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