Transplant (3/4) Flashcards
after the removal of the ________________ clamp in the neohepatic phase of liver transplant, you have the greatest risk of reperfusion syndrome
portal vein
after clamps are removed in the neohepatic phase; what should be assessed?
- bleeding
- close up to look at condition of liver
reperfusion is the first stage of the __________ phase of liver transplant
neohepatic
what causes the reperfusion syndrome with release of portal vein clamp for liver transplant
- acid load in the liver
- potassium load
when clamps are getting ready to be released from the portal vein (neohepatic phase) what drugs should you have ready to go
- epi
- atropine
__________________ can be used to reduce hemodynamic instability 2/2 reperfusion syndrome with liver transplant
Methylene blue 1-1.5mg/kg bolus
post op management of liver transplant
- management dictated by pre-op condition and graft fx
- frequent assessment of cardiac and pulmonary status / labs
- surgical re-exploration for bleeding, biliary leak, bowel obstruction, and/or infection
- risk with immunosuppressants
pain management for the liver transplant pt (postop)
- if no c/i peripheral nerve block
- multimodal techniques
- consider narcotic infusion
- ketamine bolus (0.5 mg/kg) + infusion (10 mcg/kg/min) if OR extubation planned
- ketamine infusion of 5 mcg/kg/min if not planned to extubate
indication for intestine transplant
short gut syndrome
50% of intestine transplant recipients are < ________ years of age
6
overall graft survival of intestine transplant at 1 year = ________% and at 5 years = _________%
66; 20
if someone is having an intestine transplant, why is that often combined with liver transplant?
due to TPN dependence –> liver dz and hepatic failure.
most common indications for lung transplant
- Chronic obstructive lung disease
- cystic fibrosis
- idiopathic pulmonary fibrosis
- pulmonary htn
- congential heart dz
- s/p covid-19 lung dz
what are the different types of lung transplants
- single
- sequential or en bloc double
- heart and lung
preanesthetic considerations for pt undergoing lung transplant
- severity of lung disease and what is underlying process
- comorbidities
- split lung function studies
- ERAS protocols (paravertebral, intercostal, thoracic epidural if can, multimodal pain, adequate postop pain)
induction and airway management for pt undergoing lung transplant
- careful with premedication & current level of anxiety
- preoxygenation
- RSI
- careful selection of induction agents due to hypovolemia and pulmonary htn
what gas is avoided in lung transplant pts?
nitrous
what are the most challenging intraoperative issues with lung transplant?
- ventilation-reperfusion mismatch
- pulmonary artery htn
intraoperative management of pt undergoing lung transplant
- lung protective strategies (small Tv [6mL/kg - on predicted body weight], optimize PEEP, lowest possible FiO2, pressure control ventilation
- one lung ventilation
- timing of cross clamping of PA
- tight fluid control
- risk of RV failure - so use inotropes and nitric oxide
a 180 cm male pt is undergoing a lung transplant, what tidal volume would you set on the ventilator?
- predicted body weight: 50 + [0.91(180 - 152.4)] = 75
- 6 mL/kg for TV = 6 x 75 = 450
how do you calculate predicted body weight in males
50 + 0.91 (height in cm - 152.4)
how do you calculate predicted body weight in females
45.5. + 0.91 (height in cm - 152.4)
what is the MOA of nitric oxide
- selective pulmonary vasodilator
- works by activating guanylyl cyclase to produce cGMP
nitric oxide is inactivated by __________ = ____________
heme; methemoglobin
dosing for nitric oxide in pt with pulmonary htn undergoing lung transplant
start at 20 ppm and wean; goal to have weaned before leaving OR
if a pt who has a had a lung transplant comes in for a different surgical procedure; what should you be aware of?
- be cautious/careful of bronchial suture lines or stenosis
- advantages with regional techniques
- evaluate pulmonary function
what is the gold standard for the tx of end-stage heart failure refractory to medicine
cardiac transplant
indications for heart transplant
- idiopathic cardiomyopathy
- non-ischemic cardiomyopathy (viral, postpartum, drug induced)
- ischemic cardiomyopathy
- congenital heart disease
- valvular cardiomyopathy
- redo heart transplant
contraindications for heart transplant
- terminal malignancy
- irreversible systemic organ dysfunction
- active infection
- HIV +
- ongoing etoh/drug abuse
- severe pulmonary htn
pulmonary htn that has a gradient > ________ is an absolute contraindication to heart transplant
25 (or 2.5 wood units)
preoperative preparation for heart transplant
- complete H&P
- full lab testing
- EKG and CXR
- echo
- PFTs
- bilateral heart cath
- stress testing.
to be added to transplant list for heart, the pt must have a recent ___________________
multidisciplinary evaluation
T/F: 70% of pts in end stage heart failure recieve a mechanical assist device prior to transplant
true
preoperative considerations with heart transplant
- full preop eval
- what meds are they on? inotropic support, anticoagulants
- mechanical support?
- do they have a pacer
often heart transplants require a redo sternotomy, what considerations do you have with this
- increased scar tissue and adhesions –> increased bleeding
- have blood in the room and be prepared to crash on pump
induction for heart transplant
- RSI or modified RSI
- IV access
- balanced anesthetic technique
monitors for intraoperative management of heart transplant pt
- TEE
- CVC +/- PAC (PAC would be placed at end)
- plans for immunosuppression
- plans for blood products (ensure blood CMV negative if donor/recipient are CMV neg)
98% of heart transplants are performed via _____________ technique
orthotopic
orthotopic heart transplant
- cold cardioplegia solution is injected
- the heart is packed in ice (ice into chest cavity)
- put donor heart in
- take out patient’s heart
biatrial orthotopic technique
sew the bulk of the right and left recipent atria to the donor
bicaval orthotopic technique
sewn to the recipients cavae and left atrial cuff
T/F: with orthotopic heart transplant, atrial appendages are discarded
true; reduces the risk of clot formation
with what type of heart transplant technique would you expect the patient to have 2 p waves post transplantation
biatrial orthotopic - d/t preserving portions of the recipients native atria (where SA node is) and inserting parts of new atria
postoperative problems with biatrial orthotopic heart transplant
- atrial dysrhythmias
- atrial dysfunction
- thrombus formation
- tricuspid valve dysfunction
benefits of the bicaval orthotopic heart transplant technique over the biatrial
- better preserve atrial geometry, tricuspid annulus shape, and RV function
- less TR and MR
- less conduction disturbances
- elminates the double P-wave
disadvantage of the bicaval orthotopic heart transplant technique
- longer to complete
- longer ischemic time
heterotopic heart transplant is aka
“side by side” or “piggyback
heterotopic heart transplants are performed in < ______% of cases
1-2
if a pt with pulmonary htn needs heart transplant, which technique would be best? (orthotopic or heterotopic
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
what situations would heterotopic heart transplant be better than orthotopic
- small donor heart
- pulmonary HTN
