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165 Cards in this Set

  • Front
  • Back
How many medical centers perform transplant procedures in the US?
241
What is the United Network of Organ Sharing (UNOS)?
They organize regional organ procurement organizations(OPS’s)
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
What two criteria are used to declare death?
Cardiopulmonary death & brain death
What is Cardiopulmonary death?
Irreversible cessation of circulatory and respiratory function
What is brain death?
Irreversible cessation of all brain functions
What clinical parameters must be met to declare brain death?
Coma and unresponsiveness;
Absence of motor responses to pain (spinal reflexes may cause reflex movement);
Absence of brainstem reflexes;
Total apnea.
What other confirmatory tests are used to declare brain death (besides the clinical parameters)?
EEG;
Cerebral angiography;
Pupillary signs;
Ocular movements;
Facial sensory and motor responses;
Pharyngeal and tracheal reflexes;
Apnea test.
What is done in the apnea test to declare brain death?
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.
Who is the non-heart beating donor?
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.
Why is Diabetes insipidus seen in the brain dead pt?
Due to loss of ADH production and secretion from posterior pituitary.
When is Diabetes insipidus seen in the brain dead pt?
Seen shortly before or directly after brain death
Diabetes insipidus in the brain dead pt results in?
Hypotonic diuresis that results in hypovolemia, hypokalemia, hypophosphatemia & hypocalcemia
What are the values for serum & urine osmo, serum Na and amt of the polyuria seen in diabetes insipidus in the brain dead pt?
Serum osmolality >295 mOsm/kg
Urine osmolality <300mOsm/kg
Serum sodium > 150 mEq/L
Polyuria > 4-7 ml/kg/hr
How is DI tx'd in the brain dead pt?
Sodium-free fluids @ 200-1000 ml/hr;
IV vasopressin starting at 0.5-15 U/hr.
(DDAVP - arginine desmopressin is longer-acting than vasopressin).
What are the S/Es of both vasopressin & DDVAP?
Splanchnic vasoconstriction;
Increased smooth muscle contractility (decreases blood flow to organs to be transplanted)
One of the physiological alteration seen in the brain dead is arrhythmias. What are they caused from?
Electrolyte disturbances (hypocalcemia, hypomagnesemia, hypokalemia, hypophosphatemia)
hypovolemia
hypotension
metabolic acidosis
hypoxia
hypothermia
inotrope use
myocardial contusions
increased ICP
One of the physiological alteration seen in the brain dead is tachycardia. What is it caused from?
Sudden release of catecholamines secondary to cellular anoxia
One of the physiological alteration seen in the brain dead is bradycardia. What is the pathophys behind this?
Loss of central regulatory mechanisms; resistant to atropine because pt is unable to exert vagal response
How does hypothermia affect the brain dead pt?
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.
What are relative contraindications to transplantation?
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.
What are absolute contraindication to transplantation?
Irreversible Pulmonary HTN,
unless it is a heart/lung transplant;
Active infection
(but once treated, the pt can be cleared for transplantation).
Why is having an active infection an absolute contraindication to transplantation?
Active infections can lead to death post-operatively due to immunosuppressive drugs
What is the immunosuppressant therapy?
Usually combination of Cytotoxic agents, corticosteroids, and antibody reagents
What are the complications with immunosuppressants?
Increased risk of infection;
Increased incidence of malignancy or neoplasms.
Describe patterns of donated organ/tissue rejection?
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
What is Cyclosporine?
It is produced as metabolite of fungal species Beauvaria nivea Gams & used as part of immunosuppressant therapy.
What is the MOA of Cyclosporine?
It causes preferential inhibition of T lymphocytes (especially interleukin 2)
What is the therapeutic range of Cyclosporine?
100-200 ng/ml
What drugs does Cycosporine interact with?
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
What % of pts on Cycosporine develop nephrotoxicity and how soon after the start of therapy does it occur?
Nephrotoxicity develops in 75% of patients within 6-12 months
What % of pts on Cycosporine develop HTN and how soon after the start of therapy does it occur?
Hypertension develops in 50-75% of patients within 1-3 years
What are the some s/s of nephrotoxicity r/t Cycosporine therapy?
Headache, tremor & insomnia
What are systemic complications r/t Cyclosporine therapy?
