vents & transplant

Question 1

initial vent settings

Answer 1

AC or SIMV
RR 12-16
TV 6-8ml/kg IBW
PEEP 5
FiO2 100%

Question 2

RSBI

Answer 2

rapid shallow breathing index

respiratory rate/TV

=breaths/min/L

<105 is positive = extubation

> 105 likely to fail extubation

Question 3

warm vs cold ischemic time

Answer 3

warm - amount of time the organ remains at body temp after blood supply has been stopped or reduced

cold - amount of time organ is preserved in hypothermic state prior to transplantation (4-6h for heart, <12 for liver/pancreas, <24 for kidney)

Question 4

initial blood testing prior to transplant

Answer 4

blood type testing, HLA, crossmatch

Question 5

major AE of calcineurin inhibitors (cyclosporine, tacrolimus)

Answer 5

renal insufficiency

Question 6

immunosuppression options

Answer 6

glucocorticoids
calcineurin inhibtitors
antimetabolites
proliferation signal inhibitors

Question 7

primary indication for cardiac transplant

Answer 7

stage IV heart failure-refractory to maximum medical therapy

Question 8

NYHA heart functional classification HF

Answer 8

stage I - no physical activity limitations
stage II - slight limitation of physical activity resulting in fatigue, palpitation, dyspnea, or angina
stage III - marked limitation of physical activity, less than ordinary physical activity results in symptoms
stage IV - inability to carry out any physical activity without discomfort, may have angina at rest

Question 9

what is denervation?

Answer 9

after heart transplant, the heart is denervated and has altered response to cardiac meds (digoxin, atropine)

Question 10

common findings after heart transplant

Answer 10

HTN, HLD, DM, renal dysfunction

Question 11

diagnostic for transplant rejection

Answer 11

biopsy!!!

heart - end-myocardial biopsy
lungs - transbronchial biopsy
kidney - renal biopsy
pancreas - ultrasound guided pancreatic biopsy
liver - liver biopsy
intestine - endoscopic biopsy

Question 12

heart transplant follow up

Answer 12

immunosuppression
heart Cath yearly
biopsy/ECHO periodically in first year
stresst test at 6-8 weeks
LHC at one year
CT C/A/P every 3 years

Question 13

s/s of heart transplant rejection

Answer 13

arrhythmias and HF symptoms (edema, SOB)

Question 14

main indications for lung transplant

Answer 14

advanced COPD
idiopathic pulmonary fibrosis
cystic fibrosis

Question 15

lung transplant follow up

Answer 15

CXR weekly x6 weeks, then PRN
PFTs annually
chest CT at 6 mo, annually
bronch bimonthly then PRN

Question 16

s/s of lung transplant rejection

Answer 16

dyspnea, cough, sputum production, low-grade fever

Question 17

pulmonary primary graft dysfunction

Answer 17

diffuse pulm infiltrates and hypoxemia within 72 hours of transplant

Question 18

bronchiolitis obliterans

Answer 18

chronic lung rejection syndrome characterized by decreased FEV1, dense fibrosis, cough, and DOE

treat with high dose steroids

Question 19

main renal transplant indication

Answer 19

stage IV - V ESRD

secondary to DM most common

Question 20

renal transplant monitoring

Answer 20

creatinine weekly, then monthly
doppler or MRA
renal biopsy if suspicious for rejection

manage HTN - thiazide, CCB, ACE/ARB

monitor proteinurea

Question 21

leading cause of death after kidney transplant

Answer 21

cardiovascular disease

Question 22

pancreas transplant rejection monitoring

Answer 22

hyperglycemia

monitor serum crt, urinary amylase, C peptide, serum lipase

ultrasound-guided pancreatic biopsy

Question 23

MELD components

Answer 23

serum bili, creatinine, INR

10+ should be considered for transplant

Question 24

liver transplant monitoring

Answer 24

liver biopsy if s/s of rejection

LFT biweekly for 2 weeks, then weekly, then monthly

Question 25

s/s of liver rejection

Answer 25

fever, elevated LFTs, jaundice, fatigue

Question 26

hyper acute rejection

Answer 26

occurs within minutes, humoral mediated

rapid tissue necrosis - transplanted organ must be removed immediately

Question 27

accelerated acute rejection

Answer 27

1-5 d postop

Question 28

acute rejection

Answer 28

within first months after transplant

cellular mediated

treated with high dose steroids, optimization of immunosuppression

Question 29

chronic rejection

Answer 29

occurs slowly, no difinitive treatment

Question 30

common complications after transplant

Answer 30

hypertension
post-transplant DM
renal insufficiency
hyperlipidemia
bone disease
malignancy

Question 31

antimicrobial prophylaxis

Answer 31

fist year after transplant

against oral candidiasis, toxoplasmosis, pneumocystitis, CMV

Question 32

common infections in immunosuppressed

Answer 32

viral - CMV
fungal - candida, aspergillus
bacterial - staph, psudomonas, E. coli, klebsiella

live vaccines contraindicated!!!

Question 33

pancreas transplant indications

Answer 33

DM1
hypoglycemia unawareness

Question 34

liver transplant indication

Answer 34

cirrhosis of all types
acute liver failure

CHRONIC HEPATITIS
ALCOHOLIC LIVER DISEASE

genetic disorders
Wilson’s disease
hepatocellular carcinoma

Question 35

intestinal transplant indications

Answer 35

intractable TPN-related issues

necrotizing enterocolitis
Crohn’s disease
short bowel syndrome
radiation enteritis
stenosis of the small bowel

Question 36

intestinal transplant s/s concerning for rejection

Answer 36

abdominal pain, distention, increased fecal volume/stomal output, bloody output, fever

Question 37

contraindicated vaccines in transplant

Answer 37

MMR
intranasal flu
varicella
yellow fever
live zoster
oral typhoid

absence of safety data and concern for vaccine-associated infection