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AP III > Tranplant (2/4) > Flashcards

Tranplant (2/4) Flashcards

1
Q

if doing a parent to child (<15 kg) living liver donation the _______________ lobe is donated

A

left (segments II and III)

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2
Q

adult to adult living liver donation is done via ______________ hepatectomy

A

right

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3
Q

residual liver volume of living donor must be > _________% to prevent “small for size” syndrome

A

35

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4
Q

complications with living liver donation

A
  1. air embolism
  2. atelectasis
  3. pna
  4. biliary tract damage
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5
Q

complication rates for living liver donations are ________%

A

30

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6
Q

how does a living lung donation occur?

A

two donors

  1. one donates left lower lobe
  2. second donates right lower lobe
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7
Q

T/F: extensive HLA matching required for living lung donation

A

false; HLA matching does not appear to affect outcome; however, ABO compatibility is required

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8
Q

criteria for living donation of lung

A
  1. member of recipients extended family
  2. age 18-55
  3. no prior thoracic surgery (donor side)
  4. good general health
  5. taller than recipient preferred
  6. ABO compatible
  7. FVC and FEV1 > 85% preferred
  8. PO2 > 80 on RA
  9. no chronic viral disease
  10. normal EKG and echo
  11. normal stress test in donors older than 40
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9
Q

complication rate of living lung donation

A

60%

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10
Q

complications with living lung donation

A
  1. pleural effusion requiring drainage
  2. hemorrhage
  3. phrenic nerve damage
  4. pericarditis
  5. pneumonia
  6. long term decrease in FEV, TLC, and FVC
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11
Q

anesthetic technique for living lung donation

A
  1. surgerical perservation of bronchial cuff, pulmonary artery and vein is necessary
  2. GETA
  3. lateral decubitus position
  4. IV heparin prior to graft removal
  5. std monitors are used in conventional lobectomies
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12
Q

indications for a kidney transplant

A
  1. glomerular disease
  2. DM
  3. Htn kidney dz
  4. polycystic kidney dz
  5. tubulointerstitial dz
  6. congenital and familal dz
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12
Q

why are CV considerations important perioperatively in pt undergoing kidney transplant?

A

pts (likely) have underlying ischemic heart disease and CHF

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13
Q

perioperative CV considerations for the kidney transplant pt

A
  1. increased SVR & HTN = increased MVO2
  2. LV hypertrophy and increased LVEDP –> decreased coronary perfusion and increased MVO2
  3. hyperlipidemia
  4. chronic anemia –> right shift of oxy-hgb curve and increased 2, 3 dpg
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14
Q

preop coagulopathy considerations in the pt undergoing kidney transplant

A
  1. uremia –> abnormal plt, thrombocytopenia, ineffective production of VIII and vWF
  2. PT and aPTT usually normal
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15
Q

it pt undergoing kidney transplant has some coagulopathies 2/2 to kidney dz, what medication should you consider administering

A

DDAVP

corrects bleeding time, increased levels of factor VIII & vWF & may reduce surgical losses

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16
Q

T/F: when doing a kidney transplant the diseased kidneys are left in the patient

A

true (except with PCKD)

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17
Q

anesthetic management considerations for the pt undergoing a kidney transplant

A
  1. planning for postop pain management
  2. choice of agents
  3. choice of fluids
  4. airway management
  5. IV
  6. monitors
  7. Invasive lines (+/-): like CVP on this pt
  8. immunosuppression drugs immediately prior to reperfusion
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18
Q

intraoperative anesthetic management for pt undergoing kidney transplant

A
  1. potential for major swings (induction post-dialysis hypovolemia, tx hypotension promptly)
  2. tx hypotension with reperfusion
  3. tx hypotension with volume first then vasopressors
  4. administer immunosuppressants, heparin and protamine
  5. emergence and extubated in the OR most of the time.
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19
Q

___________ is the primary cure for diabetes

A

pancreas transplant

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20
Q

what immunosuppressants have significantly improved pancreas transplant survival

A
  1. tacrolimus
  2. mycophenolate mofetil
21
Q

a lot of times if a pancreas is transplanted, what other organ is also transplanted

A

kidney

22
Q

indications for pancreas transplant

A
  1. DM (type I and II)
  2. chronic pancreatitis
  3. cystic fibrosis
  4. nonmetastatic pancreatic cancer following total pancreatectomy
23
Q

with pancreas transplant, with reperfusion of the new pancreas, blood glucose should be monitored every ______________ minutes

A

30

24
Q

typically glucose concentrations decrease _______________ mg/dl/hr

A

50

25
Q

you should plan to start a ____________ infusion if patient is undergoing pancreas transplant

A

insulin

26
Q

anesthetic management for a pancreatic transplant

A
  1. choice of induction agent (consider if there is kidney dz as well - cisatracurium)
  2. airway management
  3. monitors
  4. invasive lines and IV
  5. fluid administration guided by volume status indicators
27
Q

