Anesthesia for Organ Transplantation

1. Anesthesia for Organ Transplantation By Anselmo Serna Greg McMichael

2. UNOS Facts and Figures The United Network for Organ Sharing (UNOS) coordinates the nation's organ transplant system, providing vital services to meet the needs of men, women and children awaiting lifesaving organ transplants. Based in Richmond, Va., UNOS is a private, nonprofit membership organization. UNOS members encompass every transplant hospital, tissue matching laboratory and organ procurement organization in the United States, as well as voluntary health and professional societies, ethicists, transplant patients and organ donor advocates.UNOS Facts and Figures The United Network for Organ Sharing (UNOS) coordinates the nation's organ transplant system, providing vital services to meet the needs of men, women and children awaiting lifesaving organ transplants. Based in Richmond, Va., UNOS is a private, nonprofit membership organization. UNOS members encompass every transplant hospital, tissue matching laboratory and organ procurement organization in the United States, as well as voluntary health and professional societies, ethicists, transplant patients and organ donor advocates.

3. All vital organs: Heart, Lung, Liver and Kidney, can be supported by technology or replaced by transplantation.

4. Transplantation Expertise in the anesthetic management of the organ recipient as well as the organ donor has a major impact on the quality of the graft organ, the viability of the transplanted graft, and as a result the long term survival of the transplant recipient. Training in organ transplantation anesthesia will result in better initial management of these patients, innovative therapeutic interventions in the future, and improved outcome among transplanted patients.

5. Major Organs Transplanted Thoracic organs Heart (Deceased-donor only) Lung (Deceased-donor and Living-Donor) En bloc Heart/Lung (Deceased-donor and Domino transplant) Abdominal organs Kidney (Deceased-donor and Living-Donor) Liver (Deceased-donor and Living-Donor) Pancreas (Deceased-donor only) Intestine (Deceased-donor only) Tissues, Cells, Fluids Transplanted Hand (Deceased-donor only) Cornea (Deceased-donor only) Skin graft including Face replant (autograft) and Face transplant (extremely rare) Penis (Deceased-donor only) Islets of Langerhans (Pancreas Islet Cells) (Deceased-donor and Living-Donor) Bone marrow/Adult stem cell (Living-Donor and Autograft) Blood transfusion/Blood Parts Transfusion (Living-Donor and Autograft) Blood vessels (Autograft and Deceased-Donor) Heart valve (Deceased-Donor, Living-Donor and Xenograft[Porcine/bovine]) Bone (Deceased-Donor, Living-Donor, and Autograft) Skin (Deceased-Donor, Living-Donor, and Autograft) Major Organs Transplanted Thoracic organs Heart (Deceased-donor only) Lung (Deceased-donor and Living-Donor) En bloc Heart/Lung (Deceased-donor and Domino transplant) Abdominal organs Kidney (Deceased-donor and Living-Donor) Liver (Deceased-donor and Living-Donor) Pancreas (Deceased-donor only) Intestine (Deceased-donor only) Tissues, Cells, Fluids Transplanted Hand (Deceased-donor only) Cornea (Deceased-donor only) Skin graft including Face replant (autograft) and Face transplant (extremely rare) Penis (Deceased-donor only) Islets of Langerhans (Pancreas Islet Cells) (Deceased-donor and Living-Donor) Bone marrow/Adult stem cell (Living-Donor and Autograft) Blood transfusion/Blood Parts Transfusion (Living-Donor and Autograft) Blood vessels (Autograft and Deceased-Donor) Heart valve (Deceased-Donor, Living-Donor and Xenograft[Porcine/bovine]) Bone (Deceased-Donor, Living-Donor, and Autograft) Skin (Deceased-Donor, Living-Donor, and Autograft)

6. How much does an organ transplant cost? Bone Marrow - $250,000 Heart - $300,000 Heart/Lung - $300,000 to $350,000 Isolated Small Bowel Transplant - $350,000 Kidney - $75,000 to $100,000 Kidney/Pancreas - $150,000 Liver - $250,000 Lung - $200,000 to $250,000 Pancreas - $100,000 The cost of organ transplants varies greatly, not only with the type of transplant, but with the hospital where the procedure occurs. In addition, costs will climb greatly if the patient develops complications resulting in longer hospital stays. The costs below are broad averages for costs of various types of transplants, based on NFT’s experiences of working with patients all over the country. These costs are only for typical hospital and physician fees. They do not include any pre-transplant or follow-up treatments. The cost of organ transplants varies greatly, not only with the type of transplant, but with the hospital where the procedure occurs. In addition, costs will climb greatly if the patient develops complications resulting in longer hospital stays. The costs below are broad averages for costs of various types of transplants, based on NFT’s experiences of working with patients all over the country. These costs are only for typical hospital and physician fees. They do not include any pre-transplant or follow-up treatments.

