Transplant (1/4) Flashcards
what was the first anti-rejection drug used for organ transplant?
cyclosporine
T/F: serologic evidence of CMV infection prevents organ donation to seropositive recipients
false; if CMV + donor organ goes to CMV + recipient
when assessing donor infection risk for organ transplant, what infectious diseases are they screening for?
- HBsAg
- herpes virus
- Tb
- toxoplasmosis
- HIV Ab
- CMV
what infections if present in the organ donor are contraindicated for organ transplant?
- HBsAg (but considered for HBsAg+ recipients or HBV)
- Tb
- HIV (considered with HIV + pt)
what are the different donor types
- cadaveric (DCD or DBD)
- living related
- living non-related
which is the more common cadaveric donor? DCD or DBD
DBD
____________ is a non beating heart donation that occurs when pt or legal guardian desires to have life sustaining therapies whithdrawn but wish to proceed with organ donation after death
donation after cardiac death (DCD)
a DCD donor must “die” within ___________ minutes in order to be considered for donation
60
for DCD, circulation and respiration must be absent for a minimum of _________ minutes before the start of organ recovery
2
to declare someone brain dead, _______ physicians must independently declare when clinical picture is consistent with irreversible cessation of brain function
2
T/F: legal and medical brain death criteria differ from state to state
true
ways to determine brain death
- absence of brainstem reflexes
- apnea test
- neuro tests
what are the different types of brainstem reflex tests that can be used to declare someone as “brain dead”
- pupillary response to light
- corneal reflex
- oculocephalic reflex (dolls eyes)
- oculovestibular reflex (cold caloric response)
- gag and cough reflex
- facial motor response (jaw reflex)
what are the different neuro tests that can be done to determine brain death
- auditory evoked potentials
- EEG
- transcranial doppler
brain death donor criteria
- comotose without response to painful stimuli or spontaneous movement
- lack of brainstem activity
- confirmed apnea test & loss of reflexes
4 exclude other causes of reversible cerebral dysfunctions (hypothermia, hypotension, residual drug effects, toxins)
what is the initial physiologic response to brain death
- hyperdynamic instability
- hemodynamic instability
(htn, hotn, +/- tachycardia)
what are some issues you may experience in the OR with a brain dead donor?
- hypotension
- reduced CO
- myocardial dysfunction
- vasodilation
- thermoregulation
- may have difficulties with oxygenation
- decreased circulating ADH –> hypoNa, HypoK, and DI
- hyperglycemia
- coagulopathies
why do you use analgesics during anesthesia management in the DBD pt?
no pain perception, but the analgesic will inhibit the sympathetic response to stimulation
T/F: give NDMR to DBD pt in the OR
true - prevents the reflex somatic movement mediated by spinal reflexes
what is the goal for anesthesia management of the DBD pt?
- balanced anesthetic to meet needs of pt and procurement team
- maintain HD stability
anesthesia management for the DBD pt
- standard monitors
- A line +
- CL +
- strict I/O
- ventilator management (may have difficulty with Oxygenation)
- draw labs necessary to maintain donor status
- coordination with surgical teams
- cold protection for organs
hemodynamic goals for the DBD patient:
MAP
HR
PaO2
PaCO2
UOP
HCT
CVP
- MAP 70-110
- HR 80-100
- PaO2 > 100
- PaCO2 30-35
- UOP 1-1.5 ml/kg/hr
- hct 30%
- CVP 6-12
if your DBD pt is a LUNG donor, FiO2 should be maintained ______________
< 40%
if the brain dead donor has hypotension in the OR, what is the first line of tx?
fluid!
what fluids are preferred to tx hypotension in the brain dead patient donating lungs and/or pancreas
colloids
what is the consequence of excessive fluid resuscitation in a brain dead donor?
results in swelling and edema which could lead to loss of organs.
if your brain dead donor is having hypotension, and fluids did not treat, what is the inotrope of choice?
dopamine
T/F: bradycardia in the brain dead patient may not respond to atropine
true (d/t loss of reflexes)
if your brain dead donor is experiencing bradycardia, and atropine is not working, what should you use?
direct acting chronotrope: isoproterenol and/or epi
heart and lung time to transplant
4-6 hours
pancreas time to transplant
< 18 hours
small bowel time to transplant
12 hours
liver time to transplant
< 12 hours
kidneys time to transplant
< 36 hours
with organ procurement there is a risk of ischemia; what are some ways to prevent ischemia?
- harvest and preservation
- storage during tranportation
- rewarming during reperfusion
- reperfusion
how do we preserve donation organs until transplant?
combination of hypothermia, electrolyte, and other chemical solutions
in organ preservation ____________ will decrease metabolic needs and ______________ will maintain cellular integrity
hypothermia; electrolyte/chemical solutions
what is the purpose of the hypothermia/electrolyte & chemical solutions in organ preservation?
- prevents vasospasm
- prevents cellular swelling
- prevents buildup of toxic metabolites.
what are some common electrolytes found in organ preservation solutions
- high concentrations of K
- Na
- Mg
- glucose
high concentrations of ____________ in organ preservation solutions can be an issue with reperfusion
potassium
if the organ preservation solution is not completely flushed from organ when starting the reperfusion, ________________ could occur
hyperkalemic cardiac arrest
__________________ is the first line of defense against hypoxic injury in the organ to be donated
cold preservation
benefits of living organ donors
- higher degree of HLA matching
- reduced ischemic time
- decreased wait time
what are some ethical and pyschological concerns with living organ donors
- psychological risk due to loss of organ
- coercion (including financial)
living donors must be physical status ________
I - II
if a non-directed living donor gives organ to a recipient who has a willing donor but is incompatible, and that donor gives to another individual who they are compatible with, this describes _________________
chained or paired donation
if doing a living kidney donation via the laproscopic approach, which kidney is preferred?
the left is preferred when done laproscopically
advantages of doing kidney donation laparoscopically
- decreased postop pain
- decreased hospitalization time
- shorter recovery
- improved cosmetic results
- better surgical exposure and longer vascular supply
position for kidney donation surgery
lateral position with tabled flexed and kidney elevated (head down)
anesthesia management for the living kidney donor
- at least 1 lg bore IV
- type and cross x2UPRBC
- GETA
- postop pain management (MM, pre-emptive analgesia, and/or nerve block)
- PONV prophylaxis
- heparin and protamine with clamp and unclamp
- lg volume crystalloid (ensure optimal fx & flow)+ mannitol and lasix (maintain blood volume and urine flow)
