Organ Transplant Lecture
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Questions and Answers

What condition is defined by cirrhosis with ascites and an increase in serum creatinine?

  • Hepatopulmonary Syndrome
  • Portopulmonary Hypertension
  • Hepatic Encephalopathy
  • Hepatorenal Syndrome (correct)

    • Which of the following is NOT a criterion for diagnosing Hepatopulmonary Syndrome?

  • Pulmonary vascular dilatations
  • Elevated pulmonary pressures (correct)
  • Portal hypertension
  • Hypoxemia

    • In the context of portopulmonary hypertension, what is the potential impact of untreated severe hypertension on treatment?

  • It may require a longer hospitalization.
  • It does not impact treatment options.
  • It may promote faster recovery post-surgery.
  • It may be a contraindication to treatment. (correct)

    • Which monitoring equipment is essential in the operating room for patients with ESLD?

    <p>Standard monitors and cell saver</p> Signup and view all the answers

    Which of the following should be avoided in the treatment of hepatic encephalopathy?

    <p>Benzodiazepines</p> Signup and view all the answers

    What is the primary purpose of induction therapy in kidney transplant recipients?

    <p>To achieve rapid immunosuppression at the time of transplant</p> Signup and view all the answers

    In the context of hemodynamic management for kidney transplant surgery, which hemodynamic goal is preferred?

    <p>MAP between 90-110 mmHg</p> Signup and view all the answers

    Which of the following medications is commonly initiated immediately prior to kidney reperfusion during surgery?

    <p>Corticosteroids</p> Signup and view all the answers

    Which postoperative condition requires immediate evaluation for potential prerenal causes in kidney transplant recipients?

    <p>Decreased urine output (UOP)</p> Signup and view all the answers

    What intraoperative medication should be avoided to prevent hypotension in a kidney transplant patient?

    <p>Epinephrine</p> Signup and view all the answers

    What is the recommended intravenous access size for kidney transplant surgeries?

    <p>18G PIV</p> Signup and view all the answers

    In the context of monitoring postoperative kidney transplant patients, which parameter is essential for renal blood flow (RBF)?

    <p>Heart rate (HR)</p> Signup and view all the answers

    Which fluid is preferred in the anesthetic management of kidney transplant patients?

    <p>Isolyte</p> Signup and view all the answers

    What is the most significant anesthetic concern during the neohepatic phase post-liver transplantation?

    <p>Postreperfusion syndrome</p> Signup and view all the answers

    Which factor is crucial for determining postoperative care for liver transplant recipients?

    <p>Monitoring for extensive organ failure</p> Signup and view all the answers

    What should be monitored carefully to maintain adequate perfusion pressure to the new liver during the neohepatic phase?

    <p>Mean arterial pressure</p> Signup and view all the answers

    In organ donation, what is the primary difference between DBD and DCD donors?

    <p>DCD donors have longer ischemic times.</p> Signup and view all the answers

    What should be administered just before the clamping in the preanhepatic phase if TEG is normal?

    <p>IV heparin</p> Signup and view all the answers

    What is a critical aspect of managing fluid status during the anhepatic phase?

    <p>Target CVP of 10 to 20 cm H2O.</p> Signup and view all the answers

    Which medication is commonly used to address acidosis during the anhepatic phase?

    <p>Bicarbonate infusion</p> Signup and view all the answers

    Which of the following is NOT a typical postoperative challenge for liver transplant patients?

    <p>Pneumonia in non-ventilated patients</p> Signup and view all the answers

    When considering living organ donation, which aspect regarding the donor's health must be critically reviewed?

    <p>Medical, social, and psychological histories</p> Signup and view all the answers

    What is a necessary anesthetic guideline regarding IV fluids during the preanhepatic phase?

    <p>Maintaining CVP above 10 cm H2O.</p> Signup and view all the answers

    Which intervention is appropriate if the lactic acidosis condition worsens during the anhepatic phase?

    <p>Initiate sodium bicarbonate therapy</p> Signup and view all the answers

    In organ donation procedures, what determines whether it is classified as controlled or uncontrolled DCD?

    <p>Predefined criteria related to cardiac function cessation.</p> Signup and view all the answers

    In the context of hemodynamic management during liver transplantation, what role does norepinephrine play?

