Surgery: Transplant

Question 1

what was the first transplant and when was it?

Answer 1

1869- skin graft

Question 2

first transplant of a cornea? kidney? deceased donor organs? heart? pancreas?
(maybe weeds) ?

Answer 2

cornea: 1906
*kidney: 1954
deceased donor: 1962/63
*heart: 1967/68
pancreas: 1968

Question 3

what year did Congress passes the Uniform Anatomical Gift Act? what is this?

Answer 3

1968 makes donating organs and tissues legal

Question 4

Organ Procurement and Transplantation Network: what does it do?

Answer 4

to ensure fair and equitable allocation of donated organ and tissues.

Question 5

United Network for Organ Sharing (UNOS): what does it do?

Answer 5

provides services for equitable access and allocation of organs and sets the membership criteria and standards for transplant centers in the U.S.

Question 6

what is brain death? how is it diagnosed?

Answer 6

clinical Dx

total cessation of brain function, including brain stem function

Question 7

clinical neuro finding: Dx of brain death: absence of pupillary response

Answer 7

Absence Pupillary Response

Typically, fixed and dilated mid position pupils between 4-6 mm

Question 8

clinical neuro finding: Dx of brain death: absence of pupillary response: oculocephalic testing

Answer 8

Doll’s eye

Question 9

clinical neuro finding: Dx of brain death: absence of pupillary response: facial sensation and motor response

Answer 9

Facial sensation – Absent Corneal Reflex
Motor response – Absent Painful Stimuli
(Nailbed pressure, TMJ pressure )

Question 10

clinical neuro finding: Dx of brain death: absence of pupillary response: Pharyngeal and Tracheal Reflexes

Answer 10

Absent Cough & Gag reflexes response to bronchial suctioning.

Question 11

Apnea testing: 6 steps and what is a positive result?

Answer 11

1. Baseline ABG
2. Continuous O2 at 6 L/min
3. Remove Vent
4. Wait for approximately 8 minutes – PaCO2 should raise 3 mm Hg per
5. Observe pt’s abdomen and chest for movements
6. Repeat ABG after 8 minutes

-Positive Apnea Test if PaCO2 > 60 mm Hg or > 20 mm Hg from Baseline ABG

Question 12

what does positive apnea testing mean?

Answer 12

Positive as long as their is exclusion of confounding factors, absent brain stem reflexes and coma; therefore, the clinical diagnosis of brain death can be made.

Question 13

brain death: two confirmatory Dx tests

Answer 13

1. CT scan: diffuse brain edema
2. cerebral angiogram: No intracerebral filling at the level of the carotid bifurcation or Circle of Willis = Empty “ Champagne Glass sign”

Question 14

what temperature is ideal for neurological testing? what would be a complication of this?

Answer 14

(Temp > 32.2; best if > 35.5)

Temp below 35C (hypothermia)

Question 15

what are the complications of neuro testing for Dx of brain death?

Answer 15

drug and metabolic complications
hypothermia
shock
children (cranial nerves maybe not fully developed)
spontaneous body movements (spinal reflexes)

Question 16

donation after cardiac death (DCD)

Answer 16

Possible where life support is to be voluntarily withdrawn

Abdominal organs only

Question 17

DCD process: timing and what professional must declare it?

Answer 17

Cardiopulmonary Arrest must occur within 90 minutes of withdrawal
– > If no arrest in 90 minutes, patient will be transferred to a non-ICU bed

Patient declared dead by cardiopulmonary criteria by a non-transplant-related MD ( No palpable carotid pulse
ECG: Non-sustaining rhythm (PEA, Asystole, VF) )

Question 18

donor designation VA law

Answer 18

Virginia law requires the donor’s advance directive to be honored (like on your drivers license)

Question 19

Goals of donor management (what do we want for a viable organ)?

Answer 19

1. Oxygenation: PaO2 > 100 mmHg
2. Hydration and Perfusion
3. Normothermia
4. Asepsis
5. Normalized lab values

Question 20

of the “goals for donor mgmt” which is the most important determinant of organ viability ?

Answer 20

hydration and perfusion:

Optimal organ perfusion occurs at systolic pressures > 100 mmHg

Question 21

autograft vs isograft

Answer 21

Autograft – Same individual is both donor and recipient e.g. Blood Donation
Isograft – Donor and recipient are genetically identical e.g. Twins

Question 22

allograft vs xenograft

Answer 22

Allograft – Donor and recipient are genetically dissimilar, but of the same species e.g. Organ Transplant
Xenograft – Donor and recipient belong to different species e.g. Pig Heart Valve

Question 23

orthotopic vs heterotopic vs paratopic

Answer 23

Orthotopic – Donor Organ is placed in normal anatomic position e.g. Liver, Heart
Heterotopic – Donor organ is placed in a different site than the normal anatomic position e.g. Kidney is placed at the Iliac artery/vein
Paratopic – Donor organ is placed close to the original organ

Question 24

3 meds for transplant recipient

Answer 24

antiviral- valcyte
Abx - bactrim DS
antifungal- diflucan

Question 25

4 types of transplant rejection

Answer 25

1. hyperacute: immediate in the OR
2. accelerated acute: 7-10 post-op (via donor antigen- memory Tcells)
3. acute: up to 6 months post-op
4. chronic: months-years post-op