organs Flashcards
What is the maximum cold ischemic time for heart and lungs
4-6h
What is the maximum cold ischemic time for liver
12-24h
What is the maximum cold ischemic time for kidney
72h
brain dead patients are hypertensive or hypotensive?
hypotensive
what causes hypovolemia in the brain dead patient
diabetes insipidus, hemorrhage
when is anesthesia support of donor systems necessary until?
the proximal aorta is clamped.
when will anesthesia support be requires post cross clamp?
if the lungs are to be recovered for transplantation
why do you need to hyperventilate the lungs before they are harvested?
to insure that perfusion is delivered at the cellular level.
where do you want to keep th BP and CVP of the donor?
BP >100 systolic
CVP 8-12
where do you want to keep O2 sat and urine output of the donor
> 96% and urine >100cc/hr
T/F Muscle relaxant may be required for the donor
TRUE. may need muscle relaxant to neutralize spinal reflexes and relax the abdomen. want long acting… pavulon/vec are good choices
T/F Limit fluids in the donor before harvesting.
FALSE. Vigourous volume expansion with crystalloid and colloid is usually necessary to avoid hypotension. 6-8L
PRBC’s on hold for ____ donors. PRBC’s in the room for ____ donors.
renal on hold. liver in OR (2 or more units)
Absolute contraindications to organ implantation:
active uncontrolled infection, AIDS, inability tolerate immune suppression, severe cardiopulmonary/medical condition. continued drug/etoh abuse, extrahepatic malignancy, inability to comply with medical regimen, lack of psychosocial support
4 major indictions for kidney transplantation
DM, hypertension induced nephropathy, glomerulonephritis, polycystic kidney disease
what are the 2 most common reasons for people to need a renal transplant?
DM & HTN-induced nephropathy
a hemoglobin of __% or greater is needed for adequate O2 delivery to the heart and transplanted graft
8
which disease do patients often manifest with stiff joint syndrome making airway eval extremely important?
Type 1 IDDM.
These patients often manifest with stiff joint syndrome characterized by a fixation of the atlantooccipital joint along with limited head extension.
what is the lung function like in type 1 IDDM?
loss of elastic properties - decreased compliance - decrease in cough reactivity = restriction of lung volumes with reduced TV and FEV (forced expired ventilation)
how are you gonna calculate fluids for the living donor?
maintain UO > 100mL/hr
T/F N20 is contraindicated in renal transplants.
TRUE. distended bowel can get in surgeons way (laparoscopic)
which two drugs are given to continue perfusing kidney?
mannitol/ lasix
why would you need a PAC in a renal transplant case
to monitor CO, SVO2, and pulmonary arterial and capillary pressures
graft function is critically dependent on ____, so you should be attentive to ____ after reperfusion
perfusion pressure —- hypotension
which drugs should you avoid in the kidney patient because the transplanted kidney is sensitive to sympathomimetics?
alpha adrenergics
renal transplant patient: choice of muscle relaxant depends on K+ level. In normokalemic pts, succs is safe, otherwise ____ or _____ is preferable
cisatracurium (0.1mg/kg) or mivacurium (.15-0.2mg/kg)
T/F Reversal of muscle relaxants with neostigmine and robinul is safe with patients in ESRD.
TRUE
which drug may increase gastric emptying and LES tone
metoclopramide
if diabetic gastroparesis is a concern, _____ is administered immediately prior to the induction of anesthesia to decrease gastric acid content.
non-particulate antacid sodium citrate and citric acid oral solution 30mL
If time allows, administration of ____ 6-12h prior to induction can decrease gastric acid production
H2 blocker
before unclamping vascular supply to transplanted kidney, give ___ and ____
mannitol , loop diuretics
why is reperfusion of the kidney graft associated with hypotension
reduction in preload as a consequence of unclamping the iliac artery
how should you treat hotn related to unclamping the iliac?
crystalloid, colloid, low-dose dopamine
why should you avoid long acting beta blockers for emergence in renal transplant patients?
they may raise K+ levels.
give short acting anti-hypertensives
alcoholic cirrhosis patient may be considered for transplant if……
abstinence of alcohol for 6 months and ongoing therapy and evaluation
T/F Most livers available for transplantation come from brain dead donors.
FALSE - most come from heart beating cadaveric donors.
What happens to SVR and CI with chronic liver dysfunction and cirrhosis?
SVR is reduced, CI is increased
Differential diagnosis of hepatic encephalopathy includes which other conditions?
many other confocal neurologic conditions such as hypoglycemia, hyponatremia, intracranial hemorrgae or mass lesions, and meningitis.
blood changes expected with liver failure - platelets?
thrombocytopenia
blood changes expected with liver failure - PT and PTT?
prolonged
blood changes expected with liver failure - fibrinogen
decreased plasma fibrinogen concentration
T/F DIC as well as protein C/S deficiency is associated with Liver failure.
TRUE
T/F Hyperkalemia and hypocalcemia are associated with liver failure.
FALSE - HYPOkalemia, HYPOcalcemia.
Which acid-base imbalance is associated with liver failure
metabolic acidosis
Preanhepatic phase is associated with ___calcemia , ____kalemia, and metabolic _____
hypocalcemia, hyperkalemia, metabolic acidosis
T/F Expect preload and CVP to be elevated during the preanhepatic phase.
FALSE - impaired venous return from surgical retraction and IVC clamping
T/F Hemorrhage and coagulation problems are both concerning in the preanhepatic phase.
TRUE
The anhepatic phase begins with what part of the procedure?
clamping of hepatic blood flow
What causes profound hypotension and tachycardia in the anhepatic phase?
the bicaval clamp - clamps vena cava above and below liver. this drops preload, causing profound hypotension and tachycardia.
During which phase should you be concerned about citrate intoxication and why?
during the anhepatic phase because of rapid infusion of large volumes of blood in absence of liver function
Where do you want K levels during the neophatic phase
<4.5
severe hemodynamic instability may occur with unclamping of portal vein - also called _____ syndrome
post reperfusion
T/F You should load the patient with fluids prior to unclamping.
FALSE - fluid overload prior to unclamping should be avoided. but you may need potent vasopressors- epi, norepinephrine, both.
Reperfusion syndrome - what happens to HR and BP
DROP
may see bradyarrythmias
Reperfusion syndrome - what happens to PVR
increases
Reperfusion syndrome - what happens to SVR
decreases
Reperfusion syndrome - what happens to potassium levels
can see rapid increase
Why do severe coagulopathies occur in reperfusion syndrome?
d/t fibrinolysis, release of heparin and hypothermia
what are some signs of a functioning hepatic graft?
intraoperative bile production, intraoperative spontaneous correction of negative base excess, improvement in coagulation
T/F As a consequence of denervation, the transplanted heart has no sensory, sympathetic, and parasympathetic innervations
TRUE.
Should the HR be kept high or low post heart transplant?
high, 90-110’s because the parasympathetic innervation that normally lowers the HR is not present.