7. Most Transplant Patients... Are in surgery approximately 3-7 hours Spend 1 day on the ventilator Spend 1-2 days in the intensive care unit Are discharged 7-12 days after their surgery

8. Reasons not to transplant Advanced heart, kidney or liver disease HIV infection Cancer Hepatitis B Hepatits C with proven cirrhosis by liver biopsy Current substance abuse: tobacco, alcohol and illicit drugs Body weight less than 80% or greater than 120% of predicted Inability to carry out the responsibilities necessary to maintain a healthy lifestyle and remain compliant with all medications

9. Candidacy for Transplantation The evaluation consists of: Bloodwork Urine tests Radiologic tests Heart and Lung tests Tests for osteoporosis Dental consult Interview with a social worker Gastrointestinal consult for patients with scleroderma or a history of reflux Females: pap smear and mammogram

10. Transplantation Transplantation is a multidisciplinary field that encompasses a wide range of basic and clinical medical and biological sciences. The science of transplantation constitutes a biochemical, pathophysiologic, and clinical continuum from organ donor to organ recipient. A better understanding of the biochemical, pathophysiologic and clinical problems encountered in the management of the organ transplant recipient and organ donor can be achieved through a broad based multidisciplinary approach.

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

12. A large, upper abdominal transverse incision is used for liver transplant. A large, upper abdominal transverse incision is used for liver transplant.

14. Liver failure causes many problems, including malnutrition, problems with blood clotting, bleeding form the gastrointestinal tract, and jaundice. Frequently, patients who undergo liver transplantation are quite ill, and require hospitalization in the Intensive Care Unit prior to surgery. Liver failure causes many problems, including malnutrition, problems with blood clotting, bleeding form the gastrointestinal tract, and jaundice. Frequently, patients who undergo liver transplantation are quite ill, and require hospitalization in the Intensive Care Unit prior to surgery.

16. Anesthesia Techniques There is no particular “liver anesthetic.” It is, however, recommended that a uniform approach be used initially. For induction and intubation, fentanyl, sodium pentothal/etomidate, low dose non-depolarizing muscle relaxant, and succinylcholine will be used. Anesthesia will be maintained with fentanyl, benzodiazepines, non-depolarizing muscle relaxant, and isoflurane in air/oxygen. 5 cm PEEP will be used to reduce the risk of air emboli and to prevent atelectasis. Use caution in administering N2O as its use may lead to bowel distention and can compromise surgical exposure.

17. Preparation Monitors: central line for fluid replacement; CVP for monitoring fluid status; a-line for beat-to-beat monitoring of heart rate/pressure and multiple blood draws; foley catheter for urine output 2 large-bore peripheral IVs (16g or greater) for blood replacement Rapid transfusers Fluid and body warmers

18. Blood and Blood Products Typical transfusion requirements consists of: 15-30 units of PRBCs 15-25 units of platelets 15-30 units of FFP 10-20 units of cryoprecipitate Cell saver also helpful in reducing reliance on donor RBC transfusions

19. Intraoperatively Procedure lasts 4-18 hours and is divided into three phases: Dissection Anhepatic Revascularization

20. Dissection Through a wide subcostal incision the liver is dissected so that it remains attached only by the inferior venacava, portal vein, hepatic artery and common bile duct. Previous abdominal procedures greatly prolong the duration of this phase

21. Anhepatic Once the liver is freed the inferior venacava is clamped above and below the liver as well as the hepatic artery and portal vein Liver is then completely excised and venovenous bypass may be employed at this time Donor liver is then anastomosed to recipient patient

22. Venovenous Bypass When inferior venacava and portal vein are clamped marked decreases in cardiac output and hypotension are typically encountered. For patients identified at increased risk for venacava clamping, venovenous bypass is used. Venovenous bypass can help minimize severe hypotension, intestinal ischemia, build up of acid metabolites and postoperative renal dysfunction

