Exam 1 Flashcards
What did the Uniformed Anatomical Gift Act in 1968 grant individuals the right to do?
To decide before death whether they wished to donate organs
What did the Organ Transplantation Act of 1984 establish?
Organ procurement networks; outlawed buying and selling of organs or compensation to donor families
Omnibus Reconciliation Act of 1986 required hospitals with Medicare/Medicaid patients to do what?
Required them to ask families about organ donation
List the 5 organ transplant criteria
- Organ type, blood type and organ size
- Distance from organ to patient
- Level of medical urgency
- Time on waiting list
- Typically <55 years of age
Where is an organ first offered?
To local OPO
What specific test(s) are required of kidney transplant recipients?
antigen tests
What specific test(s) are required for liver transplant recipients?
MELD scores which include biliruben, INR and creatinine; This tells us the severity of disease
What specific test(s) are required for lung/heart transplant recipients?
Pulmonary artery pressure b/c high pressures can affect the new organ and cause disease to develop in the transplanted organ
Which type of patients provide approximately 80% of donated organs?
Brain dead patients
6 leading causes of brain death
- Trauma
- Cerebral ischemia/infarction
- Hemorrhage
- Meningitis
- Encephalitis
- Cocaine, lead, organophosphates
List 5 criteria for brain death
- Irreversible coma
- No brain stem function
- Absence of respiratory drive
- 1 physician is required; 2 may be requested by the family
- Must be in the absence of hypothermia and CNS depressants
What is considered as no brain stem function when evaluating a patient for brain death?
- No pupillary reflexes
- No corneal reflexes
- Absence of gag and cough reflexes
What does Phase 1 of Cardiac Instability for organ donors involve?
Massive release of catecholamines caused by increased ICP and is transient. Tachycardia, HTN, Incr. SVR and O2 consumption.
What is a common disease process seen in Phase 1 of Cardiac instability for organ donors?
Acute myocardial injury
What does Phase 2 of Cardiac instability for organ donors involve?
Cardiovascular collapse caused by cerebral herniation/spinal cord ischemia that is sustained. Loss of vascular tone, peripheral resistance, and cardiac output.
Why does volume depletion occur during Phase 2 of cardiac instability in organ donors?
Diuretics or diabetes insipidus
In organ donors, pulmonary instability can be related to what 3 things?
- Direct trauma
- Neurogenic pulmonary edema
- V/Q mismatches
What causes neurogenic pulmonary edema in organ donors?
- Catecholamine surge in phase 1 cardiac instability
- Elevated hydrostatic pressure leads to pulmonary capillary leakage
- Systemic inflammatory response due to neutrophil infiltration
What is metabolic instability in organ donors due to?
Dysfunction of hypothalamus and pituitary gland in up to 90% of donors
Loss of thermoregulation in organ donors leads to what?
Hyperpyrexia and then hypothermia
Why does dysfunction of the hypothalamus and pituitary gland in organ donors lead to metabolic instability? (5)
- Loss of thermoregulation
- Decreased ACTH, cortisol, T3, T4, vasopressin
- Decreased insulin concentration and insulin resistance
- Electrolyte abnormalities
- DIC in up to 33% of patients due to release of tissue thromboplastin from the brain
Describe the anesthetic steps for organ retrieval (10)
- Patient is supine
- Incision from sternal notch to pubis
- 100% O2 unless lungs are retrieved
- Ao and IVC dissected 1st, have a large line ready
- Liver, pancreas, and kidneys dissected
- Betadine/Amphotericin B via NGT in divided doses
- 30k units of heparin
- Organs are perfused with cold solution
- Ao x-clamped when everything is ready to remove the heart
- Ventilator d/c along with all of the monitors
Anesthesia for organ retrieval calls for __ and not __ until retrieval
Anesthesia for organ retrieval calls for stabilization and not anesthetic until retrieval.
Why is there significant bradycardia that does not respond to anticholinergics in organ donors and what do we treat it with.
Cardiac instability leads to no response to anticholinergics, so we use isuprel, a pure B1 agonist
What drug that we use daily reduces reperfusion injury in organ donation?
Volatiles
Why do we avoid glucose containing solutions in organ donation surgery?
The glucose is metabolized into a hypotonic solution which will cause cells to swell
What is the best vent setting for organ donation procedures?
PEEP/Lung protective strategies such a low Vt
Why do we use steroids in organ donation procedures?
To reduce the immune response in the recipient
Tell me the normal parameters for: CVP, MAP, PaO2, pH, UO, Na, Glucose, EF, Hgb and Pressors for donor organ management goals
- CVP: 4-10 (6-8 for lungs)
- MAP: 60-120 mmHg
- PaO2: >300 on 5cm PEEP/100% O2
- ABG pH: 7.3-7.45
- UO: >1mL/kg/hr
- Na: 135-160
- Glucose: <150
- EF: >50%
- Hgb: >10
- Pressors: 1 and low dose
What temp do we want to maintain for organ donors?
34-35C
What type of muscle relaxants do we use for organ donation?
