Bb Transplantation

Front 1

What combinations of medications have improved kidney survival?

Back 1

1. cyclosporin A,
2. azathioprine,
3. steroids

Front 2

When should a patient getting a kidney transplant be dialyzed prior to surgery?

Back 2

within 24 hours to correct volume, acid-base, and electrolyte abnormalities

Front 3

What is the mechanism of cyclosporine?

Back 3

it is a metabolite of fungus which inhibits T-lymphocyte mediated immune response without affecting B lymphocytes

Front 4

Besides transplantation cyclosporine is used in what other conditions?

Back 4

1. crohn's,
2. uveitis,
3. psoriasis,
4. RA

Front 5

What is the most important and frequent side effect of cyclosporine use and what should you do to monitor for it?

Back 5

nephrotoxicity
-renal function testing and cyclosporine blood levels

Front 6

Besides nephrotoxicity what other side effects are caused by cyclosporine?

Back 6

1. htn,
2. paresthesias,
3. seizures,
4. gum hyperplasia,
5. hirsuitism,
6. hyperglycemia

Front 7

What are preop considerations in renal transplant patients?

Back 7

1. volume status,
2. Hgb levels,
3. potassium
4. other electrolytes
5. weights

Front 8

What are functions of the liver?

Back 8

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

Front 9

What are indications for liver transplantation?

Back 9

1. end stage cirrhosis,
2. metabolic diseases (wilson's disease, hemochromatosis),
3. fulminant hepatic failure

Front 10

should you use an esophageal stethoscope or NG tube in a patient with esophageal varices?

Back 10

they are relatively safe

Front 11

What lines should likely be present during liver transplantation?

Back 11

1. two 14g IVs
2. 8.5F antecubital catheter attached to a rapid transfuser

Front 12

How should you induce a patient undergoing liver transplantation?

Back 12

RSI because of ascites and elevated intraperitoneal pressure

Front 13

If you use N2O during a liver transplantation when should you consider discontinuing it?

Back 13

at the time of reperfusion when the risk of venous air embolism is heightened

Front 14

What are the 4 stages of liver transplantation?

Back 14

1. mobilization of the recipeint's liver/hepatectomy
2. anhepatic phase,
3. post-revascularization
4. biliary reconstruction

Front 15

what are anesthetic concerns during the hepatectomy(mobilization of recipient liver) phase of liver transplantation?

Back 15

1. bleeding,
2. compression of IVC and pericardium
3. porto-femoral-axillary bypass

Front 16

How often should you check coagulation, acid-base, and electrolyte levels during the hepatectomy phase and why?

Back 16

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

Front 17

When does porto-femoral-axillary bypass begin during liver transplantation and what does this cause pertaining to CVP and PAP?

Back 17

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)

Front 18

What monitoring should you pay special attention to during the hepatectomy phase?

Back 18

1. check and correct coagulation, acid-base, and electrolyte abnormalities,
2. monitor and maintain fluid balance,
3. initiate diuresis

Front 19

What events mark the beginning and the end of the anhepatic phase?

Back 19

removal of the liver to hepatic arterial anastomosis

Front 20

What vessels are clamped during the anhepatic phase?

Back 20

1. portal vein,
2. hepatic artery
3. inferior vena cava above and below the liver

Front 21

What are the benefits of using veno-venous bypass during the anhepatic phase?

Back 21

1. decrease blood loss from the surgical field,
2. lessen hemodynamic instability
-outcome is not better with this technique - not universally used

Front 22

What are complications of veno-venous bypass?

Back 22

increased risk of air embolism and vascular injury

Front 23

Why would you consider giving dopamine during the anhepatic phase?

Back 23

induce diuresis during this period of decreased renal perfusion

Front 24

What metabolic abnormalities are frequently present during the anhepatic phase? How do you tx it?

Back 24

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

Front 25

What events constitute the post-revascularization phase of liver transplantation?

Back 25

unclamping of the liver to biliary reconstruction

Front 26

What are major problems during the post-revascularization phase of liver transplantation?

Back 26

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

Front 27

What age is optimal for donor hearts?

Back 27

from 35-40 yo

Front 28

What are problems that relate to the donor during heart transplantation?

Back 28

1. temperature control,
2. fluid and electrolyte balance, with frequent diabetes insipidus,
3. cardiovascular stability,
4. pulmonary function (frequent development of pulmonary edema)

Front 29

What monitors should you use for heart transplantation?

Back 29

1. foley
2. arterial line,
3. L sided IJ (R IJ is commonly utilized for subsequent punture and transvenous endomyocardial biopsy)

Front 30

What about pulmonary status in a patient getting a heart transplant is of important consideration?

Back 30

pulmonary htn
-nitric oxide can be beneficial

Front 31

What is the eventual baseline heart rate following cardiac transplantation?

Back 31

90-110 bpm

Front 32

What cardiac rhythm is frequently encountered in the first few days after cardiac transplant?

Back 32

bradycardia (secondary to sinus node dysfunction)

Front 33

What medication are patients on for 2-3 days after heart transplantation?

Back 33

isoproterenol - more selective beta agonist than epi
-alpha effects of epi are often considered undesirable(transplanted heart is denervated)

Front 34

How does the transplanted heart respond to laryngoscopy?

Back 34

sympathetic responses are usually absent

Front 35

How are baroreceptor reflexes and responses to valsalva affected after heart transplantation?

Back 35

absent

Front 36

How are changes in CO made after heart transplantation?

Back 36

changes in stroke volume because heart rate is relatively constant

Front 37

How does the transplanted heart react to sympathomimetics such as isoproteronol, epinephrine, dopamine, and dobutamine?

Back 37

receptors function normally so they have their normal effect

Front 38

What is the preservation time now of cadaver kidneys in pts receiving renal transpants?

Back 38

36-48 hrs

Front 39

What problems can be seen in pts with chronic renal failure?

Back 39

1. Anemia
2. Acidosis
3. Coagulopathies
4. CHF
5. Electrolyte problems
6. Infection
7. Htn

Front 40

What is a common co-existing problem in pts with severe liver failure? How is it manifested?

Back 40

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

Front 41

What can a large increase in the number of heart transplants be directly traced to?

Back 41

Approval of cyclosporin A in 1983

Front 42

What criteria of brain death must heart donors meet?

Back 42

1. apnea
2. dilated pupils
3. unresponsiveness
4. electrocerebral silence
5. confirmation of absence of cerebral blood flow