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Advanced Anesthesia III > Transplant Anesthesia > Flashcards

Transplant Anesthesia Flashcards

1
Q

Before initiating brain death testing, we must make sure that these factors have been ruled out ass possible causes of cerebral dysfunction

A

Hypothermia
Hypotension
Metabolic/endocrine instability
Drug overdose (recreational, is pt paralyzed?)

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2
Q

What is the definition of comatose?

A

Unresponsive to verbal stimuli

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3
Q

How can you tell if cerebral cortical function is absent?

A

No spontaneous movement, and no response to painful stimulus

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4
Q

What are two supporting studies that can be used in the brain death exam?

A

EEG and TCDs

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5
Q

What is the oculocephalic reflex?

A

Doll’s eyes response
Oculo–eyes
Cephalic – head
Seeing how their eyes move in relation to their head

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6
Q

What is the oculovestibular reflex?

A

Cold caloric testing

Stimulating the inner ear with cold water

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7
Q

What are the components of the brain death exam?

A 
Absence of pupillary response to light
Absent corneal reflex
Absent oculocephalic reflex
Absent oculovestibular reflex
Absent cough and gag reflex
Absent respiratory reflex (apnea test)
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8
Q

How do you perform an apnea test?

A

Give 100% FiO2 for 10 minutes. Ensure that PaCO2 is normal with an ABG. Take the patient off the vent and connect to a t piece for 7-10 minutes. Get another ABG. Absence of respiratory effort and PaCO2 > 60 is a positive test.

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9
Q

Hemodynamic goals for preserving organ function in the brain death donor patient for organ harvest

A 
SBP > 100
UO 1-1.5cc/kg/hr
Hgb > 10
CVP 5-10
FiO2  7.5 (again to avoid lung damage)
SaO2 > 95%
PaO2 75-150
Core temp > 34-35C
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10
Q

Why do we avoid phenylephrine in the organ harvest patient?

A

It can reduce splanchnic blood flow to the organs we are trying to procure

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11
Q

What do we give for pressers instead of neo in the organ harvest patient?

A

Dopamine, dobutamine, epi, and norepi

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12
Q

What do we give for bradycardia in the organ harvest patient?

A

They will be resistant to atropine, so give either epic or isoproterenol

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13
Q

When someone donates a kidney, which one do they usually take?

A

The left

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14
Q

In healthy liver segment donors, why do they experience more hypotension with clamping of the hepatic pedicle?

A

Because unlike those with liver disease, they are healthy and haven’t developed collaterals. To prevent this, we pretreat with albumin boluses.

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15
Q

How are the organs preserved once removed?

A

Kept cold to reduce metabolism.
Kept in a preservative solution (helps to maintain cellular integrity, prevent cellular swelling, prevent vasospasm, prevent the buildup of toxic metabolites, and to provide a source of energy for the organ

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16
Q

This solution is used to intraabdominal organs

A

UW solution

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17
Q

This solution is used or hearts

A

Celsior

18
Q

Once out of the body, organs are cooled to this temperature

A

4C

19
Q

This is an ABSOLUTE contraindication to organ transplant

A

Active infection (pt will be immunosuppressed, and needs to be able to fight off the infection)

20
Q

These are RELATIVE CIs to organ transplant

A

Malignancy, systemic disease, physical/social factors, and advanced age (although, by itself is not a CI)

21
Q

What are some of the potential SEs of the immunosuppressive agents used?

A

Life-threatening infection
Increased risk of tumors and malignancy (body isn’t fighting off abnormal cells)
Progressive vascular disease
Renal compromise

22
Q

This is the sensitization stage

A

The interaction between the graft cells and the host’s T cells. They’re meeting each other for the very first time, and the T cells are pretty suspicious of these new cells they’re seeing.