23. Revascularization Following completion of venous anastemosis the venous clamps are removed and the circulation to the new liver is completed Lastly the common bile duct of the donor is then connected to the recipient

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

25. Heart Transplant

26. Indications for Transplant Idiopathic or ischemic cardiomyopathy Viral cardiomyopathy Inoperable coronary artery disease with congestive heart failure LV ejection fraction less than 20% Amyloidosis Severe congenital heart disease without other surgical options Life-threatening abnormal heart rhythms that do not respond to other therapy Inoperable heart valve disease with congestive heart failure Amyloidosis is a rare and potentially fatal disease that occurs when substances called amyloid proteins build up in your organs. Amyloid is an abnormal protein usually produced by cells in your bone marrow that can be deposited in any tissue or organ Amyloidosis is a rare and potentially fatal disease that occurs when substances called amyloid proteins build up in your organs. Amyloid is an abnormal protein usually produced by cells in your bone marrow that can be deposited in any tissue or organ

27. Most Common Causes of End Stage Cardiac Failure Coronary artery disease Cardiomyopathy 90 percent of heart transplants Congenital and valvular heart disease A small percentage of end stage heart failure

28. Pathophysiology End stage Cardiomyopathy: both systolic and diastolic dysfunction Decreased SV Decreased CO Decreased O2 transport and exercise capacity Multiple comorbitities usually including DM, HTN, PVD, renal dysfunction

29. Compensatory Mechanisms Renal retention of NA and H2O Increased preload SNS stimulation Increased HR and contractility Increased endogenous catecholamines Increased contractility Decreased venous capitance Increased preload

30. Failed Compensatory Mechanisms Increased Preload Dilated LV, Mitral Regurg, pulmonary edema Increased afterload Hypertrophy Increased contractility from increased endogenous catecholamines Leading to a decrease in the sensitivity of the heart and the vasculature to these agents via a decrease in receptors (down-regulation) Decrease in the myocardial norepinephrine stores Increased afterload Decreased CO Renal retention of Na and H2O pulmonary vascular congestion and edema, ascites

31. Treatment Diuretics May result in hypokalemia and hypomagnesemia and hypovolemia Slow incremental B-Blockade (metoprolol) Can improve hemodynamics and improve exercise tolerance in pts awaiting transplant Inotropes (amiodarone, milrinone, enoximone) Toxic side effects and increased mortality Anticoagulants Prevent pulmonary and systemic embolization Digitalis Weak inotrope with toxic side effects Vasodilators (nitrates, hydralazine, ACE inhibitors) Decrease the impedance to LV emptying Intraaortic balloon counterpulsation Vascular complications and immobilizes pts VADs Improves myocyte contractile properties and increases B-adrenergic responsiveness

32. Donor Caveats Donors can exhibit major hemodynamic and metabolic changes and thus should be constantly monitored with inotropic and vasopressor support Hypovolemia Myocardial injury Catecholamine storm Inadequate sympathetic tone due to brainstem infarct

33. Donor Cardiectomy Median sternotomy and heparinization Cannulation of the ascending aorta for cold hyperkalemic cardioplegia SVC ligated, IVC transected to decompress the heart Topically cooled with iced saline

34. Donor Cardiectomy (cont’d) After arrest, pulmonary veins are severed SVC transected Ascending aorta divided just proximal to the innominate artery PA transected at its bifurcation Heart is then transported via ice chest Upper time limit for ex vivo storage of human hearts is approximately 6 hours

35. Transplantation: Preop Rapid H&P of recipient due to time constraints Equipment and drugs similar to those usually used for routine cases requiring CPB should be prepared Placement of invasive monitoring PA catheter, arterial line, TEE CO, PVR, CVP Aspiration Precautions Blood products: CMV negative Aseptic technique with broad spectrum antibiotic prophylaxis