    <p>It maintains mean arterial pressure.</p> Signup and view all the answers

    Which anesthetic agent is often preferred in ESRD patients due to its intermediate duration of action?

    <p>Cisatracurium</p> Signup and view all the answers

    What is a common risk factor for rejection in kidney transplant recipients?

    <p>Previous allograft rejection</p> Signup and view all the answers

    Which IV fluid is recommended to avoid for renal transplant patients due to its potassium content?

    <p>Lactated Ringer’s</p> Signup and view all the answers

    How should morphine be used in ESRD patients?

    <p>With caution due to its prolonged effects</p> Signup and view all the answers

    What should be monitored closely in ESRD patients to manage non-depolarizing muscle relaxants appropriately during surgery?

    <p>Neuromuscular block (NMB)</p> Signup and view all the answers

    Which parameter is considered beneficial for assessing central venous pressure in certain kidney transplant patients?

    <p>CVP monitoring</p> Signup and view all the answers

    What type of diuretics may be used postoperatively to increase urine output in kidney transplant patients?

    <p>Osmotic and loop diuretics</p> Signup and view all the answers

    In the context of intraoperative monitoring, which patient condition warrants the use of an arterial line?

    <p>Patients with cardiovascular disease (CAD)</p> Signup and view all the answers

    What is the main purpose of maintenance therapy in kidney transplant immunosuppression?

    <p>To offer long-term, ongoing suppression of the immune response</p> Signup and view all the answers

    Which of the following is a characteristic of chronic kidney disease (CKD)?

    <p>Persistent decrease in kidney function over time</p> Signup and view all the answers

    Which of the following factors influences the choice of immunotherapy regimen for kidney transplant recipients?

    <p>Quality of the organ and patient's vulnerability to side effects</p> Signup and view all the answers

    Why is close monitoring of hemodynamic parameters crucial in kidney transplant patients postoperatively?

    <p>To maintain renal blood flow (RBF)</p> Signup and view all the answers

    Which comorbid condition is most commonly associated with end-stage renal disease (ESRD)?

    <p>Diabetes mellitus</p> Signup and view all the answers

    What is the typical first step in initiating immunotherapy after a kidney transplant?

    <p>Corticosteroid administration</p> Signup and view all the answers

    What preoperative assessment is crucial for kidney transplant candidates?

    <p>Assessment of cardiac risk factors</p> Signup and view all the answers

    Which electrolyte abnormality is most commonly monitored in patients with ESRD?

    <p>Hyperkalemia</p> Signup and view all the answers

    In cases of acute changes in urine output post-kidney transplant, what should be prioritized in evaluation?

    <p>Determining the exact cause of the change</p> Signup and view all the answers

    What intravenous fluid is preferred for use during anesthetic management of kidney transplant patients?

    <p>Isolyte</p> Signup and view all the answers

    What does renal replacement therapy generally include?

    <p>Dialysis and transplant options</p> Signup and view all the answers

    In the context of CKD, which factor is crucial for determining the progression of the disease?

    <p>Presence of hypertension</p> Signup and view all the answers

    What type of medication should be avoided to prevent hypotension in patients undergoing kidney transplantation?

    <p>α1 agonists like norepinephrine</p> Signup and view all the answers

    What is a key hemodynamic goal for patients during kidney transplant surgeries?

    <p>CVP &gt; 12 cmH2O</p> Signup and view all the answers

    Which of the following best describes the management approach for hyperphosphatemia in ESRD?

    <p>Use phosphate binders during meal times</p> Signup and view all the answers

    What is a critical factor in assessing a living kidney donor's suitability?

    <p>Functional kidney capacity of the donor</p> Signup and view all the answers

    For patients receiving dialysis, which of the following is a common complication?

    <p>Severe hyperkalemia</p> Signup and view all the answers

    Which demographic factor significantly influences organ transplant wait times?

