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Principles 2 Test 2
Transplant Anesthesia
| Question | Answer |
|---|---|
| Do living or deceased donor grafts have greater success and survival rates? | living |
| How many lives can 1 organ donor save? | up to 8 lives! |
| Between liver, kidney, pancreas, and heart transplants, which one requires a highly specialized anesthetist and surgical team? | liver |
| True or False: kidney transplants have a better survival rate than hemodialysis at 3 years. | true |
| ESRD patients undergoing kidney transplants are likely to have what other comorbidities that make them especially sick patients? | cardiac disease, HTN, diabetes |
| What are 5 indications for kidney transplantation? | glomerular disease, polycystic kidney disease, diabetes, HTN, congenital diseases |
| What are the effects of high uremic toxins in the ESRD patient? | pericardial disease, altered lipid metabolism, dysrhythmias, small vessel atherosclerosis, decreased gastric emptying, hyper coagulation, anemia |
| Surgical outcomes of kidney transplants are based on what 3 things? | donor management, harvested organ preservation, peri-operative care of organ recipient |
| What is the greatest risk to the living kidney donor intra-operatively? | hemorrhage |
| Why is low dose dopamine (1 - 3 mcg/kg/min) used in brain dead kidney donors? | to maintain renal perfusion of graft without damaging graft (kidney) |
| What is the only absolute contraindication to kidney transplantation? | active infection |
| List 3 relative contraindications to kidney transplantation. | non compliant drug/ETOH abuse, malignancy, hepatocellular carcinoma with cirrhosis |
| What are the top 2 causes of renal failure? | Diabetes (#1) and HTN (#2) |
| Why do ESRD patients get an echocardiogram before kidney transplantation? | to evaluate EF and determine whether or not their heart is healthy enough to handle surgery |
| True or False: general anesthesia is proven to have better outcomes than regional (like an epidural) with kidney transplants. | False! Patient comfort improved with epidural but no difference in outcomes. GA used more often than epidural/regional |
| Which type of fluid is preferred in kidney transplant patients? | crystalloid - normal saline |
| Do kindney transplant surgeries require muscle relaxation? If so, which NMB is preferred? | Yes! cisatracurium preferred due to hofmann elimination |
| What types of access are required in a kidney transplant patient? | art line, CVL, large bore IV |
| Where should the kidney transplant patient's CVP be kept ideally? | 10 - 15 mmHg |
| Hypotension is common after unclamping the iliac vessels. What should the prudent CRNA do to address this? | avoid hypotension, but be careful with sympathomimetic drugs because they can harm graft --> give them in small doses and/or give renal doses of dopamine |
| What is the sign of a working and successful graft in kidney transplant surgery? | urine output, which happens immediately in most recipients |
| Is there any need to leave a kidney transplant patient intubated and in the ICU after surgery? | No. immediate post-op extubation and less than 1% of patients stay in ICU |
| What two organs are frequently transplanted together? | pancreas and kidney |
| Which type of transplant requires more immunosuppressive drug therapy: pancreas or kidney? | pancreas |
| Why are colloid fluids preferred over crystalloid fluids in pancreatic transplant? | they swell the pancreas less |
| The success of a pancreatic transplant graft is measured by what? | glucose levels |
| Why are pancreatic transplants painful and long procedures? | extensive dissection down to pancreas; epidurals have shown promise with pain management |
| What is the 3 year survival rate after liver transplantation? | > 75% |
| Describe the pathophysiology of end stage liver disease. | portal HTN develops secondary to hyperdynamic circulatory state, this causes esophageal varices which can bleed; encephalopathy related to increased ammonia levels; acites, coagulation issues, renal disease common, pulmonary HTN |
| What are 5 indications for liver transplantation? | post necrotic (non-alcoholic) cirrhosis, billiary cirrhosis, sclerosing cholangitis, primary hepatic neoplasia, alcoholic cirrhosis |
