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7835 Exam IV > Mod13: Heart Transplant > Flashcards

Mod13: Heart Transplant Flashcards

1
Q

Heart Transplant - Indications for Transplant

What’s the most common indication for heart tpx?

A

Non-ischemic cardiomyopathy

Historically, ischemic cardiomyopathy was the most common indication for heart tpx

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2
Q

Heart Transplant - Indications for Transplant

What are UNOS indications for heart tpx?

A

Continuous mechanical or ionotropic support

Peak O2 uptake <14 mL/kg/min

LV ejection fraction less than 20%

Inoperable congenital heart disease

Intractable malignant arrhythmias

PVR <2 Wood units

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3
Q

Heart Transplant - Indications for Transplant

According to UNOS which Peak O2 uptake value is an indication for heart tpx?

A

<14 mL/kg/min

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4
Q

Heart Transplant - Indications for Transplant

According to UNOS which LV ejection fraction value is an indication for heart tpx?

A

< 20%

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5
Q

Heart Transplant - Indications for Transplant

According to UNOS which PVR value is an indication for heart tpx?

A

<2 Wood units

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6
Q

Heart Transplantation - Preop

Why is a “rapid” H&P of recipient required before Heart tpx?

A

Time constraints

Short viability period of time from procurement to trasplantation

Estimated at 4 to 5 hours

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7
Q

Heart Transplantation - Preop

True or False: Equipment and drugs for heart tpx are similar to those usually used for routine cases requiring CPB.

A

True

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8
Q

Heart Transplantation - Preop

Placement of which invasive lines and monitors is required for Heart Tpx?

A

PA catheter - Arterial line - TEE

CO - PVR - CVP

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9
Q

Heart Transplantation - Preop

Why are Aspiration Precautions necessary in heart Tpx

A

Short period of time before surgery

NPO status usually not acheived

All aspirations prophylaxis measures and drugs are indicated

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10
Q

Heart Transplantation - Preop

What should you communicate to the Blood Bank?

A

Prepare Blood products

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11
Q

Heart Transplantation - Preop

Why must strict aseptic techniques with broad spectrum antibiotics prophylaxis be followed in Heart Tpx procedures?

A

Concerns for standard infections

Addition of immunosuppressive drugs post op

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12
Q

Heart Transplantation - Intraop

What’s a major benefit of using a High dose narcotic with muscle relaxant and benzodiazepines for induction of Anesthesia in Heart Tpx?

A

Risk of CV collapse limited

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13
Q

Heart Transplantation - Intraop

Why is RSI recommended in Heart Tpx? Which drugs would you use?

A

Most patients called in for transplantation have not fasted and should be considered to have a full stomach

Drugs for RSI:

Etomidate - Succinylcholine - Fentanyl (moderate dose)

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14
Q

Heart Transplantation - Intraop

Why should induction in heart Tpx be preformed in the presence of the surgeon, scrub nurse and perfusionist

A

in anticipation for cardiovascular collapse!!!

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15
Q

Heart Transplantation - Intraop

Why do drugs take longer to show effect is these patients?

A

Low CO

Slow circulation time

Decreased volume of distribution

Allow time for effect before considering a second dose

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16
Q

Heart Transplantation - Intraop

Preinduction administration of which drugs optimizes circulation and minimizes transit time of subsequently administered anesthetics?

A

Inotropic agents or pressors

Not a reason to premedicate with these drugs, but benefits are evident

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17
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

Which cardiac alteration is associated with high dose narcotic?

A

Ventricular arrhythmias

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18
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

What’s possible cause of pre-CPB hypotension?

A

Volatile agents

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19
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

True of False: heart Tpx surgery requires OG and foley placement.

A

True

20
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

If PA or CVP catheter placed, when must it be withdrawn from the right heart?

A

Prior to completion of bicaval cannulation

You don’t want it to interfere with surgery

Communicate with surgical team

21
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

How about cardiac bypass?

A

Will be discussed extensively next semester

22
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

What happens in the 1st stage of Heart Tpx surgery?

A

The donor heart’s left atrium is sewn onto the recipient’s left atrium

23
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

What happens in the 2nd stage of Heart Tpx surgery?

A

The donor heart’s right atrium is sewn onto the superior and inferior vena cava

24
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

What happens in the 3nd and last stage of Heart Tpx surgery?

