He's a fighter
What four reversible things need to be ruled out before attributing comatose state to brain death?
1. Hypothermia
2. Hypotension
3. Drugs
4. Toxins
What is your anesthetic plan for a kidney donor patient? What equipment would you like to have available?
- General anesthesia with ETT +/- epidural for postop pain (laparoscopic procedure until the kidney comes out)
- Fluid warmer: will be giving LOTS of fluids to flush out the kidney and keep high UOP
- Bladder catheter: need to maintain 10-20mL/kg/hr
What stage of liver transplantation are you most likely to give FFP and cryo?
Reperfusion phase
- giving these products during preanhepatic phase will have little effect, so you normally wait until the new liver is in and can utilize these products
Which immunosuppressive drug will increase your VA requirements to reach 1 MAC?
A. Azathioprine
B. Calcineurin inhibitors
C. Corticosteroids
D. Mammalian target of rapamycin inhibitors (mTOR)
B. Calcineurin inhibitors (Cyclosporin and Tacrolimus)
- can also prolong the effects of pancuronium
If a patient develops hyperkalemia during a liver transplant, what would you AVOID?
A. IV dextrose
B. CaCl
C. Hypoventilation
D. Sodium Bicarbonate
C. Hypoventilation
you would want to hyperventilate to steer more alkalotic in the setting of acidosis from reperfusion
What is the most important thing to manage when harvesting organs from brain-dead donor?
A. Always use 100% FiO2
B. Place invasive lines once the patient reaches the OR
C. Prevent and treat acidosis
D. Ensure each harvesting surgeon confirms brain death
C. Prevent and treat acidosis -- will compromise the integrity of the organs
A. Don't use 100% FiO2 when harvesting the lungs
B. CVC, arterial line, and PAC are normally placed in the ICU prior to donation.
D. Surgeons receiving organs cannot be involved in the declaration of brain death
Why is it important to maintain normovolemia with a kidney donor patient? SATA
A. You want to avoid pressor use when supporting BP
B. You want to make sure the kidney is being flushed of toxins
C. You want to decrease the workload on the remaining kidney
D. You're concerned pneumoperitoneum will decrease renal blood flow
A. You want to avoid pressor use when supporting BP
B. You want to make sure the kidney is being flushed of toxins
D. You're concerned pneumoperitoneum will decrease renal blood flow
Why would you see a large drop in BP after the abdominal incision for a liver recipient?
A. Increase in abd pressure from CO2 insufflation
B. Drainage of ascites with significant fluid shift
C. Tremendous blood loss
D. Increased SNS activity
B. Drainage of ascites with significant fluid shift -- can unmask volume depletion
A. Liver donor and recipient are both open cases
C. More significant blood loss during resection of the liver, not on initial incision
D. Increased SNS would increase BP
Assign each effect to either Bicaval or Piggyback clamping during the anhepatic phase:
A. Newer, more common technique
B. Significant drop in cardiac preload
C. Preserves preload and caval blood flow
D. Potential for volume overload with fluid and blood administration
E. Reduces operative time and blood product administration
F. Will lead to profound hypotension and tachycardia
Bicaval: B, D, F
Piggyback: A, C, E
A common physiologic change that occurs among solid organ donors as a consequence of brain death is:
A. Hyperthermia
B. Hypoglycemia
C. Diabetes Insipidus
D. DVT
C. Diabetes Insipidus
A. Pt would be hypothermic, not hyperthermic
B. Pt is normally hyperglycemic, not hypoglycemic
D. Normally DIC, not DVT
Before the harvesting surgeons clamp the aorta, what do you need to make sure has been adjusted? (think equipment)
What medication is sometimes administered during kidney transplantation to decrease the chance of arterial spasms with anastomosis?
Verapamil
What is an ideal K level during the anhepatic phase?
A. 4
B. 4.5
C. 3
D. 3.5
C. 3
"no K is too low during this time" since it will skyrocket with the reperfusion of the new liver. Kelly said under 3 she would start to worry maybe a little bit
What reasons would you give for doing an RSI intubation with an end-stage liver patient?