Long acting such as pavulon or roc
Which volatile do we use if a patient is hypertensive from surgical stimulation?
Iso
Do we treat cardiac arrest in organ donors?
Yes
What is DCD doantion?
Donation after cardiac death - patient is not brain dead, but no hope of recovery; patient will require ventilator and full support
With DCD patients, what 2 criteria is withdrawal of support based on?
- Clinical decision of futility
2. Wishes of patient/family
Who is not involved in the decision to withdraw support of a DCD patient?
The transplant team
Describe category 1 DCD patients
Patients DOA to hospital
Describe category 2 DCD patients
Unsuccessfully resuscitated patients on admit to the hospital
Describe category 3 DCD patients
Cardiac arrest is imminent - these are the most appropriate patients for donation due to decreased ischemic times
Describe category 4 DCD patients
Cardiac arrest has occurred in a brain dead donor; this leads to poor perfusion of the organs
Describe category 5 DCD patients
Unexpected arrest in the ICU
Which DCD category of patients are considered for donation due to being more controlled?
3 and 4
6 steps of DCD
- Patient moved to OR with 100% O2 and removed from ventilator with an independent physician
- Heparin administered @ 30k units
- When heart stops, independent physician declares death
- At 2-5 minute mark, post declaration of death, the transplant surgeon begins retrieval
- Usually retrieve only the kidney and liver in these patients
- If no cardiac arrest after 1 hour, patient is moved out of the OR and no donation occurs
When using criteria to predict cardiac death of DCD patients, a higher or lower number is indicative of a patient who will most likely arrest faster?
Higher number
What occurs during the ischemic phase of organs after they are harvested and preserved at 4 degrees C
Lack of oxygen leads to depletion of ATP/glycogen, which leads to failure of the Na/K pump, resulting in increased intracellular sodium and edema
What occurs during the reperfusion phase of organs after retrieval?
Autoimmune activation leads to cellular migration and hyperkalemia if Wisconsin solution is used. Injury to the organ is decreased if preconditioned with volatiles.
What are the ischemic times for heart/lung, liver, and kidneys?
- Heart/lung: 4-6 hours
- Liver: 12-24 hours
- Kidneys: 48-72 hours
What time frame does ischemic time include for organ donation?
Ischemic time is the time from organ retrieval from the donor body to reperfusion being reestablished.
What lab is a must have on the day of organ donation for kidneys?
K+
What 2 diseases are most common in kidney donors?
40% have CAD: Most have HTN
What is the emergence plan for kidney transplant recipients?
Extubate on the table, admitted to ICU and then D/C home the next day
Can you use anectin with kidney transplant recipients?
Yes if K+ levels appropriate
What animal are the antibodies used against Human T cells to prevent/treat acute rejection of kidney transplants from?
Rabbit-derived
What are the signs of cytokine release syndrome post kidney transplant and how do we treat it?
High grade fevers (over 39C), chills and possibly rigors.
Treated with steroids (methylprednisolone), benadryl 25-50mg, and acetaminophen 650 mg
Pre-op eval considerations for pancreas transplant recipients
- Most have Type 1 diabetes and ESRD (80% are transplanted with a kidney)
- Consider gastroparesis (RSI)
- Antithymocytes commonly used (rabbit-derived antigen)
Which paralytic should we consider using for induction and then maintenance for pancreas transplant recipients?
Anectine for induction and Cisatracurium for maint. d/t hoffman elimination
How should the A-line be placed for organ transplant recipients?
Sterile!!!
Why do we not treat the blood sugar in pancreas transplant recipients?
As soon as the organ has reperfusion, it should start working properly and secrete insulin
What is the emergence plan for pancreas transplant recipients?
Extubation on the table
Advantages of living organ donors (4)
- Eliminates cultural challenges
- Organizes time to decrease cold ischemic time
- No physiologic alterations from DBD or DCD
- Waiting times are avoided
Requirements of living organ donors (3)
- Healthy
- 2 kidneys
- No DM, HIV, liver disease or cancer
Which kidney is preferred from living organ donors?
Left kidney d/t longer vascular supply
What is the crystalloid hydration goal for living organ donors? Urine output?
Crystalloid - 10-20mL/kg/hr
UO - 2mL/kg/hr (considers lasix or mannitol)
When do we heparinize living organ donors during surgery?
Prior to ligation
What does lower insufflation pressure during nephrectomy for kidney transplant help with?
Helps minimize blunt trauma to the kidneys
What two disease processes do transplant patients having non transplant surgeries usually have?
Diabetes and CAD
List 4 big side effects of immunosuppressants in transplant patients having non-transplant surgeries?
- Lowered seizure threshold
- Systemic HTN
- Anemia
- Thrombocytopenia
What do we expect in regards to bleeding with transplant patients having non-transplant surgeries?
Higher blood loss due to adhesions, especially belly cases
What do we have to remember for heart transplant patients having non-transplant surgeries?
There is no PNS control, so they will not respond to anticholinergics and will be tachycardic at baseline
What can we expect of kidney function in transplant patients having non-transplant surgeries?
