anesthesia for organ transplantation (liver, kidney, pancreas, heart) Flashcards Preview

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Flashcards in anesthesia for organ transplantation (liver, kidney, pancreas, heart) Deck (44)
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which type of donor grafts have greater success and survival rates?

living donor grafts


how many lives can one organ donor save?

up to 8 lives


what is the most common transplant performed?

-next is liver


which transplant procedure requires specialized CRNAs



describe kidney transplantation considerations

-better survival rate than hemodialysis at 3 yrs.
-ESRD effects on other organ systems make for a challenging anesthetic: uremic conditions, fluid overload
-high incidence of cardiac disease
-high incidence of HTN and diabetes


what are kidney transplant indications?

-glomerular disease
-polycystic kidney disease
-congenital diseases


what are some characteristics of ESRD patients?

-cardiac disease most common cause of death
-uremia-induced myocardial depression (weaker heart, weaker pump; more challenging to put to sleep); normalizes after transplantation
-cardiomyopathies (60% have either RVH or LVH)
-electrolyte abnormalities, especially K+ increase


describe ESRD and cardiomyopathy

-chronic HTN state: increased circulating fluid volume; increased circulating renin levels that vasoconstrict; increased Na+ retention)
-LVH and concentric cardiomyopathy r/t increased afterload
-dilated cardiomyopathy r/t increased fluid volume
-increased afterload and preload


what are the effects of uremic toxins in ESRD?

-pericardial disease
-altered lipid metabolism
-small vessel atherosclerosis (esp. coronaries); increased risk MI, ischemia
-decreased gastric emptying ( >0.4 ml/kg; all are full stomach)
-platelet defects; clots off grafts (hypercoagulation)
-uremic frost on skin


what 3 variables determine the surgical outcome of kidney transplant?

-donor management; live vs. deceased
-harvested organ preservation
-perioperative care of organ recipient


what are anesthesia implications for the living donor?

-adequate IV access
-blood availability (**greatest risk is hemorrhage)
-use of balanced salt solution (ensures diuresis; offsets a reduced venous return r/t flank position)


what are anesthesia implications for the brain dead donor?

*graft preservation is highest priority (ensure undamaged)
-loss of sympathetic tone can cause hypotension
-hypotension regardless of volume replacement
*maintain renal perfusion of graft
-use low dose dopamine (1-3 mcg/kg/min)
-avoid high dose vasopressors which can lead to ischemia
*maintain urinary output with diuretic use


what are contraindications to kidney transplant?

-absolute: active infection
-relative: non-compliant drug or ETOH; malignancy; hepatocellular carcinoma with cirrhosis


describe the pre op assessment for kidney transplant

-determine the cause of renal failure (DM #1 cause, HTN #2)
-determine comorbid conditions: ESRD, CAD, DM, HTN, autonomic neuropathy, coagulopathy
-labs/testing: metabolic profile with glucose
-EKG and Echocardiogram with ejection fraction
-CBC with platelet count
*treat patient from renal failure perspective


describe anesthesia implications for kidney transplant

*expect hemodynamic instability
-volume overload, cardiomyopathy, weak pump
-hypotension, bradycardia upon induction if diabetic r/t autonomic neuropathy (inability to compensate for drop in SVR)
have patient hold ACE inhibitor; drops BP
*Type and crossmatch several units (although usu. little blood loss)
*dialyze prior to surgery to optimize fluid volume and electrolyte status


describe intra op considerations for kidney transplants

Large 8-10 inch incision
-GA preferred with excellent muscle paralysis
-regional has been used successfully
-normal saline preferred crystalloid (LR contains K+)
-caution with nondepolarizing NMBA (*Cisatracurium good since Hoffman elimination, organ independent)
-A line for optimal hemodynamic control and frequent blood sampling
-CVL for fluid vol. management and monitoring (*keep CVP b/w 10-15 mmHG)


what commonly happens after unclamping the iliac vessels?

*be prepared to hang vasopressors if needed


what does the graft kidney's health depend on and how is it maintained?

