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165 Cards in this Set
- Front
- Back
How many medical centers perform transplant procedures in the US?
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241
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What is the United Network of Organ Sharing (UNOS)?
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They organize regional organ procurement organizations(OPS’s)
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What are the average preservation times for:
Heart Liver Pancreas Kidneys |
Heart and lung: 5 hours
Liver: 12-18 hours Pancreas: 20-28 hours Kidneys: 48-72 hours |
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What two criteria are used to declare death?
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Cardiopulmonary death & brain death
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What is Cardiopulmonary death?
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Irreversible cessation of circulatory and respiratory function
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What is brain death?
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Irreversible cessation of all brain functions
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What clinical parameters must be met to declare brain death?
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Coma and unresponsiveness;
Absence of motor responses to pain (spinal reflexes may cause reflex movement); Absence of brainstem reflexes; Total apnea. |
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What other confirmatory tests are used to declare brain death (besides the clinical parameters)?
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EEG;
Cerebral angiography; Pupillary signs; Ocular movements; Facial sensory and motor responses; Pharyngeal and tracheal reflexes; Apnea test. |
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What is done in the apnea test to declare brain death?
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To do test - preox pt & disconnected from ventilator for approx. 10-15 minutes to confirm the absence of all respiratory efforts.
The test determines if there are any respirations above paCO2 50-60 mmHg. |
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Who is the non-heart beating donor?
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A patient who suffered cardiac arrest just before hospital arrival or who suffered an unresuscitated cardiac arrest in hospital or who is brain dead & then suffered a cardiac arrest.
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Why is Diabetes insipidus seen in the brain dead pt?
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Due to loss of ADH production and secretion from posterior pituitary.
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When is Diabetes insipidus seen in the brain dead pt?
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Seen shortly before or directly after brain death
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Diabetes insipidus in the brain dead pt results in?
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Hypotonic diuresis that results in hypovolemia, hypokalemia, hypophosphatemia & hypocalcemia
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What are the values for serum & urine osmo, serum Na and amt of the polyuria seen in diabetes insipidus in the brain dead pt?
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Serum osmolality >295 mOsm/kg
Urine osmolality <300mOsm/kg Serum sodium > 150 mEq/L Polyuria > 4-7 ml/kg/hr |
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How is DI tx'd in the brain dead pt?
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Sodium-free fluids @ 200-1000 ml/hr;
IV vasopressin starting at 0.5-15 U/hr. (DDAVP - arginine desmopressin is longer-acting than vasopressin). |
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What are the S/Es of both vasopressin & DDVAP?
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Splanchnic vasoconstriction;
Increased smooth muscle contractility (decreases blood flow to organs to be transplanted) |
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One of the physiological alteration seen in the brain dead is arrhythmias. What are they caused from?
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Electrolyte disturbances (hypocalcemia, hypomagnesemia, hypokalemia, hypophosphatemia)
hypovolemia hypotension metabolic acidosis hypoxia hypothermia inotrope use myocardial contusions increased ICP |
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One of the physiological alteration seen in the brain dead is tachycardia. What is it caused from?
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Sudden release of catecholamines secondary to cellular anoxia
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One of the physiological alteration seen in the brain dead is bradycardia. What is the pathophys behind this?
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Loss of central regulatory mechanisms; resistant to atropine because pt is unable to exert vagal response
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How does hypothermia affect the brain dead pt?
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Brain death causes the hypothalamus to become nonfunctioning, leading to hypothermia as the patient becomes poikilothermic (body temperature trends to environmental level).
Attempt to maintain donor’s temperature > 34°C. |
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What are relative contraindications to transplantation?
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Complex medical conditions not associated with the organ to be transplanted like the elderly with complex medical histories;
Cancer - hepatocellular carcinoma with underlying cirrhosis is an indication for transplantation but only if tumor is under a certain size. |
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What are absolute contraindication to transplantation?
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Irreversible Pulmonary HTN,
unless it is a heart/lung transplant; Active infection (but once treated, the pt can be cleared for transplantation). |
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Why is having an active infection an absolute contraindication to transplantation?
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Active infections can lead to death post-operatively due to immunosuppressive drugs
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What is the immunosuppressant therapy?
