Mod13: Anesthesia for Organ Procurement

Question 1

_{Anesthesia for Organ Procurement}

When a hospital identify a potential donor, which organization is notified?

Answer 1

The local organ procurement organization (OPO)

Question 2

_{Organ Procurement}

Once notified, which next steps are undertaken by the OPO?

Answer 2

Donor evaluation

Brain Death diagnosis confirmed or testing in progress

Consent once Brain Death diagnosis confirmed

Testing and Allocation of organs

Question 3

_{Organ Procurement}

The local agency that coordinate activities with the recovery of organs is known as:

Answer 3

OPO

Organ Procurement Organization

Question 4

_{Organ Procurement - OPO}

Why do OPO works within Federally designed service area?

Answer 4

To ensure no competition for organs

Question 5

_{Organ Procurement - OPO}

Which agency certifies OPOs?

Answer 5

CMS

Question 6

_{Organ Procurement - OPO}

Which agency/legislation regulates OPOs?

Answer 6

Medicare/Medicaid Act

Question 7

_{Organ Procurement - OPO}

True or False: Working Relationships exist betwen hospitals and the OPO in the OPO service area

Answer 7

True

Question 8

_{Organ Procurement - OPO}

Approximately how many OPO’s in the U.S.?

Answer 8

62

Question 9

_{Organ Procurement - CMS Regulations}

Based on on CMS Regulations, which other entities must Hospitals sign an agreement with regarding organ procurement?

Answer 9

Organ Procurement Organization (OPO’s)

Tissue Bank

Eye Bank

Question 10

_{Organ Procurement - CMS Regulations}

Hospitals must notify the OPO about what?

Answer 10

Every death and every imminent death (brain death) that occurs in the hospital

Question 11

_{Organ Procurement - CMS Regulations}

Hospital must work in conjunction with the OPO to assure that the family of every potential donor is offered what?

Answer 11

The option of donation, if they are good candidate

Question 12

_{Organ Procurement - CMS Regulations}

Any individual who initiates discussion or provides information about donation or requests donation must be:

Answer 12

an OPO Representative or have been

Trained by the OPO

Question 13

_{Organ Procurement - CMS Regulations}

Any individual who initiates discussion or provides information about donation or requests donation must be an OPO representative or have been trained by the OPO

Penalties for failure to comply include:

Answer 13

Lose JCAHO accreditation

Lose Medicare/Medicaid Funding

Question 14

_{Organ Donation - Background Information}

True or False: Organ Transplantation may be the only treatment for some chronic diseases & disorders

Answer 14

True

Question 15

_{Organ Donation - Background Information}

Number of Americans awaiting transplantation (Waiting Lists):

Answer 15

Currently over 115,000

Someone added every 10 minutes

Question 16

_{Organ Donation - Background Information}

Of those currently awaiting transplants, how many are Georgians*?

Answer 16

10,500

Question 17

_{Organ Donation - Background Information}

How many people die each day awaiting transplants?

Answer 17

20

_{Source: United Network for Organ Sharing Data}

Question 18

_{Organs and Tissues that Can be Donated}

ORGANS that Can be Donated include:

Answer 18

Heart - Lung - Liver - Kidney - Pancreas

Question 19

_{Organs and Tissues that Can be Donated}

TISSUE that Can be Donated include:

Answer 19

Heart Valve - Bone - Skin - Cornea - Intestine

Question 20

_{Definition of Brain Death}

What’s the Anatomical Definition of Brain Death?

Answer 20

Destruction of all neural tissue above the 1st vertebrae

Question 21

_{Understanding Brain Death}

In essence, what is Brain Death?

Answer 21

Loss of brain stem function

Question 22

_{Understanding Brain Death}

Absence of which brain stem reflexes constitute clinical diagnosis of Brain Death?

Answer 22

Pupillary light reflex

Corneal reflexes

Oculocephalic reflex

Oculovestibular reflex

Apnea test

Question 23

_{Understanding Brain Death}

How can the Oculocephalic reflex be tested?

Answer 23

Doll’s head maneuver

Question 24

_{Understanding Brain Death}

How can the Apnea test be performed?