36. Transplantation: Intraop Induction of Anesthesia balances risk of aspiration of gastric contents with hemodynamic changes High dose narcotic with muscle relaxant and benzodiazepines RSI: etomidate, succinylcholine, moderate dose fentanyl Most patients called in for transplantation have not fasted and should be considered to have a full stomach Induction should be preformed in the presence of the surgeon, scrub nurse and perfusionist in anticipation for cardiovascular collapse Anticipate altered drug responses due to low CO and slow circulation time as well as decreased volume of distribution Preinduction administration of inotropic agents or pressors optimizes circulation and minimizes transit time of subsequently administered anesthetics

37. Transplantation: Intraop (cont’d) Maintenance of Anesthesia High dose narcotic, benzodiazepines, muscle relaxant, O2, low dose volatile agent High dose narcotic can cause ventricular arrhythmias Volatile agents can cause pre-CPB hypotension OG and foley placed The PA should be withdrawn from the right heart prior to completion of bicaval cannulation Biatrial – (old technique) Recipient keeps most of there own atria. You have a right and left anastomoses. Bicaval – (new) Only the recipients small left atrial cuff is left behind containing the pulmonary veins This may decrease the incidence of arrhythmias, less sinus node dysfunction, preserve atria function, avoid tricuspid regurgitation, increase CO, decreased risk of thromboembolismBiatrial – (old technique) Recipient keeps most of there own atria. You have a right and left anastomoses. Bicaval – (new) Only the recipients small left atrial cuff is left behind containing the pulmonary veins This may decrease the incidence of arrhythmias, less sinus node dysfunction, preserve atria function, avoid tricuspid regurgitation, increase CO, decreased risk of thromboembolism

38. Cardiopulmonary Bypass Hypothermia 28-30* C Furosemide to promote UO Hemoconcentration for expanded blood volume Anastamosis: LA, RA, PA, aorta Glucocorticoid (methylprednisone 500 mg) is administered as the last anastamosis is being completed prior to the release of the aortic cross clamp to attenuate any hyperacute immune reaction. TEE used to monitor whether the cardiac chambers are adequately de-aired and can diagnose atrial torsion, RV outflow obstruction, and decreased R or L ventricular systolic function Longer rewarming period During reperfusion, an infusion of an inotrope is begun for both inotropy and chronotropy Donor heart should be paced if bradycardic despite inotrope infusion also the possibility of IABP, ECMO, or LVAD RV dysfunction from elevated PVR is the most common cause of perioperative heart failure, use of pulmonary vasodilators: milrinone, nitric oxide, sodium nitroprusside Arrhythmias: slow junctional or AV nodal, V fib

42. Transplantation: Postop Low CO after transplant may be due to: hypovolemia, inadequate adrenergic stimulation, myocardial injury during harvesting, acute rejection, tamponade, sepsis. Systemic hypertension may be due to pain, adequate analgesia is provided before vasodilators Atrial and ventricular tachyarrythmias are common in the immediate postop period, once rejection has been ruled out, antiarrythmics are used for conversion (except those with indirect acting mechanisms or negative inotropes) Many patients require pacing in the immediate postop period and 10-25% require permanent pacing Renal function often improves following transplantation, but immunosuppressants may again impair renal function Bacterial pneumonia is very common in the early postop period and opportunistic viral and fungal infections after the first several weeks

43. Pharmacological Agents After Transplant The transplanted heart has no autonomic innervation Agents that act indirectly via the sympathetic or parasympathetic system (atropine, ephedrine) will be ineffective. Drugs with a direct/indirect effect will only have their direct effect seen. Drugs of choice are direct effect – isoproterenol, epinephrine, etc. May require pacing

44. Cardioactive Drug Responses in the Denervated Heart Adenosine Atropine Digoxin Edrophonium Ephedrine Norepinephrine Pancuronium Phenylephrine Nifedipine Supersensitivity No vagolytic effect No vagotonic effect No vagotonic effect Less cardiostimulation Unmasked beta effects No vagolytic effect Diminished sensitivity Nodal conduction not depressed

45. Anesthesia for Patients With Previous Transplant Transplanted patients require anesthetic for surgical procedures that may or may not be cardiac related Preoperative evaluation includes extensive reevaluation of cardiac function Systolic function is usually normal but a significant number of patients develop diastolic dysfunction, manifested as exercise intolerance Abnormalities in isovolumic relaxation time correspond with varying degrees of rejection Increased peak inflow velocity and mitral deceleration are indicators of restrictive filling Rejection causes inflammatory infiltrate that causes edema The presence of rejection increases perioperative morbidity and the incidence of asymptomatic arrhythmias Complication related to immunosuppression should be considered, including opportunistic infections Immunosuppressants side effects include nephrotoxity as well as neurotoxicity and cyclosporin is associated with cholelithiasis, increasing the incidence of cholecystectomy in these patients Repeated biopsies for routine transplant management may cause injury to the tricuspid valve with severe tricuspid regurg Often requires tricuspid valve replacement