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Usually combination of Cytotoxic agents, corticosteroids, and antibody reagents
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What are the complications with immunosuppressants?
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Increased risk of infection;
Increased incidence of malignancy or neoplasms. |
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Describe patterns of donated organ/tissue rejection?
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Hyper acute rejection which is the result of antibody binding to allograft at time of revascularization in OR;
Acute rejection which occurs days to weeks after transplant; T-cell-dependent immunity chronic rejection which occurs months to years after transplant due to loss of normal histologic fibrosis and atherosclerosis |
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What is Cyclosporine?
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It is produced as metabolite of fungal species Beauvaria nivea Gams & used as part of immunosuppressant therapy.
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What is the MOA of Cyclosporine?
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It causes preferential inhibition of T lymphocytes (especially interleukin 2)
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What is the therapeutic range of Cyclosporine?
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100-200 ng/ml
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What drugs does Cycosporine interact with?
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Drug interactions that affect P-450 system.
Meds that inhibit this enzyme will decrease metabolism thus increasing serum levels of cyclosporine while meds that induce this enzyme will increase metabolism thus decreasing serum levels |
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What % of pts on Cycosporine develop nephrotoxicity and how soon after the start of therapy does it occur?
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Nephrotoxicity develops in 75% of patients within 6-12 months
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What % of pts on Cycosporine develop HTN and how soon after the start of therapy does it occur?
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Hypertension develops in 50-75% of patients within 1-3 years
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What are the some s/s of nephrotoxicity r/t Cycosporine therapy?
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Headache, tremor & insomnia
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What are systemic complications r/t Cyclosporine therapy?
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Hepatoxicity;
Neurotoxicity (headache, tremor, insomnia); Gingival hyperplasia; GI dysfunction (N/V, diarrhea, anorexia, pain); Infection; Malignancy. |
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What is Tacrolimus?
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It is a macrolide antibiotic.
It has similar properties as cyclosporine but it is 100 x more potent. |
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What is the MOA of Tacrolimus?
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It binds to T-cell binding protein FK506 and prevents synthesis of IL-2 and other lymphocytes
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What is the therapeutic serum range of tacrolimus?
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9.8-19.4 ng/ml
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How does Tacrolimus compare to Cyclosporine in terms of causing HTN & DM?
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It is associated with less HTN than Cyclosporine but has an increased incidence of diabetes mellitus
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How do steroids work?
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By prevention and treatment of rejection, attenuation of allergic reactions that may occur with antilymphocyte globulin or monoclonal antibodies, and treatment of autoimmune diseases.
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True/false?
If pt is on steroids, it may be necessary to continue therapy intraoperatively |
True
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What is Azathioprine?
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It is a purine analog metabolite and derivative of 6-mercaptopurine
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What is the MOA of Azathioprine?
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It is a phosphodiestarase inhibitor and an antagonist of NMDA.
It interferes with DNA and RNA synthesis --> inhibition of differentiation and proliferation of T and B lymphocytes |
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What are complications of Azathioprine?
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Leukopenia, anemia, thrombocytopenia, and GI toxicity
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What is the MOA of steroids in immunotherapy?
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They inhibit T-cell lymphocytes needed for macrophage and lymphocyte responses and movement of circulating T-cells from intravascular tissue compartment to lymphoid tissue
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What is Mycophenolate mofetil?
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It is a cytotoxic drug used as immunosuppressant therapy.
Its active metabolite mycophenolic acid,inhibits lymphocyte proliferation and antibody formation by B-cells |
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What is Cyclophosphamide?
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It is a cytotoxic drugs used in immunosuppressant therapy.
Specifically an antimetabolite drug from the nitrogen mustard subclass of alkylating agents |
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What is the MOA of Cyclophosphamide?
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Interferes with growth of cells, possibly by cross- linking of cellular DNA
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When is Cyclophosphamide used?
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It can be give to patients are unable to take azathioprine
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What adverse reactions are associated with Cycophosphamide therapy?
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The risk of malignancy, hemorrhagic cystitis & cardiotoxicity
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What is Antithymocyte globulin?
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It is an antibody reagents used as immunosuppressant therapy. Specifically an immunosuppressant gamma globulin obtained from animal serum after immunization with human thymic lymphocytes.
