Anesthesia for Organ Anesthesia for Organ TransplantationTransplantation

By Anselmo SernaBy Anselmo Serna

Greg McMichaelGreg McMichael

All vital organs: Heart, Lung, Liver All vital organs: Heart, Lung, Liver and Kidney, can be supported by and Kidney, can be supported by

technology or replaced by technology or replaced by transplantation.transplantation.

Except the brain, it is the only organ that cannot be functionally supported or replaced.

TransplantationTransplantation Expertise in the anesthetic management of Expertise in the anesthetic management of

the organ recipient as well as the organ the organ recipient as well as the organ donor has a major impact on the quality of donor has a major impact on the quality of the graft organ, the viability of the the graft organ, the viability of the transplanted graft, and as a result the long transplanted graft, and as a result the long term survival of the transplant recipient. term survival of the transplant recipient.

Training in organ transplantation anesthesia Training in organ transplantation anesthesia will result in better initial management of will result in better initial management of these patients, innovative therapeutic these patients, innovative therapeutic interventions in the future, and improved interventions in the future, and improved outcome among transplanted patients.outcome among transplanted patients.

How much does an organ How much does an organ transplant cost?transplant cost?

Bone Marrow - $250,000Bone Marrow - $250,000 Heart - $300,000Heart - $300,000 Heart/Lung - $300,000 to $350,000Heart/Lung - $300,000 to $350,000 Isolated Small Bowel Transplant - Isolated Small Bowel Transplant -

$350,000$350,000 Kidney - $75,000 to $100,000Kidney - $75,000 to $100,000 Kidney/Pancreas - $150,000Kidney/Pancreas - $150,000 Liver - $250,000Liver - $250,000 Lung - $200,000 to $250,000Lung - $200,000 to $250,000 Pancreas - $100,000Pancreas - $100,000

Most Transplant Most Transplant Patients...Patients...

Are in surgery approximately 3-7 Are in surgery approximately 3-7 hours hours

Spend 1 day on the ventilator Spend 1 day on the ventilator Spend 1-2 days in the intensive care Spend 1-2 days in the intensive care

unit unit Are discharged 7-12 days after their Are discharged 7-12 days after their

surgery surgery

Reasons not to Reasons not to transplanttransplant

Advanced heart, kidney or liver disease Advanced heart, kidney or liver disease HIV infection HIV infection Cancer Cancer Hepatitis B Hepatitis B Hepatits C with proven cirrhosis by liver biopsy Hepatits C with proven cirrhosis by liver biopsy Current substance abuse: tobacco, alcohol and Current substance abuse: tobacco, alcohol and

illicit drugs illicit drugs Body weight less than 80% or greater than 120% Body weight less than 80% or greater than 120%

of predicted of predicted Inability to carry out the responsibilities Inability to carry out the responsibilities

necessary to maintain a healthy lifestyle and necessary to maintain a healthy lifestyle and remain compliant with all medications remain compliant with all medications

Candidacy for Candidacy for Transplantation Transplantation

The evaluation consists of: The evaluation consists of: Bloodwork Bloodwork Urine tests Urine tests Radiologic tests Radiologic tests Heart and Lung tests Heart and Lung tests Tests for osteoporosis Tests for osteoporosis Dental consult Dental consult Interview with a social worker Interview with a social worker Gastrointestinal consult for patients with Gastrointestinal consult for patients with

scleroderma or a history of reflux scleroderma or a history of reflux Females: pap smear and mammogram Females: pap smear and mammogram

TransplantationTransplantation Transplantation is a multidisciplinary field Transplantation is a multidisciplinary field

that encompasses a wide range of basic and that encompasses a wide range of basic and clinical medical and biological sciences. clinical medical and biological sciences.

The science of transplantation constitutes a The science of transplantation constitutes a biochemical, pathophysiologic, and clinical biochemical, pathophysiologic, and clinical continuum from organ donor to organ continuum from organ donor to organ recipient. recipient.

A better understanding of the biochemical, A better understanding of the biochemical, pathophysiologic and clinical problems pathophysiologic and clinical problems encountered in the management of the encountered in the management of the organ transplant recipient and organ donor organ transplant recipient and organ donor can be achieved through a broad based can be achieved through a broad based multidisciplinary approach. multidisciplinary approach.

