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Principles 2 Test 2

Transplant Anesthesia

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