Answer 24

Normothermic patient failling to initiate a breath when arterial CO2 is > 60

Question 25

_{Potential Donors} Potential donors are patients who have sustained head injury and/or brain insult from which causes?

Answer 25

ICH 2° HTN, Aneurysm GSW to head Blunt trauma to head Brain tumor *Extensive chart review follows to make sure a potential donor is indeed a good candidate*

Question 26

_{Donor Management} What is responsible for hemodynamic instability that usually follows Brain death?

Answer 26

Wide swings in hormone levels Systemic inflammation Oxidant stress *All negatively impact organ function*

Question 27

_{Donor Management} What cause the systemic vasoconstriction (especially in the coronary circulation) usually seen after Breath Death? How can this be managed?

Answer 27

Increased levels of **Epinephrine** and **Norepinephrine** in the body Can be managed with **Verapamil** to prevent ischemic changes in the heart

Question 28

_{Donor Management-Hemodynamics} What's the fluid management goal in a transplant donor?

Answer 28

Keep pt **euvolemic** (critically important) **CVP** between **6-12 mm Hg**

Question 29

_{Donor Management-Hemodynamics} Why should you **keep Na \<155 mmol/L** and prevent hypernatremia?

Answer 29

**Hypernatremia** is associated with many _systemic issues_

Question 30

_{Organ Procurement - Donor Surgery} These are busy cases for anesthesia. What would you being doing and what are your overall goals?

Answer 30

Drawing and treating labs Ensuring donor stays stable while organs are being harvested

Question 31

_{Organ Procurement - Donor Surgery} What will you eed for Surgery?

Answer 31

Drugs - Electrocardiograph Arterial pressure catheter (for lab draws) CVP catheter - Urinary catheter Ventilator - Fluid warmers - HME - NGT Tracheal suction catheters - Infusion Pumps Heparinized blood sampling syringes (ABG draws)

Question 32

Organ Procurement - Donor Surgery Which drugs will you need for Surgery?

Answer 32

NMBs - Mannitol - Lasix - Dopamine - Heparin Epinephrine - Bicarb - Lidocaine - Verapamil

Question 33

_{Operative Management} Prior to surgery, where is donor assessment performed?

Answer 33

in the **ICU**, just as with any other case

Question 34

_{Operative Management} What should you check in the donor's chart?

Answer 34

**Brain Death pronouncement** Noting date and time of death Look for signature of physician **Consent for donation** Should be signed by donor’s next of kin

Question 35

_{Operative Management} What should you carefully assess in the donor's clinical presentation?

Answer 35

What support they are already on How stable they are Because of all the changes to happen intraop, preparation must be based on based on current/recent presentation

Question 36

_{Operative Management} True or False: Donor's operative management will continue as it has been preoperatively, making necessary adjustments in treatment to maintain BP.

Answer 36

True

Question 37

_{Operative Management} Vent settings should be set to match ICU settings. When will you Not keep them at 100% FiO2?

Answer 37

If you are having the **lungs transplanted** Keep \< 60% in this case If you are Not having the lungs transplanted Keep at 100%

Question 38

_{Operative Management} What could happen if FiO2 is \> 60% and you are having the lungs transplanted?

Answer 38

**Pulmonary Oxygen toxicity**

Question 39

_{Operative Management} Why should you keep PEEP as low as possible, preferrably not more than **5 cmH₂O**?

Answer 39

Any **PEEP \> 5 cmH₂O** will increase **Right atrial pressure** which will further increase **Hepatic congestion** which could make the _liver unsuitable for transplant_

Question 40

_{Operative Management} Why must Mannitol, Lasix and Heparin be ready to administer

Answer 40

Administration of these is extremely time sensitive

Question 41

_{Operative Management} True or False: Organ donors require anesthesia for hypnosis

Answer 41

**False** Organ donors do not require anesthetics for hypnosis But **active reflexes** often necessitate _neuromuscular blocking agents_

Question 42

_{Operative Management} What are the benfits of volatile agents in donor's surgery?