Liver TransplantsLiver Transplants Liver transplants are performed in many centers Liver transplants are performed in many centers

across the country. The healthy liver is obtained across the country. The healthy liver is obtained from a donor who has recently died but has not from a donor who has recently died but has not suffered liver injury. The healthy liver is suffered liver injury. The healthy liver is transported in a cooled saline solution that transported in a cooled saline solution that preserves the organ for up to 8 hours, thus preserves the organ for up to 8 hours, thus permitting the necessary analysis to determine permitting the necessary analysis to determine blood and tissue donor-recipient matching. The blood and tissue donor-recipient matching. The diseased liver is removed through an incision diseased liver is removed through an incision made in the upper abdomen. The new liver is put made in the upper abdomen. The new liver is put in place and attached to the patient's blood in place and attached to the patient's blood vessels and bile ducts. The operation can take up vessels and bile ducts. The operation can take up to 12 hours to complete and requires large to 12 hours to complete and requires large volumes of blood transfusions. volumes of blood transfusions.

Anesthesia TechniquesAnesthesia Techniques There is no particular “liver anesthetic.” It is, There is no particular “liver anesthetic.” It is,

however, recommended that a uniform however, recommended that a uniform approach be used initially. For induction and approach be used initially. For induction and intubation, fentanyl, sodium intubation, fentanyl, sodium pentothal/etomidate, low dose non-depolarizing pentothal/etomidate, low dose non-depolarizing muscle relaxant, and succinylcholine will be muscle relaxant, and succinylcholine will be used. Anesthesia will be maintained with used. Anesthesia will be maintained with fentanyl, benzodiazepines, non-depolarizing fentanyl, benzodiazepines, non-depolarizing muscle relaxant, and isoflurane in air/oxygen. muscle relaxant, and isoflurane in air/oxygen. 5 cm PEEP will be used to reduce the risk of air 5 cm PEEP will be used to reduce the risk of air emboli and to prevent atelectasis.emboli and to prevent atelectasis.

Use caution in administering N2O as its use Use caution in administering N2O as its use may lead to bowel distention and can may lead to bowel distention and can compromise surgical exposure.compromise surgical exposure.

PreparationPreparation

MonitorsMonitors: central line for fluid : central line for fluid replacement; CVP for monitoring fluid replacement; CVP for monitoring fluid status; a-line for beat-to-beat status; a-line for beat-to-beat monitoring of heart rate/pressure and monitoring of heart rate/pressure and multiple blood draws; foley catheter multiple blood draws; foley catheter for urine outputfor urine output

2 large-bore peripheral IVs (16g or 2 large-bore peripheral IVs (16g or greater) for blood replacementgreater) for blood replacement

Rapid transfusersRapid transfusers Fluid and body warmers Fluid and body warmers

Blood and Blood Blood and Blood ProductsProducts

Typical transfusion requirements Typical transfusion requirements consists of:consists of:– 15-30 units of PRBCs15-30 units of PRBCs– 15-25 units of platelets15-25 units of platelets– 15-30 units of FFP15-30 units of FFP– 10-20 units of cryoprecipitate 10-20 units of cryoprecipitate – Cell saver also helpful in reducing Cell saver also helpful in reducing

reliance on donor RBC transfusions reliance on donor RBC transfusions

Intraoperatively Intraoperatively

Procedure lasts 4-18 hours and is Procedure lasts 4-18 hours and is divided into three phases:divided into three phases:– DissectionDissection– AnhepaticAnhepatic– Revascularization Revascularization

DissectionDissection

Through a wide subcostal incision the Through a wide subcostal incision the liver is dissected so that it remains liver is dissected so that it remains attached only by the inferior attached only by the inferior venacava, portal vein, hepatic artery venacava, portal vein, hepatic artery and common bile duct. and common bile duct.

Previous abdominal procedures Previous abdominal procedures greatly prolong the duration of this greatly prolong the duration of this phasephase

AnhepaticAnhepatic

Once the liver is freed the inferior Once the liver is freed the inferior venacava is clamped above and venacava is clamped above and below the liver as well as the hepatic below the liver as well as the hepatic artery and portal veinartery and portal vein

Liver is then completely excised and Liver is then completely excised and venovenous bypass may be venovenous bypass may be employed at this timeemployed at this time

Donor liver is then anastomosed to Donor liver is then anastomosed to recipient patientrecipient patient

Venovenous BypassVenovenous Bypass When inferior venacava and portal vein When inferior venacava and portal vein

are clamped marked decreases in are clamped marked decreases in cardiac output and hypotension are cardiac output and hypotension are typically encountered. For patients typically encountered. For patients identified at increased risk for venacava identified at increased risk for venacava clamping, venovenous bypass is used. clamping, venovenous bypass is used.

