Transplant Anesthesia Flashcards
Max cold ischemic time hear and lungs
4-6 hrs
Max cold ischemic times for liver
12-24 hrs
Max cold ischemic times for kidney
72 hrs
Classification of organ donors
brain death donors, DCD, Living donors
Criteria for the diagnosis of brain death: Loss of cerebral cortical function
No spontaneous movement, unresponsive to external stimuli
Criterai for the diagnosis of brain death: Loss of brainstem function
Apnea, absent cranial nerve reflexes (papillary, corneal, oculocephalic, oculovestibular
Criteria for diagnosis of brain death: Supporting documentation
EEG, cerebral blood flow studies ( angiography, transcranial doppler, xenon scan)
Hypotension is a common derangement after brain death. What is the mechanism for this?
Hypovolemia r/t DI and hemorrhage, neurogenic shock
Arterial hypoxemia is a commone derangement after brain death. What is the mechanism for this?
Neurogenic pulmonary edema, aspiration, pneumonia
Hypothermia is a common physiologic derangement after brain death due to _____________ infarction
hypothalmic
Cardiac dysrhythmias are commmon after brain death and happen due to
hypothermia, arterial hypoxemia, electrlyte abnormality, myocardial ischemia
Donation after cardiac death facts
non-heart beating donors, severe whole brain dysfunction, **have electrical activity in the brain, death is defined by cessation of circulation and respiration, life support measures are used to control timing of death, organ procurement, and to maximize function of organs from these donors
Anesthesia management is required for organ donation after ____ death
brain
Anesthesia management MAY NOT be required for organ donation after ______ death
CARDIAC
The recovery of vital organs for transplantation is a sterile post mortem procedure lasting up to ___ hours. At least ___ surgeons will scrub. Anesthesia support of donor organ systems is necessary until the PROXIMAL AORTA is _______, after which the ventilator, IV’s, and cardiac monitors may be discontinued. If the lungs are being recovered, anesthesia support will be required post cross _____.
4/2/clamped / clamp
The recovery of vital organs is dependent upon what?
Adequate respiratory support and organ perfusion (BP>100 and or CVP 8-12). Maintain sp02 >96% and UOP > 100 cc/hr. Vigorous volume replacement with crystalloid and/or colloid. No anesthesia is required but muscle relaxant may be required to neutralize spinal reflexes and relax the abdomen.
Living donors acount for _____% of all donors. They are frequently related to the recipient. Should be a healthy individual between the ages of ___ and __. Should have no history of what?
44% / 18 and 60. HTN, DM, CA, Kidney dz, heart dz
Frequently required drugs for donor cases
LR, heparin 30,000 units, Thyroxin drip, panc/vec , dopamine, neo, levo, vaso,
Additional medications that may be requested by the CORE or surgeon
PRBCs, albumin, mannitol, lasix
If the liver is being split, ___ or more units of PRBCs are required in the OR
2
ABSOLUTE contraindications to organ transplantation
Active uncontrolled infection, AIDS, inability to tolerate immune suppression, severe cardiopilmonary/medical condition, continued drug or alcohol abuse, extrahepatic malignancy, inability to comply with medical regimen, lack of psychosocial support
Dramatic increases in the success of organ transplanation is due to what?
immunosuppressive regiments (cyclosporine, azathioprine, OKT3, steroids) and improved donor:recipient tissue typing
Review immunosuppressant table on slide
20
Post-transplantation organ function is dependent on multiple factors: donor demographics, organ _____ time, mechanism of death of donor, medical condtion of recipient
ischemic
How many kidneys per year?
25,500
How many livers per year
6291
How many hearts
3000
How many lungs
1000
How many heart/lungs
40
Graft survival rate at 5 years from cadaveric donors is ___% for nonextended criteria and ___% for extended criteria
72% / 57%
Graft survival rate at 5 years from living donors is ____%
81%
More than ________ people await kidney transplant
75,000
Major indications for kidney transplantation
DM, HTN induced nephropathy, glomuerolonephritis, polycystic kidney dz
What are some physiologic disturbances often present before renal transplantation
peripheral neuropathy, lethargy, anemia, platelet dysfunction, pericarditis, systemic hypertension, depressed EF, pleural effusions, skeletal muscle weakness, ileus, glucose intolerance
Patho of HTN: HTN may lead to _____, cardiac chamber dilation, increased Lt ventricular wall tension, redistribution of blood flow, myocardial fibrosis, heart failure and arrhythmias
LVH
Diabetic autonomic neuropathy can make what difficult?