46. Anesthesia for Patients With Previous Transplant Choice of anesthetic depends on the type of surgery and condition of the patient Regional anesthesia can be used cautiously, with the knowledge that these patients cannot mount the usual response to vasodilation and hypotension Cardiovascular monitoring is dependent on the nature of the planned surgery. Invasive monitoring is not necessary for minor procedures. Intraoperative echocardiography is important in managing volume status. The ECG may have a double P wave, reflecting atrial activity in the native atrial cuff and the transplanted atrium Cardiac output of the transplanted heart is preload dependent and rely on changes in stroke volume. Ephedrine or isoproterenol should be readily available to treat bradycardia as atropine will not have an effect. Patients with prior heart transplantation have undergone successful pregnancies

47. Lung Transplantation

48. Overview Indications: end-stage parenchymal disease or pulomonary hypertension. Candidates are functionally incapacitate by dyspnea and have a poor prognosis. Criteria varies according to the primary disease process

50. Single vs. Double Lung Transplant 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.

51. Single Lung Transplantation Often attempted without CPB. Procedure is performed through a posterior thoracotomy. A double-lumen tube must be used for one-lung ventilation. CPB during transplantation of one lung is based on arterial hypoxemia (spO2 <88%) or a sudden increase in PA pressures.

53. CPB 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.

54. 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.

55. 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.

56. 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.

57. 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. Transplantation disrupts the neural innervation, lymphatic drainage, and bronchial circulation of the transplanted lung. Respiratory pattern is unaffected but the cough reflex is abolished below the carina. Bronchial hyperreactivity is described in some patients. Hypoxic pulmonary vasoconstriction remains normal. Loss of lymphatic drainage increases extravascular lung water and predisposes the transplanted lung to pulmonary edema. Intraoperative fluid replacement must therefore be kept to a minimum. Loss of the bronchial circulation predisposes to ischemic breakdown of the bronchial suture line. Transplantation disrupts the neural innervation, lymphatic drainage, and bronchial circulation of the transplanted lung. Respiratory pattern is unaffected but the cough reflex is abolished below the carina. Bronchial hyperreactivity is described in some patients. Hypoxic pulmonary vasoconstriction remains normal. Loss of lymphatic drainage increases extravascular lung water and predisposes the transplanted lung to pulmonary edema. Intraoperative fluid replacement must therefore be kept to a minimum. Loss of the bronchial circulation predisposes to ischemic breakdown of the bronchial suture line.

58. Renal Transplantation

59. Renal Transplant Physiology Why the Procedure is Performed    A kidney transplant may be recommended for patients with kidney failure caused by: Severe, uncontrollable high blood pressure Infections Diabetes Glomerulonephritis A kidney transplant alone may NOT be recommended for patients who have: Heart, lung, or liver disease Other life-threatening diseases Certain infections, such as TB or osteomyelitis Difficulty taking medications several times each day for the rest of their lives Why the Procedure is Performed    A kidney transplant may be recommended for patients with kidney failure caused by: Severe, uncontrollable high blood pressure Infections Diabetes Glomerulonephritis A kidney transplant alone may NOT be recommended for patients who have: Heart, lung, or liver disease Other life-threatening diseases Certain infections, such as TB or osteomyelitis Difficulty taking medications several times each day for the rest of their lives