Lower GFR/renal blood flow = drug excretion times prolonged
3 common causes of kidney transplant failure
- Primary non-function
- Acute thrombosis
- Acute/chronic rejection with pain
A patient presents with a non-functioning kidney post transplant, but does not report pain, what do you expect for surgical intervention?
Patient will most likely not have the kidney removed and will not need surgical intervention
Risk factors for head and neck cancers
- Men > female
- Older than 50
- History of excessive alcohol use and cigarette smoking (>97%)
Common sites of metastases for head and neck cancers (3)
- Lung
- Liver
- Bone
4 common symptoms of head and neck cancers
- Hoarseness
- Stridor
- Hemoptysis
- Sore that do not go away
What is the normal procedure used when head and neck cancers are suspected
Panendoscopy (Esophagoscopy, bronchoscopy, laryngoscopy)
Where do head and neck cancers start on a cellular level
Begins in squamous cells that line moist, mucosal surfaces inside mouth, the nose and the throat
What is the TNM system
Tumor size (T) Lymph node involvement (N) Distant metastases (M)
What is metastases related to?
Lymphatic availability
4 preop labs that we look at for head and neck cancers and why
- CBC - bone marrow metastases or chemo can causes altered levels of certain blood components
- Hypercalcemia - r/t bony metastasis
- Elevated LFT’s - r/t alcohol-induced liver disease
- Serum albumin - r/t nutritional status and protein binding ability, most likely will be low
3 effects of pre-operative chemo
- Decreases bulk of primary tumor
- Eradicates occult micro-metastasis
- Damages bone marrow
What is the most important part of your preoperative airway assessment for patients with head and neck tumors
Can the patient be easily ventilated with a mask and intubated with directed laryngoscopy
Pre-op Anesthesia considerations for patients with head and neck cancers (5)
- Sedatives contraindicated in significant airway obstructions d/t possible losing airway before we are ready
- Position of comfort in pre-op
- Glyco is helpful
- Airway blocks are useful
- SCIP antibiotics for all oral/pharyngeal procedures
Glossopharyngeal nerve anatomy
Mixed nerve with 6 sensory branches
6 sensory branches of the glossopharyngeal nerve
- Tympanic: innervate TM
- Carotid: innervates carotid sinus and sinus body
- Pharyngeal: sensation from pharynx
- Muscular: Branches of the tongue
- Tonsillar: sensation from tonsils and soft palate
- Lingual: innervates epiglottis, posterior 1/3 of tongue and vallecula (this is what we want to block)
Describe the glossopharyngeal nerve block (3)
- Between internal jugular and internal carotid
- Blockade of CN X, XI, XII in addition to CN IX
- Spinal needle 0.5cm in, 3-5mL LA injected bilaterally at the tonsillar pillars
Superior laryngeal nerve anatomy (4)
- Branch of CNX
- Internal branch: sensory innervation to larynx, posterior epiglottis, arytenoids
- External branch: innervates cricothyroid, which adducts the VC
- Found inferior to greater horn of hyoid
Describe the superior laryngeal nerve block (2)
- 1 cm below the greater cornu of hyoid
2. 25g needle, inject 2mL lidocaine
Describe the laryngeal nerve block (4)
- Aerosolized
- Trans-tracheal injection with a 22g needle and 4mL of lidocaine
- Air is aspirated before injection
- Direct blocks are contraindicated due to the trauma we can cause
3 oxygenation/ventilation options for head and neck surgereis
- small endotracheal tubes/inhalation anesthetic (may need laser safe ETT)
- intermittent apnea
- manual jet ventilation
Describe cardiac stability with head and neck surgery
- Blood pressure and HR fluctuate greatly
2. Moderate anesthetic with supplementation
4 descriptors of jet ventilation use
- Inspiration 1-2 seconds to avoid barotrauma
- Pressure 30-50 psi hooked up to wall outlet or anesthetic machine
- Expiration is passive
- Only acceptable for about 30 minutes or less
4 complications of jet ventilation
- pneumothorax
- pneumomediastinum
- aspiration
- hypercapnia/acidosis
Does jet ventilation require capnography?
Yes
Describe the 3 different waveforms of light used for lasers
- monochromatic - one wave length
- coherent - oscillates in same phase
- collimated - exists as a narrow, parallel beam
What do lasers allow for?
Excellent precision with minimal edema
Describe CO2 lasers (4)
- long wave length
- greater absorption by water (soft tissue)
- No touch technique
- Great precision, poor coagulation
Describe YAG lasers (4)
- shorter wave length
- less absorption by water
- Touch technique
- Poor precision, great for coagulation
4 most common problems with laser use
- organ or vessel perforation
- gas embolism
- eye exposure
- airway fire
3 laser precautions
- evacuation of toxic fumes (laser plume)
- prevention of eye damage
- Fire prevention
Polyvinyl chloride tube advantages and disadvantages
Advantages: inexpensive, nonreflective
Disadvantages: low melting point, highly combustible
Red rubber catheter advantages and disadvantages
Advantages: puncture resistant, maintains structure, nonreflective
Disadvantages: Highly combustible