Organ Transplant and Donation Flashcards by Andrew Skuta

Max cold ischemic times for Heart and Lungs

4-6 hours

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Max cold ischemic times for Liver

12-24 hours

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Max cold ischemic times for Kidneys

72 hours

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Death definition

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

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An individual’s signature on a driver’s license or donor card indicating their desire to donate their organs is _____ _____ and_____ _____require family permission.

legally binding
does not

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Criteria for Diagnosis of Brain Death:

Loss of Cerebral Cortical Function: no spontaneous movement, unresponsive to external stimuli

Loss of Brainstem Function: Apnea, absent cranial nerve reflexes

Supporting Documentation: EEG, CBF studies

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Common physiologic Derangements after Brain Death:

Hypotension
Arterial Hypoxemia
Hypothermia
Cardiac dysrhythmias

-busy ICU patients

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(DCD) After the patients heart stops beating the transplant team waits no less than ___ minutes following pulselessness before starting organ recovery.

5 minutes

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DCD is an opportunity for families of patients
with severe brain damage, who ____ ____
meet the complete criteria for _____ ____.

do not
brain death

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Anesthesia management___required for organ donation after brain death.(DBD)

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Anesthesia management ____ ____ be required for organ donation after cardiac death.(DCD)

MAY NOT

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The recovery of vital organs for transplantation is a sterile post-mortem procedure lasting up to___ ____.

4 hours

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Anesthesia support of donor organ systems is necessary until the _____ ______ is clamped, after which the ventilator, IV’s, and cardiac monitors may be discontinued.

proximal aorta

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If the ____ are to be recovered for transplantation, anesthesia support ____ ____ required post cross-clamp. The purpose is to _______ the lungs to ensure that the perfusion is delivered at the ____ _____.

lungs
will be
hyperventilate
cellular level

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The recovery of viable organs is dependent upon adequate respiratory support and organ perfusion as indicated by :

BP > 100 systolic
CVP 8-12
O2 sat > 96%
urine output > 100cc/hr

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Vigorous volume expansion with _____ and _____ is usually necessary to avoid hypotension.

crystalloid and colloid

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High fluids may be contraindicated (_____ ______). _________ should be goal.

lung transplantation
Euvolemia

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Living Organ Donors (__%) should have NO history of:

44%

Hypertension
Diabetes
Cancer
Kidney disease
Heart disease

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Anesthesia for Organ Recovery: Frequently required drugs and fluids-

________/________ (longer acting muscle relaxants)

ICU IV medication of ______,____,____ or _____may be needed to maintain patient while in OR

6-8 Lactated Ringers
Heparin 30,000 units
Thyroxin drip may be required in certain cases (CORE coordinator will inform you)

Pancuronium/Vecuronium

dopamine, NEO, LEVO, or vasopressin

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PRBC’s on hold for extra renal donors.

If the liver is being split, _____ units of PRBC’s are REQUIRED in the OR

two (or more)

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Absolute Contraindications to Organ Implantation:

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 (NEED THIS)

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Dramatic Increase in the Success of Organ Transplantation: Immunosuppressive regimens–>

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

Post-transplantation Organ Function: Dependent on multiple factors (4):

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

Most frequent solid organ transplants:

Kidney –25,500

Liver – 6,291

Heart – 3,000

Lung – 1,000

Heart-lung - 40

Major indications for Kidney Transplant:

DM HTN-induced nephropathy Glomerulonephritis Polycystic kidney disease HTN and DM are the most common reasons.