Venovenous bypass can help minimize Venovenous bypass can help minimize severe hypotension, intestinal ischemia, severe hypotension, intestinal ischemia, build up of acid metabolites and build up of acid metabolites and postoperative renal dysfunctionpostoperative renal dysfunction

RevascularizationRevascularization

Following completion of venous Following completion of venous anastemosis the venous clamps are anastemosis the venous clamps are removed and the circulation to the removed and the circulation to the new liver is completednew liver is completed

Lastly the common bile duct of the Lastly the common bile duct of the donor is then connected to the donor is then connected to the recipientrecipient

Management of liver Management of liver reperfusionreperfusion

Take steps to bring potassium to appropriate level (< 4.0) Take steps to bring potassium to appropriate level (< 4.0) Discuss at least 4 ways to reduce potassium Discuss at least 4 ways to reduce potassiumReplace calcium to ensure normal (Replace calcium to ensure normal (>> 5.0) 5.0)Correct lactic acidosis (pH normal)Correct lactic acidosis (pH normal)Appropriate volume infusion to maintain euvolemiaAppropriate volume infusion to maintain euvolemiaHemoglobin appropriate (9 – 10 for most patients)Hemoglobin appropriate (9 – 10 for most patients)Calcium 100mg/cc attached to iv ready for administration.Calcium 100mg/cc attached to iv ready for administration.Epinephrine 10 mcg/cc attached to iv ready for Epinephrine 10 mcg/cc attached to iv ready for administrationadministrationEpinephrine 20 mcg/cc on baxter pump ready for infusionEpinephrine 20 mcg/cc on baxter pump ready for infusionCommunication with surgeon – OK for reperfusionCommunication with surgeon – OK for reperfusion

Heart TransplantHeart Transplant

Indications for TransplantIndications for Transplant Idiopathic or ischemic cardiomyopathyIdiopathic or ischemic cardiomyopathy Viral cardiomyopathyViral cardiomyopathy Inoperable coronary artery disease with Inoperable coronary artery disease with

congestive heart failure congestive heart failure LV ejection fraction less than 20%LV ejection fraction less than 20% Amyloidosis Amyloidosis Severe congenital heart disease without other Severe congenital heart disease without other

surgical options surgical options Life-threatening abnormal heart rhythms that Life-threatening abnormal heart rhythms that

do not respond to other therapydo not respond to other therapy Inoperable heart valve disease with Inoperable heart valve disease with

congestive heart failure congestive heart failure

Most Common Causes of End Most Common Causes of End Stage Cardiac FailureStage Cardiac Failure

Coronary artery disease Coronary artery disease CardiomyopathyCardiomyopathy

– 90 percent of heart transplants90 percent of heart transplants Congenital and valvular heart Congenital and valvular heart

disease disease – A small percentage of end stage heart A small percentage of end stage heart

failurefailure

Pathophysiology Pathophysiology

End stage Cardiomyopathy: both End stage Cardiomyopathy: both systolic and diastolic dysfunctionsystolic and diastolic dysfunction

Decreased SVDecreased SV Decreased CODecreased CO Decreased O2 transport and Decreased O2 transport and

exercise capacityexercise capacity Multiple comorbitities usually Multiple comorbitities usually

including DM, HTN, PVD, renal including DM, HTN, PVD, renal dysfunction dysfunction

Compensatory MechanismsCompensatory Mechanisms

Renal retention of NA and H2ORenal retention of NA and H2O Increased preloadIncreased preload

SNS stimulation SNS stimulation Increased HR and contractilityIncreased HR and contractility

Increased endogenous Increased endogenous catecholaminescatecholamines

Increased contractility Increased contractility

Decreased venous capitance Decreased venous capitance Increased preloadIncreased preload

Failed Compensatory Failed Compensatory MechanismsMechanisms

Increased PreloadIncreased Preload Dilated LV, Mitral Regurg, pulmonary edemaDilated LV, Mitral Regurg, pulmonary edema