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What is Muromanab-CD3?
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It is an antibody reagent used in immunosuppressant therapy.
Specifically, a monoclonal antibody that binds specifically to CD-3 antigen on T-cells. |
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Muromanab-CD3 is related to Cytokine release syndrome. What is this?
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A range of symptoms from flu-like to severe life-threatening shock.
(Pretreat with Solumedrol 4 hours before administration of drug). |
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What is OKT3
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It is an antibody reagent used in immunosuppressant therapy.
Specifically a monoclonal antibody used for treating acute rejection in liver transplants. |
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What side effects are associated with OKT3?
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Bronchospasm, fever, GI upset, pulmonary edema, cardiac arrest.
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What is FK506?
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It is an antibody reagent used in immunosuppressant therapy. It is used in the treatment of acute and chronic liver rejection.
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How does FK506 compare to cysclosporin?
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It is more potent and less nephrotoxic than cyclosporine
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In what order are organs and tissue harvested?
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Kidneys and pancreas first, then liver, heart and lungs; skin, corneas, and bone at the end.
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The organ donation surgery, if pressors are needed what are the considerations?
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Use inotrope like Dopamine before vasoconstrictors (like phenylephrine or levophed) to maintain perfusion of organs to be harvested.
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When harvesting major organs, where is the incision made?
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Midsternal incision
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How much blood will the anesthesia provider be asked to withdraw for the transplant coordinator?
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60-120 cc
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What cardiac parameters should be maintained during the harvesting of organs?
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Keep SBP > 90 mmHg
Keep CVP 5-15 mmHg |
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What UO should be maintained during harvesting?
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U/O > 100 ml/hr
Give crystalloids and colloids, lasix & mannitol |
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What temp should be maintained during harvesting?
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Temperature > 35° C
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What SpO2 should be maintained during harvesting?
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O2 sat > 90%
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During harvesting, what medications are given to adults at the start of the case?
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Ancef 1 gm
Solumedrol 1 gm 500 mg thyroxine (T4) in 500 cc D5W at 20 cc/hr - it increases metabolism & indirectly increases BP; it has no vasoconstriction properties |
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During harvesting, what medications are given to adults 15mins before cross clamping?
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Mannitol 25 gm
Lasix 40 mg |
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During harvesting, what medication is given to adults 5mins before cross clamping?
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Heparin 30000 units
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During harvesting, what should be done before the heart is removed?
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D/c the pulmonary artery catheter
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During harvesting and before the sterum is sawed open, what should you do?
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Turn off vent for short time then later turn it back on
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What does cross clamping of the aorta signals?
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Cardiopulmonary death.
When aorta is cross-clamped, turn off vent/ monitors/gtts. Anesthesia provider's role is complete. |
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What kind of anesthesia is used in the harvesting of the living related kidney donation
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General anesthesia with epidural (this is a very painful procedure)
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What is the pt position in the harvesting of the living related kidney donation
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Lateral decubitus with kidney rest flexed
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How long does the living related kidney donation surgery takes?
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Approx 3 hours
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What perfusion management considerations should be made in the harvesting of the living related kidney donation?
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Hydrate patient well perioperatively and keep perfusion pressure up; avoid vasoconstrictors
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What is the approx. EBL in the harvesting of the living related kidney donation?
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500 ml; T&C 2 units (autologous)
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During the living kidney donation harvesting surgery, how is the kidney acessed?
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Through lateral incision; ureter, vein, and artery are ligated and kidney removed and taken into next OR to the recipient.
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What is the treatment of choice for patients with ESRD who are on chronic HD?
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Organ transplantation
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True/false
Your pt will is scheduled to receive an kidney in 48hrs, it is not necessary proceed with HD to correct any electrolyte and volume derangement. |
False.
Since donor kidney can be preserved for up to 72 hours, HD should be used to correct electrolyte and volume derangements prior to transplantation |
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Considerations for the kidney transplant surgery include?
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Check labs carefully prior to surgery;
Hydrate patient and promote diuresis with lasix or mannitol. |
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What is the position of the pt receiving a kidney?
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Supine with bump under hip
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How long does a kidney transplant surgey takes?
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Approx 5 hours
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What is the EBL in a kidney transplant surgery?