- Ascites is considered a full stomach with delayed gastric emptying
- Encephalopathic patients may not be able to report nausea
What are the hallmark hemodynamic changes seen in end-stage liver disease?
High CO (EF is good since there is barely resistance)
Low SVR
Low BP
Why would we use the following infusions during a brain-dead donor case?
1. DDAVP
2. Insulin and Dextrose
3. Muscle relaxants
4. Albumin
5. Mannitol
1. Maintain SVR at 800-1200, also can help with DI
2. Manage hyperglycemia to keep BG <200
3. Spinal reflexes are still intact and can make pt move
4. Use with fluids to avoid having to give pressors
5. Help flush out the kidneys before harvesting
What are some medications that we would avoid in kidney transplant patients? SATA
Fentanyl
Propofol
Succinylcholine
Morphine
Sevoflurane
NSAIDs
Tylenol
Cisatricurium
Phenylephrine
Succinylcholine - K increase if they're ESRD
Morphine - histamine release and active metabolites to be excreted by kidney
NSAIDs - negative effect on renal perfusion
Phenylephrine - vasoconstriction to new graft site
What do you want to prepare prior to starting the neohepatic phase of liver transplantation? SATA
A. Prepare to increase VA
B. Have morphine in-line ready to push
C. Load Belmont infuser with 50/50 FFP and RBC
D. Have vasopressors in your hand ready to push
E. Prepare to increase MV
C. Load Belmont infuser with 50/50 FFP and RBC (may need to treat a lot of hemorrhaging)
D. Have vasopressors in your hand ready to push (will be very hypotensive)
E. Prepare to increase MV (get a little alkalotic to combat wave of acidosis coming)
DONT
A. Prepare to increase VA -- should decrease/turn off VA
B. Have morphine in-line ready to push -- morphine is primarily dependent on liver metabolism. AVOID IT
A. Ureteral obstructions
B. Thrombosis in new organ
C. Infection
D. Cardiovascular complications
D. Cardiovascular complications r/t electrolyte imbalances and previous cardiovascular disease
Which of the following is routine for intraoperative management of living kidney donors?
A. Phenylephrine infusion
B. CVP monitoring
C. Arterial line
D. Indwelling urinary catheter
D. Indwelling urinary catheter --- gotta make sure there is at least 10-20mL/kg/hr of UOP
A. Phenylephrine infusion - NO. use ephedrine or fluids to avoid vasconstriction at the graft site
B. CVP monitoring - Rare. Donor should be a regular healthy person without need for this monitoring
C. Arterial line - possibly, but not always. Donor should be a regular healthy person without need for this monitoring
List as many pathological consequences of brain death as you can (8 were listed on the slide)
1. Hypertension (can be HoTN from vasodilation/cardiac dysfunction too, but more commonly HTN related to catecholamine storm)
2. Bradycardia and other arryhythmias
3. pHTN
4. DI
5. Inflammatory changes
6. DIC
7. Hypothermia
8. Hyperglycemia
What are some lab values that you would be closely monitoring after reperfusion of the new kidney?
lots of metabolic waste products will reenter circulation: Lactic acid / K
new kidney cant concentrate urine yet, so a lot of electrolyte abnormalities: K / Na / Ca etc
What labs will you be checking throughout a liver transplant case? SATA
A. ABG
B. H/H
C. Electrolyte panel
D. POC Glucose
E. TEG
All of them :)
Q30 minutes of Q1 hour depending on the stage of the case
What are some hemodynamic effects seen in post-reperfusion syndrome after a liver transplant? SATA
A. Decreased CO
B. Pulmonary artery hypertension
C. Tachycardia
D. Systemic hypotension
E. Increased EF
F. Increased CVP and PCWP
G. Bradycardia / asystole
A. Decreased CO
B. Pulmonary artery hypertension
D. Systemic hypotension
F. Increased CVP and PCWP
G. Bradycardia / asystole
avoid citrate intoxication since you'll be giving a crazy amount of blood products