Increased afterload Increased afterload HypertrophyHypertrophy

Increased contractility from increased Increased contractility from increased endogenous catecholaminesendogenous catecholamines

Leading to a decrease in the sensitivity of the heart and the Leading to a decrease in the sensitivity of the heart and the vasculature to these agents via a decrease in receptors vasculature to these agents via a decrease in receptors (down-regulation)(down-regulation)

Decrease in the myocardial norepinephrine storesDecrease in the myocardial norepinephrine stores Increased afterloadIncreased afterload Decreased CODecreased CO

Renal retention of Na and H2ORenal retention of Na and H2O pulmonary vascular congestion and edema, ascitespulmonary vascular congestion and edema, ascites

TreatmentTreatment Diuretics Diuretics

May result in hypokalemia and hypomagnesemia and hypovolemiaMay result in hypokalemia and hypomagnesemia and hypovolemia Slow incremental Slow incremental BB-Blockade (metoprolol)-Blockade (metoprolol)

Can improve hemodynamics and improve exercise tolerance in pts awaiting Can improve hemodynamics and improve exercise tolerance in pts awaiting transplanttransplant

Inotropes (amiodarone, milrinone, enoximone)Inotropes (amiodarone, milrinone, enoximone) Toxic side effects and increased mortalityToxic side effects and increased mortality

AnticoagulantsAnticoagulants Prevent pulmonary and systemic embolizationPrevent pulmonary and systemic embolization

DigitalisDigitalis Weak inotrope with toxic side effectsWeak inotrope with toxic side effects

Vasodilators (nitrates, hydralazine, ACE inhibitors)Vasodilators (nitrates, hydralazine, ACE inhibitors) Decrease the impedance to LV emptyingDecrease the impedance to LV emptying

Intraaortic balloon counterpulsationIntraaortic balloon counterpulsation Vascular complications and immobilizes ptsVascular complications and immobilizes pts

VADsVADs Improves myocyte contractile properties and increases Improves myocyte contractile properties and increases BB-adrenergic -adrenergic

responsivenessresponsiveness

Donor CaveatsDonor Caveats

Donors can exhibit major Donors can exhibit major hemodynamic and metabolic hemodynamic and metabolic changes and thus should be changes and thus should be constantly monitored with inotropic constantly monitored with inotropic and vasopressor supportand vasopressor support

HypovolemiaHypovolemia Myocardial injuryMyocardial injury Catecholamine stormCatecholamine storm Inadequate sympathetic tone due to Inadequate sympathetic tone due to

brainstem infarctbrainstem infarct

Donor CardiectomyDonor Cardiectomy

Median sternotomy and heparinizationMedian sternotomy and heparinization

Cannulation of the ascending aorta for Cannulation of the ascending aorta for cold hyperkalemic cardioplegiacold hyperkalemic cardioplegia

SVC ligated, IVC transected to SVC ligated, IVC transected to decompress the heartdecompress the heart

Topically cooled with iced salineTopically cooled with iced saline

Donor Cardiectomy (cont’d)Donor Cardiectomy (cont’d)

After arrest, pulmonary veins are After arrest, pulmonary veins are severedsevered

SVC transectedSVC transected Ascending aorta divided just proximal to Ascending aorta divided just proximal to

the innominate arterythe innominate artery PA transected at its bifurcationPA transected at its bifurcation Heart is then transported via ice chestHeart is then transported via ice chest Upper time limit for ex vivo storage of Upper time limit for ex vivo storage of

human hearts is approximately 6 hourshuman hearts is approximately 6 hours

Transplantation: PreopTransplantation: Preop

Rapid H&P of recipient due to time constraintsRapid H&P of recipient due to time constraints Equipment and drugs similar to those usually Equipment and drugs similar to those usually

used for routine cases requiring CPB should be used for routine cases requiring CPB should be preparedprepared

Placement of invasive monitoringPlacement of invasive monitoring PA catheter, arterial line, TEEPA catheter, arterial line, TEE CO, PVR, CVPCO, PVR, CVP

Aspiration PrecautionsAspiration Precautions Blood products: CMV negativeBlood products: CMV negative Aseptic technique with broad spectrum Aseptic technique with broad spectrum

antibiotic prophylaxisantibiotic prophylaxis

Transplantation: IntraopTransplantation: Intraop Induction of Anesthesia balances risk of aspiration of gastric Induction of Anesthesia balances risk of aspiration of gastric

contents with hemodynamic changescontents with hemodynamic changes– High dose narcotic with muscle relaxant and benzodiazepinesHigh dose narcotic with muscle relaxant and benzodiazepines– RSI: etomidate, succinylcholine, moderate dose fentanylRSI: etomidate, succinylcholine, moderate dose fentanyl

