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AP III > Transplant (3/4) > Flashcards

Transplant (3/4) Flashcards

1
Q

after the removal of the ________________ clamp in the neohepatic phase of liver transplant, you have the greatest risk of reperfusion syndrome

A

portal vein

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2
Q

after clamps are removed in the neohepatic phase; what should be assessed?

A
  1. bleeding
  2. close up to look at condition of liver
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3
Q

reperfusion is the first stage of the __________ phase of liver transplant

A

neohepatic

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4
Q

what causes the reperfusion syndrome with release of portal vein clamp for liver transplant

A
  1. acid load in the liver
  2. potassium load
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5
Q

when clamps are getting ready to be released from the portal vein (neohepatic phase) what drugs should you have ready to go

A
  1. epi
  2. atropine
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6
Q

__________________ can be used to reduce hemodynamic instability 2/2 reperfusion syndrome with liver transplant

A

Methylene blue 1-1.5mg/kg bolus

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7
Q

post op management of liver transplant

A
  1. management dictated by pre-op condition and graft fx
  2. frequent assessment of cardiac and pulmonary status / labs
  3. surgical re-exploration for bleeding, biliary leak, bowel obstruction, and/or infection
  4. risk with immunosuppressants
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8
Q

pain management for the liver transplant pt (postop)

A
  1. if no c/i peripheral nerve block
  2. multimodal techniques
  3. consider narcotic infusion
  4. ketamine bolus (0.5 mg/kg) + infusion (10 mcg/kg/min) if OR extubation planned
  5. ketamine infusion of 5 mcg/kg/min if not planned to extubate
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9
Q

indication for intestine transplant

A

short gut syndrome

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10
Q

50% of intestine transplant recipients are < ________ years of age

A

6

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11
Q

overall graft survival of intestine transplant at 1 year = ________% and at 5 years = _________%

A

66; 20

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12
Q

if someone is having an intestine transplant, why is that often combined with liver transplant?

A

due to TPN dependence –> liver dz and hepatic failure.

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13
Q

most common indications for lung transplant

A
  1. Chronic obstructive lung disease
  2. cystic fibrosis
  3. idiopathic pulmonary fibrosis
  4. pulmonary htn
  5. congential heart dz
  6. s/p covid-19 lung dz
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14
Q

what are the different types of lung transplants

A
  1. single
  2. sequential or en bloc double
  3. heart and lung
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15
Q

preanesthetic considerations for pt undergoing lung transplant

A
  1. severity of lung disease and what is underlying process
  2. comorbidities
  3. split lung function studies
  4. ERAS protocols (paravertebral, intercostal, thoracic epidural if can, multimodal pain, adequate postop pain)
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16
Q

induction and airway management for pt undergoing lung transplant

A
  1. careful with premedication & current level of anxiety
  2. preoxygenation
  3. RSI
  4. careful selection of induction agents due to hypovolemia and pulmonary htn
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17
Q

what gas is avoided in lung transplant pts?

A

nitrous

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18
Q

what are the most challenging intraoperative issues with lung transplant?

A
  1. ventilation-reperfusion mismatch
  2. pulmonary artery htn
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19
Q

intraoperative management of pt undergoing lung transplant

A
  1. lung protective strategies (small Tv [6mL/kg - on predicted body weight], optimize PEEP, lowest possible FiO2, pressure control ventilation
  2. one lung ventilation
  3. timing of cross clamping of PA
  4. tight fluid control
  5. risk of RV failure - so use inotropes and nitric oxide
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20
Q

a 180 cm male pt is undergoing a lung transplant, what tidal volume would you set on the ventilator?

A
  1. predicted body weight: 50 + [0.91(180 - 152.4)] = 75
  2. 6 mL/kg for TV = 6 x 75 = 450
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21
Q

how do you calculate predicted body weight in males

A

50 + 0.91 (height in cm - 152.4)

22
Q

how do you calculate predicted body weight in females

A

45.5. + 0.91 (height in cm - 152.4)

23
Q

what is the MOA of nitric oxide

A
  1. selective pulmonary vasodilator
  2. works by activating guanylyl cyclase to produce cGMP
24
Q

nitric oxide is inactivated by __________ = ____________

A

heme; methemoglobin

25
Q

dosing for nitric oxide in pt with pulmonary htn undergoing lung transplant

A

start at 20 ppm and wean; goal to have weaned before leaving OR

26
Q

if a pt who has a had a lung transplant comes in for a different surgical procedure; what should you be aware of?