Answer 42

**Ischemic preconditioning** Will reduce the risk of ischemic reperfusion injury that can occur when that organ is transplanted onto the recipient

Question 43

_{Operative Management - Spinal Movements} In what proportion of donors are spontaneous spinal movements or spinal reflexes seen?

Answer 43

1/3

Question 44

_{Operative Management - Spinal Movements} How do Spinal Movements manifest?

Answer 44

Spontaneous “spinal” **movements of limbs** ## Footnote **Arching of the back**

Question 45

_{Operative Management - Spinal Movements} What are negative consequences of spinal or spontaneous movements

Answer 45

May **interfere with surgery** Can cause **catecholamine release** and HTN

Question 46

_{Operative Management - Spinal Movements} How can spinal or spontaneous movements be prevented?

Answer 46

Long acting NMBAs

Question 47

_{Operative Management} What's the typical incision in donor's surgery?

Answer 47

Midline incision

Question 48

_{Operative Management} How does donor's surgey typically last?

Answer 48

**2-4 hours** Depends on which and how many organ(s) are recovered

Question 49

_{Operative Management} Why is the potential for confusion greater in donor's surgery?

Answer 49

Lots of people in the room Roles sometimes unknown

Question 50

_{Operative Management} If the heart is being recovered and a central line is in place, what will you be asked to do?

Answer 50

To withdraw the line prior to cross-clamping Prevents central line from being trapped in that cross clamp area and potentially cause a shunt later when they excise the area, they could cut through the catheter and potentially loose blood out of that opening

Question 51

_{Operative Management} If the lungs are being recovered, what will you be asked to do after cross-clamping? Why?

Answer 51

To _manually_ **inflate** and **deflate** the lungs a couple of times This will _prevent_ **small airway closure** before the lung is transported

Question 52

_{Operative Management} Why are bradyarrhythmias in pts with brain death unresponsive to atropine?

Answer 52

Because the **brain stem is non functioning**

Question 53

_{Operative Management} How should you treat bradyarrhythmias in brain death patients?

Answer 53

With _direct-acting_, _beta-sympathomimetic_ agents such as **Isoproterenol**

Question 54

_{Operative Management} How can you treat ventricular arrhythmias in brain death patients?

Answer 54

**Lidocaine**

Question 55

_{Operative Management} During organ procurement, how do you know which physiologic parameters to keep the donor's in?

Answer 55

They will be very specific in what parameters they want you to keep the patient in They will let you know what's going on while it's going on They will let you know what to expect because they know No anesthesia provider is wholly comfortable with organ procurement, since we don't do them enough

Question 56

_{Operative Management} What happens once the organs are taken out?

Answer 56

They will ask you to shut off your ventilator, thank you, you can shut off your monitors, and you can leave the room And it will be weird feeling because you are used to never leaving a pt on the table. But at this point they have taken all the organs necessary, and what's left will start to shut down on its own, and they no longer need you in there assisting with anything else

Question 57

_{Facts About Transplantation} From recovery to transplantation, how long are kidneys viable?

Answer 57

24 to 36 hours

Question 58

_{Facts About Transplantation} From recovery to transplantation, how long is a **Liver** viable for?

Answer 58

**6 to 8** hours

Question 59

_{Facts About Transplantation} From recovery to transplantation, how long is a **Heart** viable for?

Answer 59

**4 to 5** hours

Question 60

_{Facts About Transplantation} From recovery to transplantation, how long is are **Lungs** viable for?

Answer 60

**4 to 6** hours

Question 61

_{Facts About Transplantation} From recovery to transplantation, how long is the **Pancreas** viable for?

Answer 61

**8 to 12** hours

Question 62

_{Benefits of Donation} From the donor's family perspective, what are the benefits of donation?

Answer 62

Helps with the grieving process Makes something positive out of a tragic situation

Question 63

_{Benefits of Donation} From the Recipient's perspective, what are the benefits of donation?

Answer 63

Gift of Life

Question 64

_{Benefits of Donation} From the Health Care Professional's perspective, what are the benefits of donation?

Answer 64

Makes something positive out of a tragic situation Be it on the procurement end or the transplantation end