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1000 ml; T&C 4 units
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What monitors are used in the kidney transplant surgery?
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Standard monitors, A-line, consider CVP
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What type of anesthesia is used in kidney transplant surgery?
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General Anesthesia with epidural (if coagulation normal)
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How does a donor kidney arrives in the OR?
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Donor kidney arrived packed in ice
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Where is the kidney placed on the body cavity?
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It is placed retroperitoneally in the upper pelvis, via lower abdominal approach
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How is Revascularization achieved in kidney transplantation?
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Revascularization involves anastomoses of renal vessels to iliac artery and vein
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How is ther ureter reconnected in kidney transplantation?
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The ureter is anastomosed directly to bladder
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What is done with the defective native kidney?
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It can be left insitu or removed
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To maintain high perfusion pressure after kidney transplant, we need to hydrate well. Some providers prefer to use colloids vs cryst. Why?
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So that kidney does not have large volume load to cope with.
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In a heart transplant surgery, how does the ananstomosis of the artery and vein affect the circulation immediately after it is done?
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There will be a “shock load” to the heart as the cold, ischemic factor-filled perfusate washes into the circulation
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How does the “shock load” to the heart that follows anastomosis of the vein & the artery affects the BP and what should the anesthesia provider do?
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BP will suddenly drop with a drop in pulmonary compliance
this should be short-lived so DO NOT overreact |
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What is the circulation goal after anastomosis of the vessels following kidney transplant?
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Maintenance of high perfusion pressure.
Use inotropes rather than vasoconstrictors to support pressure |
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Post kidney transplant, how does UO compare in the living related donor vs the cadaveric kidney?
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Urine output is usually better with living-related donor kidney than cadaveric kidney
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Which pts are usually candidates for liver transplant?
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Hepatic failure;
Treatment of hepatic cancer; Biliary tract tumor; Genetic metabolic conditions |
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What physiologic derangements are often often present before liver transplant?
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Encephalopathy (confusion to coma)
CHF Hypoxemia Anemia Thrombocytopenia DIC Hypokalemia, hypocalcemia Glucose intolerance Oliguria Ascites |
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What is often the coagulation status of pts to receive liver transplant?
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Poor.
Patients have many comorbidities especially with coagulopathies and portal hypertension. |
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What is a possible cardiac complication of of the newly transplanted liver r/t to reperfusion?
How is this tx'd? |
Reperfusion of the new liver will release a large load of toxins directly into the heart, which can cause complete arrest if potassium load is high.
Treatment: push pressure way up from the start have inotropic support ready |
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Type of anesthesia used in liver transplant?
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General Anesthesia with or without epidural (Check coagulation status)
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What is pt positioning in liver transplant?
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Supine
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What type of incision is made for the liver transplant surgery?
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The surgeon makes large chevron or mercedes incision in upper abdomen
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What vessels are clamped during the liver transplant surgery?
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The hepatic artery, portal vein, proximal and distal IVC (and bile duct) are clamped
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What happens to the native liver during the liver transplant surgery?
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The old liver is removed
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How is the biliary anastomosis done?
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Either as an end-to-end anastomosis with the old bile duct or into a Roux-en-Y segment of jejunum
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How long does a liver transplant takes
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Takes approx 6-8 hours
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What is the approx EBL in liver transplants
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EBL: up to 5000 ml; T&C for 10 units of PRBC’s, FFP, and platelets
(utilize RIS and cell saver for fluids) |
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What monitors are used in liver transplant?
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Standard plus A-line, CVP, PAC
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Why is a radial aline preferred in liver transplant surgery?
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Radial artery is preferred since abdominal aorta may be cross-clamped during hepatic artery anastomosis.
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What types of bypasses does the the surgeon use during liver transplant?
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Surgeons may use left arm for venovenous bypass procedures; femoral or portal vein to left axillary bypass is used to decompress the liver and lower extremities during clamping of the IVC
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What kinds of intavenous access does the anesthesia provider places during liver transplant surgery?
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Three introducers are commonly placed - one in each IJ and one in antecubital vein
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Liver transplants are characterized by three phases. What are they?
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Preanhepatic, Anhepatic & Neohepatic phases
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What is the anhepatic phase of liver transplant?