intra-op BP control
CRF is characterized with anemia of hgb __ to ___. A hgb of __ or greater is needed for adequate 02 delivery to the heart and transplanted graft
6 to 8 / 8 or greater
________ is another complication of autonomic neuropatny and increases the risk of aspiration during GETA
gastroparesis
In patients receiving hemodialysis or peritoneal dialysis, it is improtant to evaluate their acid-base, electrolyte and ______ status
volume
Airway evaluation is very important with DM 1 IDDM because?
stiff joint syndrome that causes fixation of AO joint along with limited head extension
Impairment of respiratory fxn in IDDM is related to a loss of lung _______ properties, and is characterized by a decrease in cough _____, significant restriction of lung volumes with a reduced _____ and _____
elastic / reactivity / tidal volume and FEV
reasonable fluid protocol for living donor
10ml/kg/hr above calculated losses, maintain UOP > 100 ml/hr, and/or titrate to specific CVP
Why do you want to avoid nitrous in these patients?
distended bowel can get in surgeons way (laparascopic)
Cadaveric kidney transplantation: Patient is positioned supine. After induction of anesthesia, a ___ way foley is placed. Incision in the right or left lower quadrant. The external and internal ____ vein and artery are identified. The ____ is clamped and anastomosed first followed by the ______, then clamps are released. ____ and _____ should be given by this point. The bladder is filled with ____ solution to fascilitate implantation of the ________.
3 / iliac / vein / artery / mannitol / lasix / antibotic / ureter
Must be attentive to _____ after reperfusioni of donor kidney because graft function is critically dependent on _______ pressure
hypotension / prefusion
Want to avoid ______ ______ drugs with transplanted kidney because it is senstive to ________ which can compromise blood flow to transplanted organ
aplha adrenergic / sympathomimetics
Muscle relaxant depends on K+ level. In normokalemic patients, _____ is safe, otherwise ________ or ______ is preferable
succs / cisatracurium (0.1 mg/kg) or mivacurium (0.15-0.2 mg/kg)
T/F reversal of muscle relaxants with neostigmine and robinul lis safe in patients with ESRD
TRUE
If diabetic gastroparesis is a concern 30 ml of ______ administered prior to induction can decrease gastric acid content
sodium citrate
Use of reglan 30 mg PO may increase gastric emptying and ____ sphincter tone
LES
H2 blocker __ to __ hrs prior to induction can decrease gastric acid production
6 to 12
What can be done to reduce intraop dosage of narcotics and inhalational agents
epidural analgesia
Vasopressor or positive inotroope agents maybe used during renal transplant surgery to increase cardiac output and renal perfusion. Which agents? What is the endpoint?
The endpoint is to having the newly grafted kidney produce urine immediately. The agents of choice are dopamine, fenoldapam, norepinpehrine, vasopressin
Want to maintain renal perfusioni pressure and enhance urine production by giving mannitol and loop diuretics ______ unclamping vascular supply to transplanted kidney
before
Reperfusion of the kidney graft may be associated with HYPOTENSION. This is most often related to a _______ in preload as a consequence of _______ the iliac _____. How is it treated?
reduction / unclamping / artery / treat with crystalloid, colloid or low-dose dopamine
Prompt urine production after transplant is desired. If UOP is decreased what is the significance of this?
May indicate mechanical impingement of graft, anastamosing vessel or ureter
What can be used to assess flow through the arterial and venous anastomosis?
intra-op ultrasound
Review TABLE on slide
slide 43
During emergence a moderate to severe HTN may accompany emergence from anesthesia for renal transplant and should be treated with _______.
short-acting anti-hypertensives. The use of longer acting beta blockers should be avoided as they may raise K+ levels
Anesthesia considerations for the patient with a prior renal transplant
renal excretion of drugs is usually decreased compared to those with native kidneys. Avoid muscle relaxants that rely on renal excretion, provide adequate hydration and avoid hypotension. There are consequences from long-term immunosuppressive therapy.
Liver transplant facts
10 year survival rate is 60% and 17500 on the wait list
Indications for liver transplant
cholestatic disease, alcoholic cirrhosis, metabolic diseases, malignant disease of liver, acute and chronic hepatitis, post necrotic cirrhosis, scelrosing cholangitis
Most livers available for transplantation come from ________ cadaveric donors
heart-beating
When caring for organ donors, the focus of care has shifted from preserving the patient to preserving the function of the graft ______
organs
Due to the shortage of cadaveric donors, the use of ________ donors is growing
living
Patients with chronic liver dysfunction and cirrhosis have a ________ circulation with _____ peripheral vascualr resistance and _______ cardiac index
hyperdynamic / low / increased
Common physiologic presentation of chronic liver dysfunction
coagulopathies, edema, ascites, renal dysfunctions, portopulmonary hypertension, hepatopulmonary syndrome, autonomic neuropathies
Hepatic encephalopathy cause is believed to be __________. It resembles and must be differentiated from many other nonfocal neurologic conditions such as ________, ________, intracranial hemorrhage, mass lesions and meningitis
multifactorial / hypoglycemia / hyponatremia
Review table on slie
slide 57
T/F avoid nitrous in liver transplants
TRUE
T/F drugs that rely on hepatic metabolism and excretion are safe to use due to implantation of functioning liver
TRUE
What are the phases of liver transplantation
preanhepatic phase, anhepatic phase, neohepatic phase
Preanhepatic phase: Lysisi of adhesions and ___________ of abdomen. Mobilization of liver and careful dissection of hepatic artery, common bile ducts, supra and infra-hepatic ________ and _________. There is a shunting and non-shunting procedure.