A

The donor heart’s other major vessels are sewn onto the recipient’s major vessels

25
Q

Heart Transplantation - Intraop - Maintenance of Anesthesia

Why is cardiac bypass required during Heart Tpx?

A

There would be a significant amount of blood loss from major vessels if not bypassed

26
Q

Heart Transplantation - Postop

Low CO after transplant may be due to:

A

Hypovolemia

Inadequate adrenergic stimulation

Myocardial injury during harvesting or transport

Acute rejection

Tamponade

Sepsis

27
Q

Heart Transplantation - Postop

Why shouldn’t you treat post op systemic Hypertension with vasodilators at 1st?

A

Because it may be due to pain

Adequate analgesia is provided before vasodilators

28
Q

Heart Transplantation - Postop

Atrial and ventricular tachyarrythmias are common in the immediate postop period. What must be ruled out prior to using antiarrythmics are used for conversion?

A

Acute rejection

29
Q

Heart Transplantation - Postop

Why would you consider bringing these pts out of the OR paced?

A

Many patients require pacing in the immediate postop period

30
Q

Heart Transplantation - Postop

What % of patients require permanent pacing following heart Tpx?

A

10 - 25%

They will require temporary pacing initially

They will be switched to permanent pacing if they remain highly dependent

31
Q

Heart Transplantation - Postop

Renal function often improves following transplantation, but which drugs may again impair renal function?

A

Immunosuppressants

32
Q

Heart Transplantation - Postop

Which type of infection is very common in the early postop period?

A

Bacterial pneumonia

33
Q

Heart Transplantation - Postop

Which type of infections is very common after the first several weeks? and why?

A

Opportunistic viral and fungal infections

d/t

Immunosuppressants

Pts must be advised to consult providers immediately with signs and symptoms

34
Q

Heart Transplantation - Pharmacological Agents After Transplant

Why would agents that act indirectly via the sympathetic or parasympathetic system (Atropine, Ephedrine) be ineffective after heart Tpx?

A

The transplanted heart has no autonomic innervation

Atropine will loose its vagolytic property and won’t increase HR

Ephedrine won’t increase HR because of its indirect effect

35
Q

Heart Transplantation - Pharmacological Agents After Transplant

Which drugs would you choose to increase HR in a transplanted heart? and why?

A

Isoproterenol

Epinephrine

Because the have direct effect

36
Q

Heart Transplantation - Pharmacological Agents After Transplant

Which modality would you use to increase HR if drugs are inneffective?

A

Pacing

37
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to certain drugs with a denervated heart following transplantation?

A

Effect of Denervation on Cardiac Pharmacology

(See table)

38
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Digitalis with a denervated heart following transplantation? and why?

A

Normal increase in contractility

Minimal effect on AV node

d/t:

Direct myocardial effect - Denervation

39
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Atropine with a denervated heart following transplantation? and why?

A

No reaction

Reason: Denervation

40
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Epinephrine or Adrenaline with a denervated heart following transplantation? and why?

A

Increased contractility

Reason: <em>Denervation hypersensitivity</em>

Increased chronotropy

41
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Norepinephrine or Noradrenaline with a denervated heart following transplantation? and why?

A

Increased contractility

Mechanism: <em>Denervation</em>

Increased chronotropy

Mechanism: <em>No neuronal uptake</em>

42
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Isoproterenol with a denervated heart following transplantation?

A

Normal increase in contractility

Normal increase in chronotropy

43
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Quinidine with a denervated heart following transplantation? and why?

A

No vagolytic effect

Mechanism: <em>Denervation</em>

44
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Verapamil with a denervated heart following transplantation? and why?

A

AV block

Mechanism: <em>Direct effect</em>

45
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Nifedipine with a denervated heart following transplantation? and why?

A

No reflex tachycardia

Mechanism: <em>Denervation</em>

46
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to Hydralazine with a denervated heart following transplantation? and why?

A

No reflex tachycardia

Mechanism: <em>Denervation</em>

47
Q

Effect of Denervation on Cardiac Pharmacology

How would a recipient react to beta-blocker with a denervated heart following transplantation? and why?

A

Increased antagonist effect

Mechanism: <em>Denervation</em>

7835 Exam IV (21 decks)

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