Kidney: An extensive pre-operative work-up with an emphasis on:

Cardio-pulmonary system Extent of renal failure and associated conditions Normalization of electrolyte imbalance Normalization of volume status Pre-operative renal dialysis if necessary

______ and ____ are common causes of ESRD

HTN and DM

Kidney: Pts. may be......

volume overloaded, hypovolemic, anemic, or hyperkalemic

Kidney: type of intubation

RSI

Kidney: Diabetic autonomic neuropathy can make intra-op ____ _______difficult

BP control

______ evaluation is very important for patients with type 1 IDDM.

Airway These patients often manifest with stiff joint syndrom characterized by a fixation of the atlantooccipital joint along with limited head extension

Living Donor: Reasonable fluid protocol

10mL/kg/hr. above calculated losses Maintain UO > 100mL/hr.

Kidney: No _____ ______, distended bowel can get in surgeon’s way (laparoscopic)

nitrous oxide

Cadaveric Kidney Transplantation: patient position

SUPINE

Avoid ________because transplanted kidney is sensitive to sympathomimetics.

alpha adrenergic drugs (phenylephrine)

Kidney: Be attentive to hypotension after reperfusion of donor kidney because graft function is critically dependent on_____ ____

perfusion pressure.

Kidney: Choice of muscle relaxant depends on the __ level. In normokalemic pts, _____ is safe, otherwise _____ or _____is preferable.

K+ Succs (1-1.5 mg.kg) cisatracurium (0.1 mg/kg) or mivacurium (0.15-0.2 mg/kg)

Kidney: Reversal of muscle relaxants with _____ and _____ is safe in patients with ESRD

Neostigmine and robinul Propofol fine – metabolized by liver

Kidney: If diabetic gastroparesis is a concern, non-particulate antacid (________) is administered immediately prior to the induction of anesthesia to decrease the gastric acid conte

sodium citrate and citric acid oral solution 30 mL

Use of ________ may increase gastric emptying and lower esophageal sphincter tone

metoclopramide (30 mg PO)

Kidney: _______ or ________ agents may be needed during renal transplant surgery to increase cardiac output and renal perfusion pressure. which ones?

Vasopressor or positive inotropic Dopamine Fenoldopam (D1 receptor agonist) Norepinephrine Vasopressin

Kidney: Used before unclamping vascular supply to transplanted kidney

Mannitol and loop diuretics Maintain renal perfusion pressure and enhance urine production. Dopamines role is controversial

Reperfusion of the kidney graft may be associated with ______ This is most often related to a reduction in the preload as a consequence of unclamping the ___ _____. Treat with:

hypotension iliac artery crystalloid, colloid or low-dose dopamine

Prompt ______ production is desired Significance of decreased urine output:

urine May indicate mechanical impingement of graft, anastamosing vessel, or ureter. Intra-operative ultrasound may be used to assess flow through arterial and venous anastamosis

Kidney tx and Emergence: Moderate to severe ________ may accompany emergence from anesthesia for renal transplant. Short-acting anti-hypertensives may be considered: The use of ______ _____ ______ should be avoided as they may raise ___ levels

hypertension longer acting beta-blockers K+

Liver: Alcoholic cirrhosis May be considered for transplant if abstinence of alcohol for______and ongoing therapy and evaluation

6 months

Pts. with chronic liver dysfunction and cirrhosis have a _________ circulation with low ____ and an increased ______

hyperdynamic circulation PVR CI

Liver Anhepatic phase Bicaval Clamp: Clamp vena cava above and below liver. Causes.....

Drop preload Profound hypotension and tachycardia

Post operative care of liver transplant patient: Extubation is ______.

deferred ICU – direct admit Serial ultrasound assessments of hepatic artery and portal vein patency

Liver: _______ may require re-transplantation

Thrombosis is the ENEMY!!!

Heart and Lung: Pressure in the pulmonary arteries becomes so high that it causes oxygen-poor blood to flow from right to left ventricle then to the body causing cyanosis

Eisenmenger”s Syndrome

Heart and Lung: Standard anesthesia monitoring and invasive hemodynamic to include

ABP PA catheter CVP TEE RV assist device

As a consequence of denervation, the transplanted heart has no ____, ______, and _____ innervations.

sensory, sympathetic, and parasympathetic innervations