23
Q

This is the effector stage

A

Those T cells be activated. They realized this shit ain’t what dey used to, and shit’s about to get real. The T cells become activated and secrete cytokines, and amplify T cell activation via DNA synthesis and T cell proliferation.

24
Q

Why are glucocorticoids given? What glucocorticoid is commonly given?

A

They decrease macrophage production of interleukins. This decreases T cell development and proliferation of T helper cells.

Methylprednisolone is commonly given, and can cause adrenal suppression, infection, and DM.

25
Q

These are two Calcineurin Inhibitors used in transplant. What are their names and how do they work? What are their SEs?

A

Cyclosporine and Tacrolimus
These inhibit T cell differentiation and cytokine synthesis.

SE: Nephrotoxic, hepatotoxic, neurotoxic, HTN, HLD, and hyperglycemia.

Cyclosporine can prolong NM blockade

26
Q

Tacrolimus is also called FK5

A

FK506

27
Q

This is a monoclonal antibody used as an immunosuppressant

A

Daclizumab. Has no major SEs.

28
Q

These immunosuppressants work by inhibiting adhesion molecules

A

Rabbit/Horse Antithymocyte Globulin
- Can cause anaphylaxis, increased CMV or epstein-barr viral infection, and pulmonary edema

Antilymphotcyte globulin (ALG)
- Decreased the availability of activated T cells and their proliferation. Specific for T3 complex located on the surface of mature T cells and blocks their function.
29
Q

This immunosuppressant works by inhibiting DNA synthesis

A

Azathroprine.

SE include pancytopenia, severe upper airway edema (rare), and antagonist of NM blockade

30
Q

These are some common causes of ESRD

A 
DM
HTN
Glomerulonephritis
PKD
Chronic pyelonephritis
Obstructive uropathy
SLE
Alport's syndrome
31
Q

Matching tests needed for renal transplant

A

ABO
HLA
Patient specific crossmatch

32
Q

Hemodynamic goals for kidney transplant

A

SBP > 90
MAP > 60
CVP 10-15

33
Q

Why are lasix and mannitol administered before reperfusion of the kidney?

A

To stimulate diuresis. Mannitol, along with adequate volume decreases the risk for ATN. Adequate volume increases renal blood flow, and improve immediate graft function.

34
Q

This is the first choice vasoactive infusion in kidney transplants if pressure does not come up with fluids

A

Dopamine

35
Q

Emergence in kidney transplant

A

May have hyper dynamic responses, especially in those with uncontrolled HTN
Avoid excessive coughing, which could disrupt the graft
ESRD patients may have delayed emergence from anesthesia
Extubatne awake d/t aspiration risk (we want to know they’re awake and capable of protecting their own airway before we remove the tube)

36
Q

Key during organ reperfusion

A

Watch for hypotension. This is expected d/t release of ROS, but should be avoid to maintain graft perfusion

37
Q

What is the most common indication for liver transplant?

A

Hep C

38
Q

When the pressure gradient between hepatic and portal veins is severe (__-__mmHg), complications such as ascites, esophageal varices, encephalopathy, and hepatorenal syndrome can develop

A

10-12

39
Q

Why do ESLD patients have hyper dynamic circulation?

A

Hyperdynamic circulation is high CO, low BP, and low SVR.

It is caused by portal HTN-induced production of vasodilators, most importantly, NO. The overproduction of vasodilators is responsible for reduced circulatory responsiveness to sympathetic stimulation. Clinically, this frequently results in a need for increased doses of vasopressors.

40
Q

What is hepatopulmonary syndrome?

A

A syndrome that is defined as having portal HTN, PaO2

41
Q

What is portopulmonary HTN?

A 
Defined as pulmonary hypertension in the presence of portal hypertension in a patient without other predisposing factors. 
Diagnosis:
Mean PAP > 25
PVR > 240
PCWP
42
Q

What are some examples of natural anticoagulants?

A

Protein C, Protein S, and AT-III

Advanced Anesthesia III (6 decks)

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