-avoid hypotension
-studies show vessels of transplanted organs are highly sensitive to sympathomimetics so don't use high dose vasopressor that can lead to ischemia
*avoid high doses of alpha 1 agonists
*renal dose dopamine is beneficial (D1 receptor; 1-3 mcg/kg)


what determines success of kidney transplant?

urine production
*immediate in most recipients


describe post op considerations for kidney transplant

-completely reverse muscle relaxant
-goal is extubation immediately after surgery
-rarely admit to ICU post op
-post op pain is usually easily controlled


describe pancreatic transplantation

-primarily to cure DM
-nephropathy is present in 50-60% of diabetics causing many to receive kidney and pancreas
-comorbid conditions r/t long term diabetes typically present: autonomic neuropathy, CAD, HTN, ESRD
*usually more of an immunosuppressant challenge; require more immunosuppressant therapy


what are intra op considerations with pancreatic transplants?

-long surgery time
-large, painful incision
-extensive dissection to pancreas (pre op epidurals have shown promise with pain management)
-immunosuppression increased


describe intra op management for pancreatic transplant

-a line to optimize hemodynamic status
-colloids swell the pancreas LESS than crystalloid
-CVL to optimize fluid vol. management and CVP measurements
-frequent blood sampling: electrolytes, serial glucose
-serial glucose checked hourly prior to unclamping and every 30 minutes after
**success of graft is measured by glucose levels


describe liver transplantation outcomes

-increased discrepancy between organ supply and recipient waiting list (more extensive surgery; all organs may be effected by end stage liver disease)
-3 yr. survival rate > 75%
-hepatitis C recipients may need retransplanting in the future, causing greater demand for livers


describe end-stage liver disease and pathophysiology

-portal HTN develops: cirrhotic changes increase portal resistance and portal venous pressure > 12 mmHg
-hyperdynamic circulatory state r/t vasodilation and volume expansion
-increased ICP can occur
-ammonia levels lead to encephalopathy
-upper GI bleeding r/t varicosities


what are indications for liver transplant?

-post necrotic (non-alcoholic) cirrhosis (portal HTN, hyperdynamic circulatory status
-biliary cirrhosis
-sclerosing cholangitis
-primary hepatic neoplasia
-alcoholic cirrhosis (usu. must abstain from for > 2 yrs.)


what medical issues usually present with patients requiring liver transplant?

-hepato and porto-pulmonary syndrome: results in decreased PaO2 and shunting; resolves after transplantation
-cardiac status: hyperdynamic state (ascites, SVR low, BP normal to low); HR increased
*coagulation disorders (most challenging): decreased factors II, V, VII, IX, X, protein C, S, antithrombin III; thrombocytopenia lead to increased bleeding
**require frequent transfusions
-accompanying renal disease common: hepatorenal syndrome (r/t liver decreased vasodilators and increased vasoconstrictor factors; perfusion deficit to kidney)


describe liver transplant pre op

-extensive multi-specialty workup: hematology-coagulation studies; pulmonology; cardiology; nephrology
-cardiac eval: EKG; echo (EF, cardiomyopathy, portal HTN, pulmonary HTN); arteriogram (assess vascular issues); right heart cath (assess pulm. vascular status)
-type and crossmatch and blood product preparation
*10 units PRBCs, 10 units FFP, Platelets, cryoprecipitate


describe liver transplant monitoring

-correct coagulopathy prior to line placement
-need dependable large bore IV access for fluid and blood administration
-a line for hemodynamic instability and frequent bloodwork
-CVL- CVP measurement (used in 50% of centers)
-TEE (used in 11% of centers)
-PA catheter (used in 30%): assess pulmonary HTN


what are the three stages of liver transplant procedure?

-dissection: extensive lysis of adhesions
-anhepatic: removal of native liver and implanting donor
-reperfusion (neohepatic): anastomosis, restore hemostasis , reperfusion
**complex and challenging management (fluid shifts, electrolytes up and down, and severe hypotension)