Transplant Anesthesia

Question 1

Before initiating brain death testing, we must make sure that these factors have been ruled out ass possible causes of cerebral dysfunction

Answer 1

Hypothermia
Hypotension
Metabolic/endocrine instability
Drug overdose (recreational, is pt paralyzed?)

Question 2

What is the definition of comatose?

Answer 2

Unresponsive to verbal stimuli

Question 3

How can you tell if cerebral cortical function is absent?

Answer 3

No spontaneous movement, and no response to painful stimulus

Question 4

What are two supporting studies that can be used in the brain death exam?

Answer 4

EEG and TCDs

Question 5

What is the oculocephalic reflex?

Answer 5

Doll’s eyes response
Oculo–eyes
Cephalic – head
Seeing how their eyes move in relation to their head

Question 6

What is the oculovestibular reflex?

Answer 6

Cold caloric testing

Stimulating the inner ear with cold water

Question 7

What are the components of the brain death exam?

Answer 7

Absence of pupillary response to light
Absent corneal reflex
Absent oculocephalic reflex
Absent oculovestibular reflex
Absent cough and gag reflex
Absent respiratory reflex (apnea test)

Question 8

How do you perform an apnea test?

Answer 8

Give 100% FiO2 for 10 minutes. Ensure that PaCO2 is normal with an ABG. Take the patient off the vent and connect to a t piece for 7-10 minutes. Get another ABG. Absence of respiratory effort and PaCO2 > 60 is a positive test.

Question 9

Hemodynamic goals for preserving organ function in the brain death donor patient for organ harvest

Answer 9

SBP > 100
UO 1-1.5cc/kg/hr
Hgb > 10
CVP 5-10
FiO2  7.5 (again to avoid lung damage)
SaO2 > 95%
PaO2 75-150
Core temp > 34-35C

Question 10

Why do we avoid phenylephrine in the organ harvest patient?

Answer 10

It can reduce splanchnic blood flow to the organs we are trying to procure

Question 11

What do we give for pressers instead of neo in the organ harvest patient?

Answer 11

Dopamine, dobutamine, epi, and norepi

Question 12

What do we give for bradycardia in the organ harvest patient?

Answer 12

They will be resistant to atropine, so give either epic or isoproterenol

Question 13

When someone donates a kidney, which one do they usually take?

Answer 13

The left

Question 14

In healthy liver segment donors, why do they experience more hypotension with clamping of the hepatic pedicle?

Answer 14

Because unlike those with liver disease, they are healthy and haven’t developed collaterals. To prevent this, we pretreat with albumin boluses.

Question 15

How are the organs preserved once removed?

Answer 15

Kept cold to reduce metabolism.
Kept in a preservative solution (helps to maintain cellular integrity, prevent cellular swelling, prevent vasospasm, prevent the buildup of toxic metabolites, and to provide a source of energy for the organ

Question 16

This solution is used to intraabdominal organs

Answer 16

UW solution

Question 17

This solution is used or hearts

Answer 17

Celsior

Question 18

Once out of the body, organs are cooled to this temperature

Answer 18

4C

Question 19

This is an ABSOLUTE contraindication to organ transplant

Answer 19

Active infection (pt will be immunosuppressed, and needs to be able to fight off the infection)

Question 20

These are RELATIVE CIs to organ transplant

Answer 20

Malignancy, systemic disease, physical/social factors, and advanced age (although, by itself is not a CI)

Question 21

What are some of the potential SEs of the immunosuppressive agents used?

Answer 21

Life-threatening infection
Increased risk of tumors and malignancy (body isn’t fighting off abnormal cells)
Progressive vascular disease
Renal compromise

Question 22

This is the sensitization stage

Answer 22

The interaction between the graft cells and the host’s T cells. They’re meeting each other for the very first time, and the T cells are pretty suspicious of these new cells they’re seeing.

Question 23

This is the effector stage

Answer 23

Those T cells be activated. They realized this shit ain’t what dey used to, and shit’s about to get real. The T cells become activated and secrete cytokines, and amplify T cell activation via DNA synthesis and T cell proliferation.

