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42 Cards in this Set

  • Front
  • Back
What combinations of medications have improved kidney survival?
1. cyclosporin A,
2. azathioprine,
3. steroids
When should a patient getting a kidney transplant be dialyzed prior to surgery?
within 24 hours to correct volume, acid-base, and electrolyte abnormalities
What is the mechanism of cyclosporine?
it is a metabolite of fungus which inhibits T-lymphocyte mediated immune response without affecting B lymphocytes
Besides transplantation cyclosporine is used in what other conditions?
1. crohn's,
2. uveitis,
3. psoriasis,
4. RA
What is the most important and frequent side effect of cyclosporine use and what should you do to monitor for it?
nephrotoxicity
-renal function testing and cyclosporine blood levels
Besides nephrotoxicity what other side effects are caused by cyclosporine?
1. htn,
2. paresthesias,
3. seizures,
4. gum hyperplasia,
5. hirsuitism,
6. hyperglycemia
What are preop considerations in renal transplant patients?
1. volume status,
2. Hgb levels,
3. potassium
4. other electrolytes
5. weights
What are functions of the liver?
1. glucose homeostasis,
2. fat metabolism,
3. protein synthesis,
4. cholinesterase,
5. conjugation,
6. coagulation factor production,
7. bilirubin production,
8. bile excretion,
9. acid disposition/disposal
What are indications for liver transplantation?
1. end stage cirrhosis,
2. metabolic diseases (wilson's disease, hemochromatosis),
3. fulminant hepatic failure
should you use an esophageal stethoscope or NG tube in a patient with esophageal varices?
they are relatively safe
What lines should likely be present during liver transplantation?
1. two 14g IVs
2. 8.5F antecubital catheter attached to a rapid transfuser
How should you induce a patient undergoing liver transplantation?
RSI because of ascites and elevated intraperitoneal pressure
If you use N2O during a liver transplantation when should you consider discontinuing it?
at the time of reperfusion when the risk of venous air embolism is heightened
What are the 4 stages of liver transplantation?
1. mobilization of the recipeint's liver/hepatectomy
2. anhepatic phase,
3. post-revascularization
4. biliary reconstruction
what are anesthetic concerns during the hepatectomy(mobilization of recipient liver) phase of liver transplantation?
1. bleeding,
2. compression of IVC and pericardium
3. porto-femoral-axillary bypass
How often should you check coagulation, acid-base, and electrolyte levels during the hepatectomy phase and why?
every one half to one hour
1. glucose levels increase,
2. administration of FFP to keep PT withing 2 sec of control and sometimes fibrinogen to prevent depletion (keep above 100mg/dl),
3. can also monitor thromboelastogram - info about clotting and platelet function, and fibrinolysis
When does porto-femoral-axillary bypass begin during liver transplantation and what does this cause pertaining to CVP and PAP?
at the conclusion of the hepatectomy phase,
-CVP and PAP increase due to increased flow through the SVC system (adult flow is 1-4 L/min)
What monitoring should you pay special attention to during the hepatectomy phase?
1. check and correct coagulation, acid-base, and electrolyte abnormalities,
2. monitor and maintain fluid balance,
3. initiate diuresis
What events mark the beginning and the end of the anhepatic phase?
removal of the liver to hepatic arterial anastomosis
What vessels are clamped during the anhepatic phase?
1. portal vein,
2. hepatic artery
3. inferior vena cava above and below the liver
What are the benefits of using veno-venous bypass during the anhepatic phase?
1. decrease blood loss from the surgical field,
2. lessen hemodynamic instability
-outcome is not better with this technique - not universally used
What are complications of veno-venous bypass?
increased risk of air embolism and vascular injury
Why would you consider giving dopamine during the anhepatic phase?
induce diuresis during this period of decreased renal perfusion
What metabolic abnormalities are frequently present during the anhepatic phase? How do you tx it?
1. metabolic acidosis - Na bicarb
2. hyperkalemia - diuresis induced with low dose dopamine and furosemide + glucose, insulin, bicarb
3. citrate toxicity - CaCl 1-2 gm
What events constitute the post-revascularization phase of liver transplantation?
unclamping of the liver to biliary reconstruction
What are major problems during the post-revascularization phase of liver transplantation?
1. metabolic and hemodynamic perturbations,
2. hyperkalemia,
3. metabolic acidosis,
4. hypothermia - vol is cold
5. air embolism
6. RV overload - rapidity of its admin may cause sudden myocardial stretch - arrhythmias
7. fibrinolysis
What age is optimal for donor hearts?
from 35-40 yo
What are problems that relate to the donor during heart transplantation?
1. temperature control,
2. fluid and electrolyte balance, with frequent diabetes insipidus,
3. cardiovascular stability,
4. pulmonary function (frequent development of pulmonary edema)
What monitors should you use for heart transplantation?
1. foley
2. arterial line,
3. L sided IJ (R IJ is commonly utilized for subsequent punture and transvenous endomyocardial biopsy)
What about pulmonary status in a patient getting a heart transplant is of important consideration?
pulmonary htn
-nitric oxide can be beneficial
What is the eventual baseline heart rate following cardiac transplantation?
90-110 bpm
What cardiac rhythm is frequently encountered in the first few days after cardiac transplant?
bradycardia (secondary to sinus node dysfunction)
What medication are patients on for 2-3 days after heart transplantation?
isoproterenol - more selective beta agonist than epi
-alpha effects of epi are often considered undesirable(transplanted heart is denervated)
How does the transplanted heart respond to laryngoscopy?
sympathetic responses are usually absent
How are baroreceptor reflexes and responses to valsalva affected after heart transplantation?
absent
How are changes in CO made after heart transplantation?
changes in stroke volume because heart rate is relatively constant
How does the transplanted heart react to sympathomimetics such as isoproteronol, epinephrine, dopamine, and dobutamine?
receptors function normally so they have their normal effect
What is the preservation time now of cadaver kidneys in pts receiving renal transpants?
36-48 hrs
What problems can be seen in pts with chronic renal failure?
1. Anemia
2. Acidosis
3. Coagulopathies
4. CHF
5. Electrolyte problems
6. Infection
7. Htn
What is a common co-existing problem in pts with severe liver failure? How is it manifested?
Portal htn
1. ascites - tx with diuretics; usually volume depleted
2. splenomegaly - platelet sequestration and thrombocytopenia; difficult to correct with tranfusion
3. collateral venous flow - varices
4. AV shunting - increased CO and intrapulmonary shunting
What can a large increase in the number of heart transplants be directly traced to?
Approval of cyclosporin A in 1983
What criteria of brain death must heart donors meet?
1. apnea
2. dilated pupils
3. unresponsiveness
4. electrocerebral silence
5. confirmation of absence of cerebral blood flow