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It begins when the native liver is removed after transection of blood supply and occlusion of suprahepatic and infrahepatic portions of the IVC
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Why is venovenous bypass utilized preanhepatic phase of liver transplant?
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To avoid drastic decreases in venous return and cardiac output as well as to decrease venous congestion (GI tract, kidneys).
(Can also utilize IVC clamping). |
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Why is calcium administerd during the preanhepatic phase of liver transplant?
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Calcium is administered to prevent hypocalcemia and citrate intoxication
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Placement of donor liver may require extensive retraction near the diaphragm,what complication may this cause?
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Impairment of ventilation and oxygenation
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What is the neohepatic phase of liver transplant?
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It begins with reanastomoses of major vascular structures
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After reanastomoses of major vascular structures and before removal of vascular clamps,what should be done?
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Donor liver should be flushed of air, debris, and preservative solution.
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Despite flushing of the donor liver after reanastomosis what may still happen?
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Unclamping can still cause large release of potassium and metabolic acids
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Administration of clotting factors may be given during what phase of liver transplantation?
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During the neohepatic phase (after clamping).
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What is the preanhepatic phase of liver transplant?
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It involves mobilization and removal of native liver
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How does the mobilization and removal of native liver affect CV status?
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It can cause cardiovascular instability d/t hemorrhage, venous pooling d/t sudden decreases in intra-abdominal pressure, and impaired venous return d/t surgical retraction
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How are electrolytes affected & what is usually the UO status during the preanhepatic phase of liver transplantation?
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Hypocalcemia, hyperkalemia, and metabolic acidosis can occur. Oliguria is common
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When can liver lobe segments can be utilized for partial transplant?
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When pts are pediatric or smaller adults (< 100 lbs.)
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What are transjuglar intrahepatic portosystemic shunt procedures used to treat?
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Esophageal varices.
The shunt is placed radiographically and does not involve hepatic vascular anatomy. |
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When are panreatic transplants done?
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They are usually done for end-stage diabetics who are very sick preoperatively
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What other organ transplants commonly accompany pancreas transplants?
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Kidney transplants.
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What is the approximate length of a pancreas/kidney transplant?
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Approx 7 hours or 5 hours for a pancreas transplant alone
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What is the approx EBL?
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500 ml; T&C 2 units
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What is done with the native pancreas during transplant?
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It is left alone
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What is the perfusion goal in pancreas transplant?
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As with all transplants, keep perfusion pressure adequate, hydrate and transfuse early
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What monitors are needed for pancreas surgery?
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Standard monitors, A-line
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What kind of anesthesia is used during pancreas transplant?
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General anesthesia +/- epidural
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Who are heart transplants indicated for?
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They are the only effective treatment for patients with end-stage heart disease due to CAD or Cardiomyopathy
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Why is severe and irreversible pul HTN an absolute contraindication for heart transplant?
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Because the normal right ventricle of donor heart is unable to abruptly compensate to a fixed an elevated PVR.
Heart & lung transplants are the only option in these patients. |
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In what position is the pt placed in heart surgery?
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Supine
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What is the approximate length of time of a heart transplant surgery
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Approx 6 hours
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What is the EBL in a heart transplant surgery
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EBL: 2000 ml;
T&C 10 units PRBC’s, FFP, platelets, cryoprecipitate; There is increased bleeding when compared to other open heart surgeries due to the extent of exposed suture lines & length of bypass. |
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How long is the pt intubated for?
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The pt remain intubated usually for 24 hours postoperatively
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Monitors used in heart transplant surgery?
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Standard, A-line, CVP or PAC, TEE.
It will be necessary to pull back CVP or PAC into the internal jugular when heart removed; the catheter is then repositioned into donor heart. |
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Intravenous access in heart transplant surgery?
|
Place central lines in LIJ to save the RIJ for multiple endocardial biopsies post-transplant
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Explain where the native heart is excised for removal and how donor heart is connected.
|
Midsternal incisionis made; bypass initiated and native heart removed at a line halfway across the atria; remaining atrial flaps sewn to transplanted atria, great vessels connected. (Patient rewarmed, and separation from bypass attempted).
|
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After donor heart is transplanted, what are some of the potential complications?
|
Right heart failure - treat with hyperventilation and pulmonary vasodilators (Isuprel or PGE1);
AV node dysfunction - may necessitate AV pacing. |
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The transplanted heart is denervated. What is the intrinsic of rate of the denervated heart & is this rate always enough to support adequate CO?
|
Denervated heart has intrinsic rate of 70.