Most patients called in for transplantation have not fasted and should be Most patients called in for transplantation have not fasted and should be considered to have a full stomachconsidered to have a full stomach

Induction should be preformed in the presence of the surgeon, Induction should be preformed in the presence of the surgeon, scrub nurse and perfusionist in anticipation for cardiovascular scrub nurse and perfusionist in anticipation for cardiovascular collapsecollapse

Anticipate altered drug responses due to low CO and slow Anticipate altered drug responses due to low CO and slow circulation time as well as decreased volume of distributioncirculation time as well as decreased volume of distribution

Preinduction administration of inotropic agents or pressors Preinduction administration of inotropic agents or pressors optimizes circulation and minimizes transit time of subsequently optimizes circulation and minimizes transit time of subsequently administered anestheticsadministered anesthetics

Transplantation: Intraop Transplantation: Intraop (cont’d)(cont’d)

Maintenance of AnesthesiaMaintenance of Anesthesia– High dose narcotic, benzodiazepines, High dose narcotic, benzodiazepines,

muscle relaxant, O2, low dose volatile muscle relaxant, O2, low dose volatile agentagent High dose narcotic can cause ventricular High dose narcotic can cause ventricular

arrhythmiasarrhythmias Volatile agents can cause pre-CPB hypotensionVolatile agents can cause pre-CPB hypotension

– OG and foley placedOG and foley placed– The PA should be withdrawn from the right The PA should be withdrawn from the right

heart prior to completion of bicaval heart prior to completion of bicaval cannulationcannulation

Cardiopulmonary BypassCardiopulmonary Bypass Hypothermia 28-30* CHypothermia 28-30* C Furosemide to promote UOFurosemide to promote UO Hemoconcentration for expanded blood volumeHemoconcentration for expanded blood volume Anastamosis: LA, RA, PA, aortaAnastamosis: LA, RA, PA, aorta Glucocorticoid (methylprednisone 500 mg) is administered as the last Glucocorticoid (methylprednisone 500 mg) is administered as the last

anastamosis is being completed prior to the release of the aortic cross anastamosis is being completed prior to the release of the aortic cross clamp to attenuate any hyperacute immune reaction.clamp to attenuate any hyperacute immune reaction.

TEE used to monitor whether the cardiac chambers are adequately de-TEE used to monitor whether the cardiac chambers are adequately de-aired and can diagnose atrial torsion, RV outflow obstruction, and aired and can diagnose atrial torsion, RV outflow obstruction, and decreased R or L ventricular systolic functiondecreased R or L ventricular systolic function

Longer rewarming periodLonger rewarming period During reperfusion, an infusion of an inotrope is begun for both inotropy During reperfusion, an infusion of an inotrope is begun for both inotropy

and chronotropyand chronotropy Donor heart should be paced if bradycardic despite inotrope infusion also Donor heart should be paced if bradycardic despite inotrope infusion also

the possibility of IABP, ECMO, or LVADthe possibility of IABP, ECMO, or LVAD RV dysfunction from elevated PVR is the most common cause of RV dysfunction from elevated PVR is the most common cause of

perioperative heart failure, use of pulmonary vasodilators: milrinone, nitric perioperative heart failure, use of pulmonary vasodilators: milrinone, nitric oxide, sodium nitroprussideoxide, sodium nitroprusside

Arrhythmias: slow junctional or AV nodal, V fibArrhythmias: slow junctional or AV nodal, V fib

Transplantation: PostopTransplantation: Postop Low CO after transplant may be due to: hypovolemia, inadequate Low CO after transplant may be due to: hypovolemia, inadequate

adrenergic stimulation, myocardial injury during harvesting, acute adrenergic stimulation, myocardial injury during harvesting, acute rejection, tamponade, sepsis.rejection, tamponade, sepsis.