Question 24

Why are glucocorticoids given? What glucocorticoid is commonly given?

Answer 24

They decrease macrophage production of interleukins. This decreases T cell development and proliferation of T helper cells.

Methylprednisolone is commonly given, and can cause adrenal suppression, infection, and DM.

Question 25

These are two Calcineurin Inhibitors used in transplant. What are their names and how do they work? What are their SEs?

Answer 25

Cyclosporine and Tacrolimus These inhibit T cell differentiation and cytokine synthesis. SE: Nephrotoxic, hepatotoxic, neurotoxic, HTN, HLD, and hyperglycemia. Cyclosporine can prolong NM blockade

Question 26

Tacrolimus is also called FK5

Answer 26

FK506

Question 27

This is a monoclonal antibody used as an immunosuppressant

Answer 27

Daclizumab. Has no major SEs.

Question 28

These immunosuppressants work by inhibiting adhesion molecules

Answer 28

Rabbit/Horse Antithymocyte Globulin - Can cause anaphylaxis, increased CMV or epstein-barr viral infection, and pulmonary edema ``` Antilymphotcyte globulin (ALG) - Decreased the availability of activated T cells and their proliferation. Specific for T3 complex located on the surface of mature T cells and blocks their function. ```

Question 29

This immunosuppressant works by inhibiting DNA synthesis

Answer 29

Azathroprine. SE include pancytopenia, severe upper airway edema (rare), and antagonist of NM blockade

Question 30

These are some common causes of ESRD

Answer 30

``` DM HTN Glomerulonephritis PKD Chronic pyelonephritis Obstructive uropathy SLE Alport's syndrome ```

Question 31

Matching tests needed for renal transplant

Answer 31

ABO HLA Patient specific crossmatch

Question 32

Hemodynamic goals for kidney transplant

Answer 32

SBP > 90 MAP > 60 CVP 10-15

Question 33

Why are lasix and mannitol administered before reperfusion of the kidney?

Answer 33

To stimulate diuresis. Mannitol, along with adequate volume decreases the risk for ATN. Adequate volume increases renal blood flow, and improve immediate graft function.

Question 34

This is the first choice vasoactive infusion in kidney transplants if pressure does not come up with fluids

Answer 34

Dopamine

Question 35

Emergence in kidney transplant

Answer 35

May have hyper dynamic responses, especially in those with uncontrolled HTN Avoid excessive coughing, which could disrupt the graft ESRD patients may have delayed emergence from anesthesia Extubatne awake d/t aspiration risk (we want to know they're awake and capable of protecting their own airway before we remove the tube)

Question 36

Key during organ reperfusion

Answer 36

Watch for hypotension. This is expected d/t release of ROS, but should be avoid to maintain graft perfusion

Question 37

What is the most common indication for liver transplant?

Answer 37

Hep C

Question 38

When the pressure gradient between hepatic and portal veins is severe (__-__mmHg), complications such as ascites, esophageal varices, encephalopathy, and hepatorenal syndrome can develop

Answer 38

10-12

Question 39

Why do ESLD patients have hyper dynamic circulation?

Answer 39

Hyperdynamic circulation is high CO, low BP, and low SVR. It is caused by portal HTN-induced production of vasodilators, most importantly, NO. The overproduction of vasodilators is responsible for reduced circulatory responsiveness to sympathetic stimulation. Clinically, this frequently results in a need for increased doses of vasopressors.

Question 40

What is hepatopulmonary syndrome?

Answer 40

A syndrome that is defined as having portal HTN, PaO2

Question 41

What is portopulmonary HTN?

Answer 41

``` Defined as pulmonary hypertension in the presence of portal hypertension in a patient without other predisposing factors. Diagnosis: Mean PAP > 25 PVR > 240 PCWP ```

Question 42

What are some examples of natural anticoagulants?

Answer 42

Protein C, Protein S, and AT-III