Transplant Anesthesia

Question 1

What are the maximum ischemic times for the heart, liver, and kidneys?

Answer 1

Heart- 4-6 hours
Liver- 12-24 hours
Kidneys- up to 36 hours

Question 2

T or F: Brain death is associated with hemodynamic instability, wide swings in hormone levels, systemic inflammation, and oxidant stress, all of which negatively impact donor organ function

Answer 2

True

Question 3

T or F: Just after brain death, adrenergic surges can cause ischemia and ­ischemia–reperfusion injuries.

Answer 3

True

Question 4

T or F: Studies of head trauma patients suggest that the onset of brain death is associated with a transient period of hypotension with increased cardiac index and tissue perfusion. During this period, vasoactive drugs administered to increase blood pressure can cause rapid circulatory deterioration.

Answer 4

True- This period precedes the autonomic storm associated with herniation of the brain and emphasizes the wide dynamic swings in blood chemistries and hemodynamics after brain death. The timing of therapies to support hemodynamics is difficult as catecholamine storm is often followed quickly by pituitary failure. Once pituitary failure ensues, hormone therapy may help stabilize donors hemodynamically and thereby extend the donor pool.

Question 5

T or F: Recently, in a rare prospective trial, a lung-sparing ventilation strategy was shown to increase the lung donor pool. Patients ventilated with tidal volumes of 6 to 8 mL/kg body weight and 8 to 10 cm water (H2O) PEEP were more likely to be lung donors than patients managed with tidal volumes 10 to 15 mL/kg and 3 to 5 cm PEEP

Answer 5

True

Question 6

T or F: The mainstay of donor management is maintenance of euvolemia; therefore, central venous pressure (CVP) monitoring is standard. CVP is maintained at 6 to 12 mm Hg, and when pulmonary artery (PA) catheters are used to assess cardiac function, pulmonary capillary wedge pressure is maintained at

Answer 6

True

Question 7

T or F: high molecular weight hydroxyethyl starch (HES, 200/0.6) had a negative impact on long-term renal function in recipients of these donor grafts compared with low molecular weight (130/0.4) HES

Answer 7

True

Question 8

T or F: Generally, packed cells are used to maintain hematocrit of 30%, and fresh-frozen plasma (FFP) is used to maintain the international normalized ratio (INR)

Answer 8

True

Question 9

What is antithymocyte globulin? When is it administered, and what are potential side effects?

Answer 9

Antithymocyte globulin is a polyclonal antibody immunosuppressive agent used to deplete T cells from the circulation. It also interacts with a wide variety of cell surface molecules involved in adhesion and cell trafficking and ischemia–reperfusion injury.

It has a long history of use in treating acute rejection and induction of immunosuppression, particularly in sensitized transplant recipients and in steroid- and calcineurin-sparing regimens.

Side effects:
- leukopenia, thrombocytopenia, fever, anaphylactic reaction, increased incidences of both CMV and Epstein-Barr virus infections, and acute and severe serum sickness, a rare side effect of ATG administration, presenting as jaw pain, and is treated by stopping the drug, plasmapheresis, and corticosteroids.

• on administration, the most importnat side effect is hypotension, so administer slowly. Corticosteroid, diphenhydramine, slow infusion, and acetaminophen will help prevent the development of hypotension. Hypotension may develop regardless of central or peripheral administration.

Question 10

Side effects of the following medications:

azathioprine
cyclosporine
OKT4A
Rapamycin

Answer 10

azathioprine- pancytopenia, cardiac arrest, airway edema

cyclosporine- increased risk of CAD, HTN, ishcemic vascular disease, and nephrotoxicity

OKT4A- fatigue/weakness/fever/childs, hypotension

rapamycin- increased infection risk, myelosuppression, and hyperlipidemia

Question 11

Describe the transplanted heart.

Answer 11

• Lacks autonomic innervation –> lack of vagal nerve influence results in a resting heart rate of 100-120 bpm
• cardiac output is preload dependent and has a fixed heart rate
• sympathetic denervation leads to loss in catecholamine stores necessary in the indirect vasopressors mechanism of action
• 2 p waves are presence as a result of the presence of both the donors and recipient’s sinatrial nodes.
• administer glycopyrrolate with neostigmine, as noncardiac effects of muscarinic activation will still occur.