Hepatoxicity;
Neurotoxicity (headache, tremor, insomnia);
Gingival hyperplasia;
GI dysfunction (N/V, diarrhea, anorexia, pain);
Infection;
Malignancy.
What is Tacrolimus?
It is a macrolide antibiotic.
It has similar properties as cyclosporine but it is 100 x more potent.
What is the MOA of Tacrolimus?
It binds to T-cell binding protein FK506 and prevents synthesis of IL-2 and other lymphocytes
What is the therapeutic serum range of tacrolimus?
9.8-19.4 ng/ml
How does Tacrolimus compare to Cyclosporine in terms of causing HTN & DM?
It is associated with less HTN than Cyclosporine but has an increased incidence of diabetes mellitus
How do steroids work?
By prevention and treatment of rejection, attenuation of allergic reactions that may occur with antilymphocyte globulin or monoclonal antibodies, and treatment of autoimmune diseases.
True/false?
If pt is on steroids, it may be necessary to continue therapy intraoperatively
True
What is Azathioprine?
It is a purine analog metabolite and derivative of 6-mercaptopurine
What is the MOA of Azathioprine?
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
What are complications of Azathioprine?
Leukopenia, anemia, thrombocytopenia, and GI toxicity
What is the MOA of steroids in immunotherapy?
They inhibit T-cell lymphocytes needed for macrophage and lymphocyte responses and movement of circulating T-cells from intravascular tissue compartment to lymphoid tissue
What is Mycophenolate mofetil?
It is a cytotoxic drug used as immunosuppressant therapy.
Its active metabolite mycophenolic acid,inhibits lymphocyte proliferation and antibody formation by B-cells
What is Cyclophosphamide?
It is a cytotoxic drugs used in immunosuppressant therapy.
Specifically an antimetabolite drug from the nitrogen mustard subclass of alkylating agents
What is the MOA of Cyclophosphamide?
Interferes with growth of cells, possibly by cross- linking of cellular DNA
When is Cyclophosphamide used?
It can be give to patients are unable to take azathioprine
What adverse reactions are associated with Cycophosphamide therapy?
The risk of malignancy, hemorrhagic cystitis & cardiotoxicity
What is Antithymocyte globulin?
It is an antibody reagents used as immunosuppressant therapy. Specifically an immunosuppressant gamma globulin obtained from animal serum after immunization with human thymic lymphocytes.
What is Muromanab-CD3?
It is an antibody reagent used in immunosuppressant therapy.
Specifically, a monoclonal antibody that binds specifically to CD-3 antigen on T-cells.
Muromanab-CD3 is related to Cytokine release syndrome. What is this?
A range of symptoms from flu-like to severe life-threatening shock.
(Pretreat with Solumedrol 4 hours before administration of drug).
What is OKT3
It is an antibody reagent used in immunosuppressant therapy.
Specifically a monoclonal antibody used for treating acute rejection in liver transplants.
What side effects are associated with OKT3?
Bronchospasm, fever, GI upset, pulmonary edema, cardiac arrest.
What is FK506?
It is an antibody reagent used in immunosuppressant therapy. It is used in the treatment of acute and chronic liver rejection.
How does FK506 compare to cysclosporin?
It is more potent and less nephrotoxic than cyclosporine
In what order are organs and tissue harvested?
Kidneys and pancreas first, then liver, heart and lungs; skin, corneas, and bone at the end.
The organ donation surgery, if pressors are needed what are the considerations?
Use inotrope like Dopamine before vasoconstrictors (like phenylephrine or levophed) to maintain perfusion of organs to be harvested.
When harvesting major organs, where is the incision made?
Midsternal incision
How much blood will the anesthesia provider be asked to withdraw for the transplant coordinator?
60-120 cc
What cardiac parameters should be maintained during the harvesting of organs?
Keep SBP > 90 mmHg
Keep CVP 5-15 mmHg
What UO should be maintained during harvesting?
U/O > 100 ml/hr
Give crystalloids and colloids,
lasix & mannitol
What temp should be maintained during harvesting?
Temperature > 35° C
What SpO2 should be maintained during harvesting?
O2 sat > 90%
During harvesting, what medications are given to adults at the start of the case?
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
During harvesting, what medications are given to adults 15mins before cross clamping?
