancreas is in
- Anticipate ICU admission: need to be monitored for complications more closely
- Blood sugar control: do NOT be overly aggressive; can plummet after the pancreas is in- Want 120-180
- Insulin gtt needs concurrent D5 infusion and frequent blood sugar checks!!!
Liver anatomy review?
- largest internal organ in the body
- 25% to 30% of the cardiac output
- dual blood supply
- hepatic artery provides 25% (50% of O2 delivery)
- portal vein provides 75% (50% of O2 delivery)
Functions:
- metabolic pathway of carbohydrates, fats, and proteins.
- glucose is stored as glycogen and is converted by the liver to lactate, with the generation of energy.
- Protein is metabolized to ammonia and urea for excretion
- produces nearly all the plasma proteins, except immunoglobulins; produces albumin, the body’s primary transport protein and major determinant of oncotic pressure. ESLD w/ hypoalbuminemia
- drug metabolism, especially via the cytochrome p450 isoenzymes.
- hormone, vitamin, and mineral metabolism
- hepatic synthesis of procoagulant factors such as the vitamin K–dependent coagulation factors; the liver also produces the anticoagulant factors protein C, protein S, and antithrombin III- complex prob w/ liver dx of anticoag abnormals & procoag abnormals. Mass bleeding & issues w/ clotting or maintenance of clots or production of clots w/o suffic clot breakdown because don’t have protein C
- sequesters platelets
CNS, Pulmonary and CV S/S seen with ESLD?
- CNS
- encephalopathy- fatigue
- BBB disruption and intracranial HTn (in acute liver failure)
- encephalopathy- fatigue
- Pulmonary
- respiratory alkalosis
- reduced diffusing capacity- hypoixemia/hepatopulmonary syndrome
- pulm htn- reduced R heart function
- CV
- Reduced Svr- hyperdynamic circulation
- Diastolic dysfunction
- prolonged QT
- Blunted response to inotrop
- blunted response to vasopressor
- diabetes
- caution with TEE with bleeding esophageal varices!!!
GI/Renal, hematologic, endocrine, and other s/s with ESLD?
- GI
- gastrointestinal bleeding from varices- caution TEE
- Ascites
- delayed gastric emptying
- nutritional/metabolic- muscle wasting and weakeness
- Hematologic
- decreased synthesis of clotting factors- risk of massive surgical bleeding
- hypersplenism (pancytopenia)- prone to injury
- impaired fibrinolytic mechanisms
- Renal
- hepatorenal syndrome- impaired renal excretion drugs
- hyponatremia
- Endocrine
- glucose intolgerance
- osteoporosis- fracture susceptibility
- Other
- poor skin integrity; pruritis
- increased VD of drugs
- decreased citrate metabolism- calcium requirement with rapid fresh frozen plasma infusion