Systemic hypertension may be due to pain, adequate analgesia is Systemic hypertension may be due to pain, adequate analgesia is provided before vasodilatorsprovided before vasodilators

Atrial and ventricular tachyarrythmias are common in the Atrial and ventricular tachyarrythmias are common in the immediate postop period, once rejection has been ruled out, immediate postop period, once rejection has been ruled out, antiarrythmics are used for conversion (except those with indirect antiarrythmics are used for conversion (except those with indirect acting mechanisms or negative inotropes)acting mechanisms or negative inotropes)

Many patients require pacing in the immediate postop period and Many patients require pacing in the immediate postop period and 10-25% require permanent pacing10-25% require permanent pacing

Renal function often improves following transplantation, but Renal function often improves following transplantation, but immunosuppressants may again impair renal functionimmunosuppressants may again impair renal function

Bacterial pneumonia is very common in the early postop period Bacterial pneumonia is very common in the early postop period and opportunistic viral and fungal infections after the first several and opportunistic viral and fungal infections after the first several weeksweeks

Pharmacological Agents After Pharmacological Agents After TransplantTransplant

The transplanted heart has no autonomic The transplanted heart has no autonomic innervationinnervation

Agents that act indirectly via the Agents that act indirectly via the sympathetic or parasympathetic system sympathetic or parasympathetic system (atropine, ephedrine) will be ineffective. (atropine, ephedrine) will be ineffective.

Drugs with a direct/indirect effect will only Drugs with a direct/indirect effect will only have their direct effect seen. have their direct effect seen.

Drugs of choice are direct effect – Drugs of choice are direct effect – isoproterenol, epinephrine, etc.isoproterenol, epinephrine, etc.

May require pacingMay require pacing

Cardioactive Drug Responses Cardioactive Drug Responses in the Denervated Heartin the Denervated Heart

AdenosineAdenosine AtropineAtropine DigoxinDigoxin EdrophoniumEdrophonium EphedrineEphedrine NorepinephrineNorepinephrine PancuroniumPancuronium PhenylephrinePhenylephrine NifedipineNifedipine

SupersensitivitySupersensitivity No vagolytic effectNo vagolytic effect No vagotonic effectNo vagotonic effect No vagotonic effectNo vagotonic effect Less cardiostimulationLess cardiostimulation Unmasked beta Unmasked beta

effectseffects No vagolytic effectNo vagolytic effect Diminished sensitivityDiminished sensitivity Nodal conduction not Nodal conduction not

depresseddepressed

Anesthesia for Patients With Anesthesia for Patients With Previous TransplantPrevious Transplant

Transplanted patients require anesthetic for surgical procedures that may Transplanted patients require anesthetic for surgical procedures that may or may not be cardiac relatedor may not be cardiac related

Preoperative evaluation includes extensive reevaluation of cardiac functionPreoperative evaluation includes extensive reevaluation of cardiac function Systolic function is usually normal but a significant number of patients Systolic function is usually normal but a significant number of patients

develop diastolic dysfunction, manifested as exercise intolerancedevelop diastolic dysfunction, manifested as exercise intolerance Abnormalities in isovolumic relaxation time correspond with varying Abnormalities in isovolumic relaxation time correspond with varying

degrees of rejectiondegrees of rejection Increased peak inflow velocity and mitral deceleration are indicators of Increased peak inflow velocity and mitral deceleration are indicators of

restrictive fillingrestrictive filling Rejection causes inflammatory infiltrate that causes edemaRejection causes inflammatory infiltrate that causes edema The presence of rejection increases perioperative morbidity and the The presence of rejection increases perioperative morbidity and the

incidence of asymptomatic arrhythmiasincidence of asymptomatic arrhythmias Complication related to immunosuppression should be considered, Complication related to immunosuppression should be considered,

including opportunistic infectionsincluding opportunistic infections Immunosuppressants side effects include nephrotoxity as well as Immunosuppressants side effects include nephrotoxity as well as

neurotoxicity and cyclosporin is associated with cholelithiasis, increasing neurotoxicity and cyclosporin is associated with cholelithiasis, increasing the incidence of cholecystectomy in these patientsthe incidence of cholecystectomy in these patients

Repeated biopsies for routine transplant management may cause injury to Repeated biopsies for routine transplant management may cause injury to the tricuspid valve with severe tricuspid regurgthe tricuspid valve with severe tricuspid regurg

Often requires tricuspid valve replacementOften requires tricuspid valve replacement

Anesthesia for Patients With Anesthesia for Patients With Previous TransplantPrevious Transplant

Choice of anesthetic depends on the type of surgery and condition of the Choice of anesthetic depends on the type of surgery and condition of the patientpatient

Regional anesthesia can be used cautiously, with the knowledge that these Regional anesthesia can be used cautiously, with the knowledge that these patients cannot mount the usual response to vasodilation and hypotensionpatients cannot mount the usual response to vasodilation and hypotension

Cardiovascular monitoring is dependent on the nature of the planned Cardiovascular monitoring is dependent on the nature of the planned surgery. Invasive monitoring is not necessary for minor procedures. surgery. Invasive monitoring is not necessary for minor procedures. Intraoperative echocardiography is important in managing volume status.Intraoperative echocardiography is important in managing volume status.