60. A kidney transplant is a surgical procedure to implant a healthy kidney into a patient with kidney failure. Description    Kidney transplants are second only to corneal transplant as the most common transplant operation in the United States. There are over 9,000 kidney transplants performed each year. Patients with chronic kidney disease can receive life-saving dialysis therapy until a donor becomes available. The donated kidney may be from: Living related donor -- genetically related to the recipient, like a parent, sibling, or offspring Living unrelated donor -- like a friend or spouse Deceased donor -- a recently deceased individual who has no known chronic kidney disease The healthy kidney is transported in a cool saline solution that preserves the organ up to 48 hours. This gives time to perform blood and tissue donor-recipient matching tests, which are done before the operation. PROCEDURE FOR A LIVING KIDNEY DONOR While the patient is unconscious and pain-free (under general anesthesia), an incision is made in the side of the abdomen. The kidney is removed and the incision is closed. The traditional operation requires a long incision. However, improvements in technique use a short incision (mini-nephrectomy) or use laparoscopic techniques. PROCEDURE FOR THE KIDNEY RECIPIENT While the patient is unconscious and pain-free (under general anesthesia), an incision is made in the lower abdomen. The new kidney is stitched into place within the pelvis and the incision is closed. A kidney transplant is a surgical procedure to implant a healthy kidney into a patient with kidney failure. Description    Kidney transplants are second only to corneal transplant as the most common transplant operation in the United States. There are over 9,000 kidney transplants performed each year. Patients with chronic kidney disease can receive life-saving dialysis therapy until a donor becomes available. The donated kidney may be from: Living related donor -- genetically related to the recipient, like a parent, sibling, or offspring Living unrelated donor -- like a friend or spouse Deceased donor -- a recently deceased individual who has no known chronic kidney disease The healthy kidney is transported in a cool saline solution that preserves the organ up to 48 hours. This gives time to perform blood and tissue donor-recipient matching tests, which are done before the operation. PROCEDURE FOR A LIVING KIDNEY DONOR While the patient is unconscious and pain-free (under general anesthesia), an incision is made in the side of the abdomen. The kidney is removed and the incision is closed. The traditional operation requires a long incision. However, improvements in technique use a short incision (mini-nephrectomy) or use laparoscopic techniques. PROCEDURE FOR THE KIDNEY RECIPIENT While the patient is unconscious and pain-free (under general anesthesia), an incision is made in the lower abdomen. The new kidney is stitched into place within the pelvis and the incision is closed.

62. Renal 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

63. Preoperative 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

64. Pharmacologic 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. Iso and des have the least affect on cardiac output. Sevo at low flows has a greater risk for fluoride accumulation and slightly decreases rbf. vecuronium may be used with only modest prolongation of its effects The mechanism of toxicity involves the combination of the fluoride anion with the calcium ions in the blood to form insoluble calcium fluoride, resulting in hypocalcemia Iso and des have the least affect on cardiac output. Sevo at low flows has a greater risk for fluoride accumulation and slightly decreases rbf. vecuronium may be used with only modest prolongation of its effects The mechanism of toxicity involves the combination of the fluoride anion with the calcium ions in the blood to form insoluble calcium fluoride, resulting in hypocalcemia

65. 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

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

67. Preop, Induction, Maintenance Ensure pt is T&C for prbc, ffp, plasma 2 large bore IVs Art line placement for BP variability and multiple lab draw RSI with anectine and etomidate. Cricoid pressure until Ett placement confirmed Maintenance with Iso at 1 MAC without use of N20

68. Intra and Postop Placement of central line with CVP and Foley to monitor renal perfusion Have pressors ready for induction and clamping of the blood vessels. Admit pt to ICU, may need to stay intubated Placement of central line with CVP Foley to monitor renal perfusion. Placement of central line with CVP Foley to monitor renal perfusion.

69. Question 1 Which organization oversees Organ Donation in the U. S.? A. Health Department B. National Institute of Health C. United Network for Organ Sharing (UNOS) D. Center for Disease Control E. Department of Homeland Security CC

70. Question 2 What is the most transplanted organ? A. Liver B. Heart C. Kidney D. Pancreas E. Lung CC

71. Question 3 Which anesthetic agent is not recommended for kidney transplant? A. Low flow O2 B. Desflurane C. Nitrous Oxide D. Sevoflurane E. Isoflurane CC

72. Question 4 Which of the following individuals do not make the best candidates to receive a lung transplant? A. Cancer patients B. HIV infection C. Hepatitis B or Hepatits C with proven cirrhosis by liver biopsy D. Current substance abuse: tobacco, alcohol and illicit drugs E. Body weight less than 80% or greater than 120% of predicted F. All of the above FF

73. Question 5 Which of the following organs cannot be transplanted at this time? A. Liver B. Kidney C. Heart D. Lung E. Brain EE