    <p>Geographic location of donor and recipient</p> Signup and view all the answers

    Study Notes

    Intraoperative Considerations

    • Monitoring & Hemostasis: Point-of-service laboratory equipment is crucial for real-time analysis of electrolytes, glucose, ABGs, ionized calcium and magnesium levels and hemostasis profiles.
    • Coagulopathies: Coagulopathies can develop. TEG or rotational thromboelastography for real-time coagulation assessment.
    • Induction of Anesthesia: Limit sedative premeds due to liver disease sensitivity. Induction agents include midazolam, ketamine, propofol, or etomidate.
    • Postinduction Hypotension: Common in patients with ESLD due to decreased peripheral vascular resistance. Vasopressors like phenylephrine and vasopressin are used to maintain MAP and organ perfusion.
    • Pharmacokinetic Considerations: Drugs metabolized by the liver and cytochrome P-450 pathways exhibit altered pharmacokinetics and pharmacodynamics in ESLD patients. Aseptic technique is crucial when placing invasive lines.
    • Neuromuscular Blockade: Use non-depolarizing muscle relaxants cautiously considering the duration of surgery and need for prolonged mechanical ventilation. Quantitative neuromuscular monitoring is recommended.
    • Maintenance of Anesthesia: Maintain anesthesia with volatile agents titrated to the patient’s hemodynamic profile.
    • Invasive Monitoring: Placement of a central venous line, pulmonary artery catheter is optional, large-bore peripheral access, oral/nasogastric tube, and transesophageal echocardiography probe after intubation. Consideration for esophageal placement is important (varices)
    • Neurologic Monitoring: Intraoperative neurologic monitoring is crucial due to the risk of various neurologic complications in liver disease patients, including cerebral edema, encephalopathy, seizures, and increased intracranial pressure.
    • ICP Monitoring: Typically invasive, but transcranial Doppler to measure cerebral perfusion pressure noninvasively is under evaluation.
    • Antibiotics & Immunosuppression: Coordinate antibiotic dosages and timing, as well as immunosuppression administration, in consultation with the surgical team.

    Liver Transplantation Phases

    • Preanhepatic: Starts with surgical incision and ends with cross-clamping of the portal vein, suprahepatic IVC, infrahepatic IVC, and hepatic artery.
    • Anhepatic: Begins with occluding liver vascular inflow and ends with graft reperfusion.
    • Neohepatic: Associated with increased serum potassium and hydrogen ions and increased preload with a decrease in systemic vascular resistance and blood pressure.

    Preanhepatic Phase

    • Ascites drainage & fluid shifts: Can lead to volume depletion.
    • Volume expansion: 5% albumin is preferred over large volumes crystalloids.
    • Blood loss: Can be significant.
    • Maintaining low to low-normal CVP: Aids in reducing blood loss.
    • INR: Has no predictive value for intraoperative blood loss.
    • TEG: Gold standard for coagulation management.
    • Cell saver: Can be used to limit transfusion.
    • Anesthesia Guidelines: Modified rapid sequence induction, invasive monitors (CVP, A-line, PAC, TEE), forced air and rapid infusers with warmers, IV antibiotics, baseline laboratory values, norepinephrine or vasopressin to keep mean BP >60 mm Hg, dopamine or epinephrine to keep CO at >5 L/min, maintain Hgb > 7 g/dL, plt > 40k, MA (TEG) > 45, fibrinogen > 100 mg/dL, mannitol 0.5 g/kg IV over 1 hr prior to anticipating clamping, just before clamping: IV heparin if TEG is normal or hypercoagulable, increase CVP to 10 cm H2O with crystalloids, 25% albumin in severe hypoalbuminemia.

    Anhepatic Phase

    • Clamping of hepatic blood supply & venous drainage: Begins with clamping of hepatic blood supply and venous drainage.
    • Surgical approach: Bicaval clamp, piggyback, or venovenous bypass impacts hemodynamic and fluid management.
    • Bicaval Clamp: Can lead to profound hypotension and tachycardia.
    • Piggyback Technique: Preserves some caval flow, reducing blood product use.
    • Fluid loading: Targets CVP of 10 to 20 cm H2O.
    • Lactic acidosis: May occur due to hepatic metabolism cessation.
    • Anesthesia Guidelines: IV fluids to keep CVP at least 5 cm H2O, crystalloids unless hematocrit is < 21%, at which time blood transfusions should be considered, norepinephrine and/or vasopressin to keep MAP > 60 mm Hg & CO > 5 L/min, bicarbonate infusion to correct base deficit, IV calcium chloride to sustain normocalcemia.