Mannitol 25 gm
Lasix 40 mg
During harvesting, what medication is given to adults 5mins before cross clamping?
Heparin 30000 units
During harvesting, what should be done before the heart is removed?
D/c the pulmonary artery catheter
During harvesting and before the sterum is sawed open, what should you do?
Turn off vent for short time then later turn it back on
What does cross clamping of the aorta signals?
Cardiopulmonary death.
When aorta is cross-clamped, turn off vent/ monitors/gtts.
Anesthesia provider's role is complete.
What kind of anesthesia is used in the harvesting of the living related kidney donation
General anesthesia with epidural (this is a very painful procedure)
What is the pt position in the harvesting of the living related kidney donation
Lateral decubitus with kidney rest flexed
How long does the living related kidney donation surgery takes?
Approx 3 hours
What perfusion management considerations should be made in the harvesting of the living related kidney donation?
Hydrate patient well perioperatively and keep perfusion pressure up; avoid vasoconstrictors
What is the approx. EBL in the harvesting of the living related kidney donation?
500 ml; T&C 2 units (autologous)
During the living kidney donation harvesting surgery, how is the kidney acessed?
Through lateral incision; ureter, vein, and artery are ligated and kidney removed and taken into next OR to the recipient.
What is the treatment of choice for patients with ESRD who are on chronic HD?
Organ transplantation
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
Considerations for the kidney transplant surgery include?
Check labs carefully prior to surgery;
Hydrate patient and promote diuresis with lasix or mannitol.
What is the position of the pt receiving a kidney?
Supine with bump under hip
How long does a kidney transplant surgey takes?
Approx 5 hours
What is the EBL in a kidney transplant surgery?
1000 ml; T&C 4 units
What monitors are used in the kidney transplant surgery?
Standard monitors, A-line, consider CVP
What type of anesthesia is used in kidney transplant surgery?
General Anesthesia with epidural (if coagulation normal)
How does a donor kidney arrives in the OR?
Donor kidney arrived packed in ice
Where is the kidney placed on the body cavity?
It is placed retroperitoneally in the upper pelvis, via lower abdominal approach
How is Revascularization achieved in kidney transplantation?
Revascularization involves anastomoses of renal vessels to iliac artery and vein
How is ther ureter reconnected in kidney transplantation?
The ureter is anastomosed directly to bladder
What is done with the defective native kidney?
It can be left insitu or removed
To maintain high perfusion pressure after kidney transplant, we need to hydrate well. Some providers prefer to use colloids vs cryst. Why?
So that kidney does not have large volume load to cope with.
In a heart transplant surgery, how does the ananstomosis of the artery and vein affect the circulation immediately after it is done?
There will be a “shock load” to the heart as the cold, ischemic factor-filled perfusate washes into the circulation
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?
BP will suddenly drop with a drop in pulmonary compliance
this should be short-lived so DO NOT overreact
What is the circulation goal after anastomosis of the vessels following kidney transplant?
Maintenance of high perfusion pressure.
Use inotropes rather than vasoconstrictors to support pressure
Post kidney transplant, how does UO compare in the living related donor vs the cadaveric kidney?
Urine output is usually better with living-related donor kidney than cadaveric kidney
Which pts are usually candidates for liver transplant?
Hepatic failure;
Treatment of hepatic cancer;
Biliary tract tumor;
Genetic metabolic conditions
What physiologic derangements are often often present before liver transplant?
Encephalopathy (confusion to coma)
CHF
Hypoxemia
Anemia
Thrombocytopenia
DIC
Hypokalemia, hypocalcemia
Glucose intolerance
Oliguria
Ascites
What is often the coagulation status of pts to receive liver transplant?
Poor.
Patients have many comorbidities
especially with coagulopathies and portal hypertension.
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
Type of anesthesia used in liver transplant?
General Anesthesia with or without epidural (Check coagulation status)
What is pt positioning in liver transplant?
Supine
What type of incision is made for the liver transplant surgery?
The surgeon makes large chevron or mercedes incision in upper abdomen
What vessels are clamped during the liver transplant surgery?
The hepatic artery, portal vein, proximal and distal IVC (and bile duct) are clamped
What happens to the native liver during the liver transplant surgery?