exploration / vena cava and portal vein
If portal HTN is severe to the degree that mobilizing the liver may result in significant ______ _____ or the patient is UNSTABLE, then a ________ shunt or venous bypass may be instituted
blood loss / portocaval
Non-shunting procedures are aimed at controlling hemorrhage from ___________ varices
portosystemic
Shunting procedures redirect the portal _______ flow into the systemic _______ circulation via a non variceal conduit, thus reliveing portal htn, decompressing varices and at the same time relieving ascites.
venous / venous
Problems associated with the Pre-Anhepatic phase
hemorrhage, coagulation problems, impaired venous return from surgical retraction and IVC clamping, hypocalcemia, hyperkalemia and metabolic acidosis
What electrolyte abnormalities are associated with the pre-anhepatic phase?
hypocalcemia, hyperkalemia, metabolic acidosis
The ANHEPATIC phase begins with the ________ of hepatic blood flow
CLAMPING
During the anhepatic phase there is _______ of the native liver. The vena cava is removed with the liver, leaving two cuffs, one jyst below the diaphragm and the other above the entry of the ______ ______
removal / renal veins
Implanation of the donor liver also happens in the ________ phase. The first vascualr anastomosis consists of the allograft ________ vena cava and the cuff of the recipients infradiaphragmatic vena cava. The the liver is flushed with ______ or _______. Finally the ____ _____ reconstruction and the clamps are removed.
anhepatic / suprahepatic / crystalloid or albumin / portal vein
In the anhepatic phase, Bicaval clamping where the vena cava is clamped above and below liver which can result in what?
dropped preload, hypotension and tachycardia
This technique of clamping preserves some caval flow and preload and is accomplished by sideclamping the inferior vena cava
piggyback technique
During the anhepatic phase there is a risk of hemorrhage, _________ fibrinlolysis, coagulopathy, acidosis, hypothermia and decreased renal function. Cardiac output and systemic BP may need to be supported with ____ and ______
increasing / inotropes and vasopressors
During the anhepatic phase, ________ intoxication may occur from rapid transfustion of large volumes of blood in absence of liver function. They may require ______ administration if the patient is hypocalcemic
citrate / calcium
The NEOHEPATIC phase begins with the ___________ of the portal vein, hepatic artery and vena cava and reperfusion to the liver
unclamping
Preparatioin for the neohepatic phase is important because this may be a period of great _________instability
hemodynamic
What should happen prior to unclamping to prevent post reperfusion syndrome
ionized calcium should be normal, acidosis should be corrected and K+ should be <4.5
T/F Fluid overload prior to unclamping should be avoided
TRUE
When do hemodynamics begin to stabilize?
once allograft begins to function
Reperfusion syndrome is characterized by decreased ___, ____ and ____, conduction defects (bradyarrhythmias and asystole), Pulmonary _____ and _____ SVR
CO, HR, BP / HTN / decreased
A rapid increase in ____ can occur so ensure normal pH and electrolytes prior to unclamping
K+
Severe coagulopathies can happen during a reperfusion syndrome and is related to what?
fibrinolysis, release of heparin and hypothermia
Initial indirect signs of functioning graft
intraoperative bile production, intraoperative spontaneous correction of negative base excess, improvement in coagulation
Review table on slide 72
slide 72 - coagulopathy
Review management stages on slide
slide 73
Post op care of liver transplant patient includes that _________ is deferred, direct admit to ICU, and serial ________ assessments of hepatic artery and porta vein patency. A thrombosis may require re-transplantation.
extubation / ultrasound
Most frequent indications for lung transplant
COPD, idiopathic PF, CF, alpha-1 antitrypsin deficiency, sarcoidosis, CHD (eisenmenger’s syndrome)
With Eisenmenger syndrome the pulmonary artery wall thickens towards ______
lungs
Post-heart transplant: As a consequence of _______, the transplanted heart has no sensory, sympathetic and parasympathetic innervations. The HR should be high around 90-110 because ________ innervation that normally lowers the HR is not present
denervation / parasympathetic