    Neohepatic Phase

    • Reperfusion of the new liver: After caval and arterial anastomoses.
    • Maintaining adequate perfusion pressure: To the new liver is essential.
    • Avoid high CVP: To prevent graft venous congestion.
    • Diuresis: May be appropriate but should be carefully managed.
    • Monitoring: Stable glucose and acid-base status.
    • Postreperfusion Syndrome: Most significant anesthetic concern during this phase.
    • Postreperfusion Syndrome Characterization: Decreased CO, systemic hypotension, bradyarrhythmias, asystole, pulmonary artery HTN, and raised pulmonary capillary wedge pressure in conjunction with increased CVP.
    • Postreperfusion Syndrome Definition: A >30% decrease in systemic MAP below baseline for at least 1 minute during the first 5 minutes of hepatic reperfusion.
    • Postreperfusion Syndrome Cause: Thought to be due to acute left ventricular diastolic dysfunction.
    • Primary Goal: Maintain liver perfusion pressure and avoid high CVP.
    • Anesthesia Guidelines: When SVR is declining, IV vasopressin 1-5 unit bolus to keep mean BP at >60 mm Hg, epinephrine 20-100 mcg boluses if heart rate is 5 L/min and mean BP at >60 mm Hg, TEE if needed for detailed hemodynamic assessment, maintain Hgb at > 7 g/dL, platelets at > 40k, fibrinogen at > 100 mg/dL, TEG: protamine 30 mg IV, if R is more than twofold compared to heparinase-R, maintain MA at > 45 mm with platelet transfusion, if Ly30 is > 8%, give IV EACA 5 g over 15 min, consider indication for postoperative mechanical ventilation per usual criteria, transfer to critical care unit.

    Postoperative Considerations

    • Admission: Most liver transplant recipients are admitted to a specialized ICU postpartum due to critical illness.
    • Multisystem Organ Failure: Patients typically have at least one major organ failure and often multisystem organ failure prior to transplant.
    • Common Challenges: Hemodynamic and cardiac instabilities, fluid shifts, coagulopathies, bleeding anastomoses, graft failure, and ventilation requirements are common postoperative challenges.
    • Fast Tracking: May be considered for ideal liver transplant candidates in the future.
    • Early Intubation: Beneficial when appropriate; decreased intra-abdominal pressure and aids in graft perfusion.
    • Early Extubation Benefits: Shorter ICU stay, decreased resource use, and cost savings (up to 13% reduction).
    • Pain Control: PCA IV narcotic use and oral medications once the patient can take pills.
    • Epidural Pain Management: May be limited in coagulopathic or suspected coagulopathic patients.

    Organ Donation: Anesthetic Considerations

    • Care of the organ donor: Involves specialized protocols guided by transplant surgeons and coordinators.
    • Type of Donation: The type of donation (DCD or DBD) and the patient’s underlying condition influence management plan.
    • Organ Availability: A significant discrepancy exists between patients awaiting transplant and the available organs.
    • Physiologic Changes: Vary between DBD and DCD donors.
    • DBD: Hyper- or hypotension, arrhythmias, pulmonary edema, DIC, hyperglycemia, and hypothermia.
    • DCD: Longer ischemic times.
    • DCD Categorization: Controlled or uncontrolled based on predefined criteria.
    • Transplant Teams & Life Support: Transplant teams should not be involved in the decision to withdraw life support in DCD cases.
    • Independent physician: Determines cessation of cardiac function before organ procurement.
    • DCD Guidelines: Anesthetists should be familiar with institution-specific DCD guidelines.

    Organ Donation: Living Donor

    • Directed Donation: Involves a directed donation from a friend or family member.
    • Medical, social, and psychological histories: Are thoroughly reviewed.
    • Elective procedure: Often elective, scheduled, and timely, reducing cold ischemia time.
    • Donor Health: Donors are generally in better health, but there are concerns about the impact on their quality of life and medical risks.
    • Financial Considerations: Associated with living donation should also be addressed.
    • Donor Pool: Living organ donation can increase the pool of donated organs, especially for liver transplant.

    Portopulmonary Hypertension

    • Differentiate between portopulmonary hypertension & & elevated pulmonary pressures in ESLD patients.
    • Severe, untreated portopulmonary hypertension: May be a contraindication to transplant.