Diagnoses that may lead to liver transplant

A
  1. hep C , B
  2. laennec cirrhosis (alcoholic)
  3. combined HCV/etoh cirrhosis
  4. autoimmune hepatitis
  5. cryptogenic (idiopathic ) cirrhosis
  6. small hepatocellular carcinoma
  7. nonetoh steatohepatitis
  8. primary biliary cirrhosis
  9. primary sclerosing cholangitis
  10. viral
  11. acute viral hepatitis (A, B, C)
  12. drug induced liver failure
  13. wilson dz
28
Q

contraindications to liver transplant

A
  1. cardipulmonary dz that is uncorrectable (moderate to severe PAH or cardiac dysfunction)
  2. uncontrolled infection or sepsis
  3. untreated Tb
  4. advanced malignant hepatic dz or metatstatic dz
  5. acute liver failure with elevated intracerebral pressures or decreased CPP
  6. active etoh or drug use
  7. lack of social support system
  8. nonadherence to medical care
  9. AIDS
  10. age > 65
  11. BMI > 40
29
Q

what are you looking for in the pts hx (in the chart) for the pt undergoing liver transplant

A
  1. CV workup
  2. cause of liver dz
  3. labs
  4. echo
30
Q

what would you look for on physicial exam for pt presenting for liver transplant

A
  1. JVD
  2. ascites - how much?
  3. s/sx of volume overload/HF
31
Q

pre-op prep for liver transplant pt

A
  1. H & P
  2. labs and radiologic exams
  3. plan for airway control with ETT
  4. lg bore IV/CL
  5. normothermia
32
Q

how is the CV system effected in a pt with end-stage liver disease

A
  1. hyperdynamic circulation with high CO, low SVR, low-normal ABP, normal-increased SV, normal filling pressures and mildly elevated HR
  2. increased total blood volume with decreased central volume and increased splanchnic blood volume
  3. cardiomyopathy
  4. s/sx of CHF
  5. inotropic and chronotropic incompetence
33
Q

how is the pulmonary system effected by endstage liver disease

A
  1. elevated MPA pressures > 25 mmHg
  2. hypoxemia (2/2 intrapulmonary shunt/hepatopulmonary syndrome & A-a gradient of > 15 mmHg)
  3. V/Q mismatch
  4. diffusion issues
34
Q

what type of vascular access do you want for a pt liver transplant pt

A
  1. large cath both central and peripheral
  2. large neck line for resuscitation (8Fr)
  3. a line (possibly 2 [one femoral one radial])
  4. CL +/- PAC
  5. TEE
35
Q

what issues would you expect on induction/intubation for the pt undergoing a liver transplant and how would you tx it?

A

hypotension - need lots of fluid and pressors ready to go

36
Q

what are the different types of incisions used for liver transplants

A
  1. humped incision
  2. mercedes benz incision
  3. modified mercedes benz incision
37
Q

intraoperative anesthetic management for the liver transplant pt

A
  1. antibiotics, immunosuppressants
  2. EMERGENCY drugs! (epi 100 per and 1 per)
  3. keep map > 60
  4. consider pressors early
  5. give 0.5 mg/kg mannitol prior to XC
  6. give IV heparin prior to XC (if coags approp)
  7. increase CVP to 10 with crystalloids
  8. keep INR < 1.5, plts > 50K, and fibrinogen > 150
  9. calcium (esp with blood)
  10. amicar or TXA
38
Q

what are the three phases of a liver transplant

A
  1. preanhepatic
  2. anhepatic
  3. neohepatic
39
Q

_________________ phase of a liver transplant includes the dissection and isolation of the intra and suprahepatic vena cava, exposure of the porta hepatis and hilar structures

A

pre-anhepatic phase

40
Q

blood loss may be very high during which stage of liver transplant

A

pre-anhepatic

41
Q

what is the anesthetic goal in the pre-anhepatic phase for liver transplant

A

correction of coagulopathies and maintenance of intravascular volume

42
Q

when does the anhepatic phase of a liver transplant begin

A

when the hepatic blood supply and venous drainage is cross clamped (IVC, portal vein, hepatic artery)

43
Q

what HD change would you expect in the anhepatic phase of liver transplant

A

hypotension due to XC –> significant drop in venous return

44
Q

in the ____________ phase of liver transplant you should administer crystalloids to increase CVP to __________

A

anhepatic; 10-20

45
Q

in what phase of liver transplant is lacate no longer metabolized

A

anhepatic

46
Q

in what phase of liver transplant are caval and arterial anastomoses completed?

A

anhepatic

47
Q

what is the most important part of the neohepatic phase for liver transplant

A

reperfusion

48
Q

neohepatic phase of liver transplant starts with ____________________

A

reperfusion of the graft

49
Q

what is the order the clamps are removed with neohepatic phase of liver transplant

A
  1. caval clamps
  2. portal vein clamps
  3. hepatic artery clamp

AP III (20 decks)

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