A
  1. be cautious/careful of bronchial suture lines or stenosis
  2. advantages with regional techniques
  3. evaluate pulmonary function
27
Q

what is the gold standard for the tx of end-stage heart failure refractory to medicine

A

cardiac transplant

28
Q

indications for heart transplant

A
  1. idiopathic cardiomyopathy
  2. non-ischemic cardiomyopathy (viral, postpartum, drug induced)
  3. ischemic cardiomyopathy
  4. congenital heart disease
  5. valvular cardiomyopathy
  6. redo heart transplant
29
Q

contraindications for heart transplant

A
  1. terminal malignancy
  2. irreversible systemic organ dysfunction
  3. active infection
  4. HIV +
  5. ongoing etoh/drug abuse
  6. severe pulmonary htn
30
Q

pulmonary htn that has a gradient > ________ is an absolute contraindication to heart transplant

A

25 (or 2.5 wood units)

31
Q

preoperative preparation for heart transplant

A
  1. complete H&P
  2. full lab testing
  3. EKG and CXR
  4. echo
  5. PFTs
  6. bilateral heart cath
  7. stress testing.
32
Q

to be added to transplant list for heart, the pt must have a recent ___________________

A

multidisciplinary evaluation

33
Q

T/F: 70% of pts in end stage heart failure recieve a mechanical assist device prior to transplant

A

true

34
Q

preoperative considerations with heart transplant

A
  1. full preop eval
  2. what meds are they on? inotropic support, anticoagulants
  3. mechanical support?
  4. do they have a pacer
35
Q

often heart transplants require a redo sternotomy, what considerations do you have with this

A
  1. increased scar tissue and adhesions –> increased bleeding
  2. have blood in the room and be prepared to crash on pump
36
Q

induction for heart transplant

A
  1. RSI or modified RSI
  2. IV access
  3. balanced anesthetic technique
37
Q

monitors for intraoperative management of heart transplant pt

A
  1. TEE
  2. CVC +/- PAC (PAC would be placed at end)
  3. plans for immunosuppression
  4. plans for blood products (ensure blood CMV negative if donor/recipient are CMV neg)
38
Q

98% of heart transplants are performed via _____________ technique

A

orthotopic

39
Q

orthotopic heart transplant

A
  1. cold cardioplegia solution is injected
  2. the heart is packed in ice (ice into chest cavity)
  3. put donor heart in
  4. take out patient’s heart
40
Q

biatrial orthotopic technique

A

sew the bulk of the right and left recipent atria to the donor

41
Q

bicaval orthotopic technique

A

sewn to the recipients cavae and left atrial cuff

42
Q

T/F: with orthotopic heart transplant, atrial appendages are discarded

A

true; reduces the risk of clot formation

43
Q

with what type of heart transplant technique would you expect the patient to have 2 p waves post transplantation

A

biatrial orthotopic - d/t preserving portions of the recipients native atria (where SA node is) and inserting parts of new atria

44
Q

postoperative problems with biatrial orthotopic heart transplant

A
  1. atrial dysrhythmias
  2. atrial dysfunction
  3. thrombus formation
  4. tricuspid valve dysfunction
45
Q

benefits of the bicaval orthotopic heart transplant technique over the biatrial

A
  1. better preserve atrial geometry, tricuspid annulus shape, and RV function
  2. less TR and MR
  3. less conduction disturbances
  4. elminates the double P-wave
46
Q

disadvantage of the bicaval orthotopic heart transplant technique

A
  1. longer to complete
  2. longer ischemic time
47
Q

heterotopic heart transplant is aka

A

“side by side” or “piggyback

48
Q

heterotopic heart transplants are performed in < ______% of cases

A

1-2

49
Q

if a pt with pulmonary htn needs heart transplant, which technique would be best? (orthotopic or heterotopic

A

heterotopic d/t native RV being conditioned for load to the lungs.

the native right ventricle pumps to the lungs and the donor LV pumps to the body

50
Q

what situations would heterotopic heart transplant be better than orthotopic

A
  1. small donor heart
  2. pulmonary HTN

AP III (20 decks)

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