The ECG may have a double P wave, reflecting atrial activity in the native The ECG may have a double P wave, reflecting atrial activity in the native atrial cuff and the transplanted atriumatrial cuff and the transplanted atrium

Cardiac output of the transplanted heart is preload dependent and rely on Cardiac output of the transplanted heart is preload dependent and rely on changes in stroke volume. Ephedrine or isoproterenol should be readily changes in stroke volume. Ephedrine or isoproterenol should be readily available to treat bradycardia as atropine will not have an effect.available to treat bradycardia as atropine will not have an effect.

Patients with prior heart transplantation have undergone successful Patients with prior heart transplantation have undergone successful pregnanciespregnancies

Lung TransplantationLung Transplantation

OverviewOverview

IndicationsIndications: end-stage parenchymal : end-stage parenchymal disease or pulomonary hypertension. disease or pulomonary hypertension. Candidates are functionally Candidates are functionally incapacitate by dyspnea and have a incapacitate by dyspnea and have a poor prognosis.poor prognosis.

Criteria varies according to the Criteria varies according to the primary disease processprimary disease process

Single vs. Double Lung Single vs. Double Lung TransplantTransplant

Single-lung transplantation may be performed for selected patients with chronic obstructive pulmonary disease, whereas double-lung transplantation is typically performed for patients with cystic fibrosis, bullous emphysema, or vascular diseases. Younger patients are more likely to receive bilateral lung transplants.

Single Lung TransplantationSingle Lung Transplantation

Often attempted without CPB. Often attempted without CPB. Procedure is performed through a Procedure is performed through a posterior thoracotomy. A double-posterior thoracotomy. A double-lumen tube must be used for one-lumen tube must be used for one-lung ventilation. lung ventilation.

CPB during transplantation of one CPB during transplantation of one lung is based on arterial hypoxemia lung is based on arterial hypoxemia (spO2 <88%) or a sudden increase in (spO2 <88%) or a sudden increase in PA pressures. PA pressures.

CPB for one lungCPB for one lung

When CPB is necessary, femoral-vein-to-femoral-artery bypass is employed during left thoracotomy, whereas right-atrium-to-aorta bypass is used during right thoracotomy.

Double-Lung Transplantation

A "clamshell" transverse sternotomy can be used for double-lung transplantation.

The procedure is occasionally performed with normothermic CPB; sequential thoracotomies for double-lung transplantation without CPB is more common.

Induction

modified rapid-sequence induction with moderate head-up position

A slow induction withketamine, etomidate, an opioid is employed to avoid precipitous drops in blood pressure.

Succinylcholine or a nondepolarizing NMBA is used to facilitate laryngoscopy.

Hypoxemia and hypercarbia must be avoided to prevent further increases in pulmonary artery pressure.

Maintenance of Anesthesia

Anesthesia is usually maintained with an opioid infusion with or without a low dose of a volatile agent.

Intraoperative difficulties in ventilation are not uncommon. Progressive retention of CO2 can also be a problem intraoperatively. Ventilation should be adjusted to maintain a normal arterial pH to limit metabolic alkalosis.

Patients with cystic fibrosis have copious secretions and require frequent suctioning.

Posttransplantation Management

After anastomosis ventilation to both lungs is resumed

peak inspiratory pressures should be maintained at the minimum pressure compatible with good lung expansion, and the inspired oxygen concentration should be maintained at <60%.

Methylprednisolone is usually given prior to release of vascular clamps.