No. May need drugs/pacing to increase rate to 90 to support cardiac output. |
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In the transplanted heart, HR responses do not occur with administration of anticholinergics or Anticholinesterases. Why?
|
Because vagus nerve is severed.
The transplanted heart responds to direct-acting catecholamines with indirect drugs (Ephedrine) having less effect. |
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In the post heart transplant pt, what is the most common cause of death?
|
Most common cause of death post-transplant is opportunistic infection, possibly due to immunosuppressant therapy.
|
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What adverse effect is often associated with the use of Cyclosporine in the transplant pt?
|
Cyclosporine-induced hypertension is present in majority of transplant patients
|
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What % of post heart transplant pts develop CAD and within what time period post-op?
|
½ of patients develop CAD within 3 years post-transplant
|
|
List the selection criteria for lung transplant candidates
|
End-stage pulmonary disease with life expectancy < 18 months;
No other significant systemic disorder or psychiatric disorder; No contraindication to immunosuppressant therapy; Adequate support system; Age < 60 (not always); Negative HIV; No cigarette smoking, alcohol or drug abuse. |
|
Who is single-lung transplant (SLT) indicated for?
|
Patients with end-stage respiratory failure, especially chronic interstitial pulmonary fibrosis.
|
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Describe the anastomosis involved in single-lung transplant (SLT)
|
Involves anastomosis of mainstem bronchus, left atrial cuff, and pulmonary artery
|
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Who is Double-lung transplant (DLT) indicated for?
|
Patients with COPD, cystic fibrosis, alpha 1-antitrypsin disease, idiopathic pulmonary hypertension
|
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Describe the anastomosis involved in double-lung transplant (DLT)
|
Involves anastomosis of trachea, left atrium, and pulmonary artery
|
|
If the transplant is a heart/lung transplant, describe the anastomosis
|
It involves anastomosis of trachea, aorta, right atrium
|
|
Describe the attaching of the donated lung?
|
Donor lung reanastomosed and lung perfused while bronchial anastomosis completed; flap of omentum brought up from abdomen to secure around bronchial anastomosis
|
|
How long does the lung transplant surgery takes
|
Approx 6 hours
|
|
What is the EBL in a lung transplant?
|
EBL: 500 ml; T&C 4 units PRBC’s, FFP, platelets
|
|
Lung transplant surgery - what type of anesthesia is used?
|
General anesthesia with epidural
|
|
Lung transplant surgery - what monitors are used?
|
Monitors: Standard, A-line, PAC
|
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Lung transplant surgery - what is the expectation for the oxygenation status intraop?
|
May have fair amount of hypoxia and hypercarbia with one lung ventilation; must tolerate it until ischemic shock passes
|
|
What does the denervation involved in lung transplant result in?
|
Denervated donor lung deprives patient of normal cough reflex and predisposes to pneumonia
|
|
Describe the pathophysiology of the transplanted lung
|
Vagal denervation;
Decreased response to hypercapnia; Increased sensitivity to narcotics; Bronchodilation; No change in HPV Occasional RLN damage; Increased aspiration risk; Decreased pulmonary clearance r/t less effective cough; Absence of lymphatics; Risk of O2 toxicity; Release of free radical scavengers. |
|
What is bone marrow transplant (BMT)used to treat?
|
It is a potential cure for fatal leukemia.
It is usually combined with chemotherapy and total body radiation |
|
How is bone marrow harvested?
|
Donor bone marrow (1500 ml) is harvested by multiple aspirations from superior iliac cest and spine.
|
|
What type of anesthesia is used for BMT & which gas is contraindicated?
|
General anesthesia or regional.
Avoid N20 due to potential bone marrow depression. |
|
list complications of BMT r/t
graft-versus-host disease? |
Oral ulcers and mucositis;
Esophageal ulcers; Fluid and electrolyte loss due to diarrhea; Hepatic failure; Coagulopathy; Pancytopenia; Acute respiratory failure; Renal failure. |