| Prior to liver transplant, an excessive specialty work up is required which involves which 4 medical specialties? | hematology, pulmonology, cardiology, nephrology |
| What are the minimum blood product requirements needed to be on hand for liver transplant surgery? | 10 units PRBCs; 10 units FFP, platelets, cryoprecipitate |
| What are the 3 stages of liver transplant surgery? | dissection, anhepatic, reperfusion |
| What contributes to the altered drug metabolism experienced by patients undergoing liver transplant surgery? | decreased biotransformation r/t liver failure, hypoalbuminemia means less drug binding, increased volume of distribution r/t ascites |
| Why is there a significant incidence of hypotension early on in live transplant surgery? | removal of ascites, manipulation of liver impedes venous return |
| Why would a prudent CRNA insert an orogastric tube in a patient undergoing a liver transplant? | oro- rather than naso- means less bleeding, it decompresses stomach so that surgeon can more easily visualize liver |
| Why would the prudent CRNA avoid use of nitrous oxide during a liver transplant case? | it will inflate intestine and make surgical field harder to view |
| Is hyper or hypoglycemia more commonly seen intraoperatively in liver transplants? | hyperglycemia -- altered insulin-mediated glucose uptake |
| Which two electrolyte abnormalities are most common with liver transplant cases? | hyperkalemia and hyponatremia (be careful to avoid pontine myelinolysis by slowly increases sodium levels) |
| What percentage of heart transplant cases are related to idiopathic cardiomyopathy and ischemic heart disease? | 90% |
| In addition to normal monitoring for a patient under anesthesia, what else is required to monitor patients undergoing heart transplant? | art line, CVP (via CVL), PA catheter, TEE |
| Why are indirect heart drugs not effective in heart transplant surgery? | because the heart is denervated; the response to hemodynamic changes is eliminated |
| Why is rocuronmium now the preferred NMB over pancuronium with heart transplants? | fast-tracking of patients; also, procedure generally emergent, some patients even have full stomachs -- RSI |
| Which inhalation agents and at what dosage are primarily used in heart transplants? | sevoflurane and desflurane at 1 MAC (end tidal) or less |
| Which IV anesthetic is primarily used in heart transplants due to its good cardiac profile? | etomidate |
| Why is fentanyl used in high doses in cardiac transplant surgery? | it prevents increases in systemic after load during periods of intense surgical stimulation |
| Why is nitrIC oxide used in cardiac transplant surgery? | helps dilate pulmonary artery to improve graft survival with reperfusion and does so locally rather than systemic vasodilation which would be problematic |
| What can be used to stimulate diuresis in a kidney transplant patient after graft has been placed? | albumin, loop diuretics (lasix), osmotic diuretics (mannitol), calcium channel blockers inserted into renal artery |
| What is the ideal MAP for kidney transplant patients intraoperatively? | 60 - 70 mmHg |
| Why should you typically avoid sedative premedication in liver failure patients pre-transplant surgery? | they are very sensitive to these medications, especially if they have encephalopathy |
| True or False: regarding liver transplant, the specific types of lines placed are less important than the confidence that the CRNA has in high or her ability to transfuse large amounts of colloids and blood products. | True |
| Because liver transplant patients are particularly susceptible to massive blood loss and hemodynamic fluctuations, what should be in the OR? | some form of rapid transfusion device |
| Why is the ideal CVP in liver transplant patients around 5 mmHg? | keeping them fluid underloaded means lower BP and more control over bleeding --> it is a balance between keeping adequate preload and perfusion and keeping a handle on significant surgical bleeding |
| The an hepatic phase of liver transplant lasts about 1 - 1.5 hours and involves clamping the IVC. How much will this decrease venous return? | By up to 50% |
| What is the most significant anesthetic concern during the reperfusion phase of liver transplant surgery? | post-reperfusion syndrome (SEVERE cardiac dysfunction) |
Created by:
Mary Beth
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