The old liver is removed
How is the biliary anastomosis done?
Either as an end-to-end anastomosis with the old bile duct or into a Roux-en-Y segment of jejunum
How long does a liver transplant takes
Takes approx 6-8 hours
What is the approx EBL in liver transplants
EBL: up to 5000 ml; T&C for 10 units of PRBC’s, FFP, and platelets
(utilize RIS and cell saver for fluids)
What monitors are used in liver transplant?
Standard plus A-line, CVP, PAC
Why is a radial aline preferred in liver transplant surgery?
Radial artery is preferred since abdominal aorta may be cross-clamped during hepatic artery anastomosis.
What types of bypasses does the the surgeon use during liver transplant?
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
What kinds of intavenous access does the anesthesia provider places during liver transplant surgery?
Three introducers are commonly placed - one in each IJ and one in antecubital vein
Liver transplants are characterized by three phases. What are they?
Preanhepatic, Anhepatic & Neohepatic phases
What is the anhepatic phase of liver transplant?
It begins when the native liver is removed after transection of blood supply and occlusion of suprahepatic and infrahepatic portions of the IVC
Why is venovenous bypass utilized preanhepatic phase of liver transplant?
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).
Why is calcium administerd during the preanhepatic phase of liver transplant?
Calcium is administered to prevent hypocalcemia and citrate intoxication
Placement of donor liver may require extensive retraction near the diaphragm,what complication may this cause?
Impairment of ventilation and oxygenation
What is the neohepatic phase of liver transplant?
It begins with reanastomoses of major vascular structures
After reanastomoses of major vascular structures and before removal of vascular clamps,what should be done?
Donor liver should be flushed of air, debris, and preservative solution.
Despite flushing of the donor liver after reanastomosis what may still happen?
Unclamping can still cause large release of potassium and metabolic acids
Administration of clotting factors may be given during what phase of liver transplantation?
During the neohepatic phase (after clamping).
What is the preanhepatic phase of liver transplant?
It involves mobilization and removal of native liver
How does the mobilization and removal of native liver affect CV status?
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
How are electrolytes affected & what is usually the UO status during the preanhepatic phase of liver transplantation?
Hypocalcemia, hyperkalemia, and metabolic acidosis can occur. Oliguria is common
When can liver lobe segments can be utilized for partial transplant?
When pts are pediatric or smaller adults (< 100 lbs.)
What are transjuglar intrahepatic portosystemic shunt procedures used to treat?
Esophageal varices.
The shunt is placed radiographically and does not involve hepatic vascular anatomy.
When are panreatic transplants done?
They are usually done for end-stage diabetics who are very sick preoperatively
What other organ transplants commonly accompany pancreas transplants?
Kidney transplants.
What is the approximate length of a pancreas/kidney transplant?
Approx 7 hours or 5 hours for a pancreas transplant alone
What is the approx EBL?
500 ml; T&C 2 units
What is done with the native pancreas during transplant?
It is left alone
What is the perfusion goal in pancreas transplant?
As with all transplants, keep perfusion pressure adequate, hydrate and transfuse early
What monitors are needed for pancreas surgery?
Standard monitors, A-line
What kind of anesthesia is used during pancreas transplant?
General anesthesia +/- epidural
Who are heart transplants indicated for?
They are the only effective treatment for patients with end-stage heart disease due to CAD or Cardiomyopathy
Why is severe and irreversible pul HTN an absolute contraindication for heart transplant?
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.
In what position is the pt placed in heart surgery?
Supine
What is the approximate length of time of a heart transplant surgery
Approx 6 hours
What is the EBL in a heart transplant surgery
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.
How long is the pt intubated for?
The pt remain intubated usually for 24 hours postoperatively
Monitors used in heart transplant surgery?
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.
Intravenous access in heart transplant surgery?
Place central lines in LIJ to save the RIJ for multiple endocardial biopsies post-transplant
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).
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.
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.
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.
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.
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
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.
Describe the anastomosis involved in single-lung transplant (SLT)
Involves anastomosis of mainstem bronchus, left atrial cuff, and pulmonary artery
Who is Double-lung transplant (DLT) indicated for?
Patients with COPD, cystic fibrosis, alpha 1-antitrypsin disease, idiopathic pulmonary hypertension
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
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.