Renal TransplantationRenal Transplantation

Renal Transplant PhysiologyRenal Transplant Physiology

Renal Transplant OverviewRenal Transplant Overview The success of renal transplantation, which is

largely due to advances in immunosuppressive therapy, has greatly improved the quality of life for patients with end-stage renal disease

With modern immunosuppressive regimens, cadaveric transplants have achieved almost the same 3-year graft survival rates (80–90%) as living related donor grafts

In addition, restrictions on candidates for renal transplantation have gradually decreased; infection and cancer are the only remaining absolute contraindications with advanced age (>60) and severe cardiovascular disease being relative contraindications

Preoperative ConsiderationsPreoperative Considerations Preoperative optimization of the patient's

medical condition with dialysis is mandatory Current organ preservation techniques allow

ample time (24–48 h) for preoperative dialysis of cadaveric recipients

Living-related transplants are performed electively with the donor and recipient anesthetized simultaneously but in separate rooms

The recipient's serum potassium concentration should be below 5.5 mEq/L, and existing coagulopathies should be corrected

Pharmacologic agentsPharmacologic agents

All general anesthetic agents have been employed without any apparent detrimental effect on graft function; nonetheless, sevoflurane is best avoided

Atracurium, cisatracurium, and rocuronium may be the muscle relaxants of choice, as they are not primarily dependent on renal excretion for elimination.

Maintenance

Central venous pressure monitoring is very useful in ensuring adequate hydration but avoiding fluid overload

Normal saline or half-normal saline solutions are commonly used

A urinary catheter is placed to assess graft function postoperatively

Case StudyCase Study

A 23-year-old woman develops fulminant hepatic failure after ingesting wild mushrooms. She is not expected to survive without a liver transplant.

Preop, Induction, Preop, Induction, MaintenanceMaintenance

Ensure pt is T&C for prbc, ffp, plasma Ensure pt is T&C for prbc, ffp, plasma 2 large bore IVs2 large bore IVs Art line placement for BP variability and Art line placement for BP variability and

multiple lab drawmultiple lab draw RSI with anectine and etomidate. RSI with anectine and etomidate.

Cricoid pressure until Ett placement Cricoid pressure until Ett placement confirmedconfirmed

Maintenance with Iso at 1 MAC without Maintenance with Iso at 1 MAC without use of N20use of N20

Intra and PostopIntra and Postop

Placement of central line with CVP Placement of central line with CVP and Foley to monitor renal perfusionand Foley to monitor renal perfusion

Have pressors ready for induction Have pressors ready for induction and clamping of the blood vessels. and clamping of the blood vessels.

Admit pt to ICU, may need to stay Admit pt to ICU, may need to stay intubatedintubated

Question 1Question 1

Which organization oversees Organ Which organization oversees Organ Donation in the U. S.?Donation in the U. S.?

A. Health DepartmentA. Health Department B. National Institute of HealthB. National Institute of Health C. United Network for Organ Sharing C. United Network for Organ Sharing

(UNOS)(UNOS) D. Center for Disease ControlD. Center for Disease Control E. Department of Homeland SecurityE. Department of Homeland Security

Question 2Question 2

What is the most transplanted What is the most transplanted organ?organ?

A. LiverA. Liver B. HeartB. Heart C. KidneyC. Kidney D. PancreasD. Pancreas E. LungE. Lung

Question 3Question 3

Which anesthetic agent is not Which anesthetic agent is not recommended for kidney transplant?recommended for kidney transplant?

A. Low flow O2A. Low flow O2 B. DesfluraneB. Desflurane C. Nitrous OxideC. Nitrous Oxide D. SevofluraneD. Sevoflurane E. IsofluraneE. Isoflurane

Question 4Question 4 Which of the following individuals do not make Which of the following individuals do not make

the best candidates to receive a lung transplant?the best candidates to receive a lung transplant?

A. Cancer patientsA. Cancer patients B. HIV infection B. HIV infection C. Hepatitis B or Hepatits C with proven cirrhosis C. Hepatitis B or Hepatits C with proven cirrhosis

by liver biopsy by liver biopsy D. Current substance abuse: tobacco, alcohol and D. Current substance abuse: tobacco, alcohol and

illicit drugs illicit drugs E. Body weight less than 80% or greater than E. Body weight less than 80% or greater than

120% of predicted120% of predicted F. All of the above F. All of the above

Question 5Question 5

Which of the following organs cannot Which of the following organs cannot be transplanted at this time?be transplanted at this time?

A. LiverA. Liver B. KidneyB. Kidney C. HeartC. Heart D. LungD. Lung E. BrainE. Brain