Shock/transplant

Question 1

Hypovolemic shock

Answer 1

Acute blood or plasma loss, fluid sequestration, GI loss, insensible loss
Low CO/CI
Low CVP
Low PCWP
high SVR
Low SVO2

Question 2

Cardiogeneic shock

Answer 2

STEMI, NSTEMI, massive PE, pulmonary HTN, valvular disease; cardiac arrhythmia, end stage CM
-If wet and cold peripheral-classic CS, decreased CI, increased SVRI and PCWP
-if wet and warm peripheral- vasodilatory CS, or mixed shock, decreased CI, SVRI varies, increased PCWP
-if dry and cold peripheral-euvolemic, decreased CI, and increased SVRI, PCWP varies
-if dry and warm peripheral-vasodilatory shock not CS, increased CI, decreased SVRI and PCWP

Low CO/CI
High CVP
HIGH PCWP
HIGH SVR
LOW SVO2

Question 3

Distributive shock

Answer 3

Vasodilation, reduced SVR and loss of capillaries integrity
-sepsis, anaphylaxis, neurogenic
Anaphylaxis and neurogenic Hemo
LOW CI/CO
LOW CVP
LOW PCWP
LOW SVR
LOW SVO2

Question 4

Obstructive shock

Answer 4

Physical obstruction impairing ventricular filling and decreases CO
PE, tension pneumo, tamponade
Low BP, tachycardia, tachypnea
Similar to cardiogenic shock-but not due to myocardial dysfunction
LOW CO/CI
HIGH CVP
LOW/HIGH PCWP
HIGH SVR
LOW/HIGH SVO2

Question 5

Induction agents non depleting

Answer 5

-steroids-non depleting, blocks cytokine gene expression, high dose methyl prednisonlone
-simulect-non depleting, interleukin 2 receptor antagonist, halts T cell proliferation, given in day 9 and repeat on day 4

Question 6

Induction meds depleting agents

Answer 6

-Thymoglobulin and atgam- poly specific binding of antibodies immunocompetent T cells using surface antigens for rapid lymphopenia
-alemtuzumab-antibody directed against CD52 for cellular mediated lysis, dosing is institutional deepened, maybe once or twice

Question 7

Maintenance immunosuppressant

Answer 7

Lifelong
Usually triple therapy to include calcineurin inhibitor, antimetabolite, and steroids

Question 8

Calcineurin inhibitor

Answer 8

Prevents T cell proliferation by blocking Il 2 signal production
Cyclosporine and tacrolimus-level
CYP450 3A4 inhibitor-non dibydropyridine CCB, azoles, erythromycin, amiodarone, protease inhibitor, grapefruit
Inducers-Dilantin, phenobarbital, carbamazepine, rifampin, nafcillin, St. John’s wort

Question 9

Antimetabolites

Answer 9

Inhibits purine synthesis and inhibits DNA synthesis and decreases proliferation of immune cells
Imuran and mycophenolate

Question 10

Steroid

Answer 10

Block cytokine gene expression, anti inflammatory affect, redistribution of lymphocytes
Prednisone, methyl prednisolone

Question 11

mTOR inhibitors

Answer 11

Binds to FKBP-12, negative mTOR activity, decreased phosphorylation proteins, decreased translation and protein synthesis, decreased lymphocyte proliferation
Sirolimus and everolimus

Question 12

Costinulatory blocker

Answer 12

Binds to T cell proliferation CD28 receptors, decreases cell division, by cytokine production, anergy and apoptosis, decreased or no cell proliferation
Belatacept

Question 13

Allocation scoring system for transplant

Answer 13

Heart- hemodynamics, functional status, CHF severity, and therapies, status 1-6
Lung-lung allocation score
Liver- score based on probability of death within 3 months by MELD score
Kidney- multiple scores, kidney profile donor index, estimated post transplant survival, calculated panel reactive antibody

Question 14

Heart transplant

Answer 14

Refractory CHF
mechanical circulatory support through LVAD, ECMO, IABP
Life threatening ventricular arrhythmia
Congenital heart disease
CM
Cariogenic shock
Contraindications: increased pulmonary vascular resistance, major systemic disease, severe infection, substance abuse, malignancy, psychosocial instability, age, HIV, repeated and documented non compliance
Tricuspid regurgitation common post transplant **

Question 15

Kidney transplant

Answer 15

Patients with ESRD on dialysis, CKD 4 that may need another organ
Contraindications-metastatic CA, recurrent or ongoing infection, severe cardiac or peripheral vascular disease, hepatic disease unless also listed for liver transplant, medical non compliance, HIV*
CX- delayed graft function, renal artery stenosis, renal artery thrombosis, AKI/ATN

Question 16

Lung transplant

Answer 16

Single or double
COPD, IPF, CF, pulmonary HTN, alpha 1 antitrypsin, sarcoidosis
High risk greater than 50% from lung disease within 2 years if no transplant, high likelihood of surviving at least 90 days post transplant, high likelihood of 5 year post transplant survival from medical perspective
Contraindications-malignancy, organ dysfunction, CAD not amendable to realization, end stage organ ischemia, active TB, BMI greater than 35, non adherence
CX-primary graft dysfunction- ischemic perfusion injury, 72 hrs post transplant

Question 17

Prophylaxis

Answer 17

Anti viral
Antifungal
Anti Protozoa

Question 18

Liver transplant

Answer 18

Hepatitis B or C cirrhosis; NASH, alcoholic cirrhosis; cholestatic liver disease; acute hepatic fulminant failure, alpha 1 antitrypsin, Wilson’s disease
Contraindications-meld less than 15, severe cardiac or pulmonary disease, ongoing illness or alcohol use; hepatocellular CA with metastatic disease, infection, chronic renal disease unless also listed for kidney liver transplant, medication resistant hepatitis B, poor psychosocial or non compliance; portal or mesenteric vein thrombosis, extra hepatic malignancy, especially secondary liver malignancy

Question 19

Kidney transplant

Answer 19

Patients with ESRD on dialysis, CKD 4 that may need another organ
Contraindications-metastatic CA, recurrent or ongoing infection, severe cardiac or peripheral vascular disease, hepatic disease unless also listed for liver transplant, medical non compliance, HIV*
CX- delayed graft function, renal artery stenosis, renal artery thrombosis, AKI/ATN