    Hepatopulmonary Syndrome (HPS)

    • HPS: Characterized by arterial hypoxemia caused by intrapulmonary vascular dilatations.
    • Dx criteria: Portal HTN + hypoxemia + pulmonary vascular dilatations.
    • MELD Exception points: Patients with HPS receive MELD exception points.

    Preoperative Considerations

    • Ascites & Hepatic Hydrothorax: Ascites can lead to hepatic hydrothorax, which may require preoperative drainage in patients with respiratory compromise.
    • Hepatorenal Syndrome: Hepatorenal syndrome is a severe form of acute kidney injury in patients with advanced ESLD.
    • Hepatorenal Syndrome Dx Criteria: Cirrhosis with ascites and increased serum creatinine.
    • Hepatic Encephalopathy: Hepatic encephalopathy is characterized by the accumulation of neurotoxins, primarily ammonia in the brain.
    • Hepatic Encephalopathy Tx: Decreased nitrogen load, dietary adjustments, medications like metronidazole and rifaximin, and avoiding benzodiazepines.

    Operating Room Preparation

    • Operating room equipment: Ensure the operating room is equipped with standard monitors, arterial line, large-bore IV access, central venous catheter, PAC, continuous cardiac output/function monitoring, thromboelastogram (TEG), TEE, cell saver, rapid infuser devices, and immediate access to blood products.

    Kidney Transplantation Immunosuppression

    • Induction aims for rapid immunosuppression at transplant while maintenance therapy uses oral agents.
    • Induction Therapy: Varies but may include antibodies or interleukin-2 receptor antagonists.
    • Immunotherapy Initiation: Typically begins with corticosteroid administration and then antilymphocyte agents immediately prior to kidney reperfusion.
    • Immunosuppressive Regimens depend on patient factors, organ quality, and vulnerability to side effects.
    • Kidney Transplant Recipients: Receive tacrolimus, mycophenolate mofetil (MMF), and often steroids.

    Postoperative Considerations

    • Monitoring: Close monitoring of hemodynamic parameters (BP and HR) are essential for renal blood flow.
    • UOP Changes: Any acute changes in urine output should be evaluated for cause and appropriate treatment.
    • Prerenal Cause: May require aggressive fluid therapy.
    • Postrenal Cause: May necessitate surgical exploration and intervention.

    Anesthetic Considerations: Short-Hand Summary

    • Preoperative: ABO/Cross Match, BMP, CBC, H/H, PT/PTT/INR, IV Access (18G PIV), Invasive Lines (CVL, A-line)
    • Anesthetic: GETA + RSI, Cisatracurium or Rocuronium and volatile agents for maintenance.
    • Hemodynamic Goals: CVP > 12 cmH2O + MAP 90-110 + Hgb > 8 g/dL.
    • Avoid Hypotension: Avoid α1 agonists (NO neo or epi), dopamine 1-5 mcg/kg/min.
    • Immunosuppression: Solumedrol 500mg started in preop or just after induction, plus other meds based on protocol.
    • Fluids: Isolyte preferred, NS, no LR, colloids ok.
    • Other: Foley catheter.
    • Postoperative: Immediate attention to urine output, kidney function, hemodynamic stability, and closely monitor immunosuppression.

    History of Organ Transplantation

    • Organ transplantation addresses the increasing demand for life-saving procedures.
    • Organ supply and patient need are balanced based on severity.
    • The concept dates back to the early 1900s.
    • Alexis Carrel pioneered transplant vascular surgery with anastomosis, earning the Nobel Prize in Medicine in 1912.
    • His techniques are still used today.
    • Transplantable organs include: kidney, liver, pancreas, heart, lungs, cornea, intestines, uterus, and stem cells.

    Immune System Challenge

    • Early transplants faced the challenge of organ rejection by the recipient's immune system.
    • Peter Medawar's theory of graft rejection due to immunologic incompatibility earned him the Nobel Prize for Medicine.
    • His theory paved the way for immunosuppression therapies.

    Immunosuppression Therapy

    • Early methods included corticosteroids and whole-body radiation.
    • A major development in 1974 was the introduction of Cyclosporine, which is still used to prevent graft rejection.

    Types of Organ Donation

    • Donation After Brain Death (DBD):
      • The traditional method where the donor is declared dead due to the absence of viable brain activity.
      • Brain death results from a lack of blood supply and oxygen, causing irreversible brain cell death.
      • The most common form of organ donation today.
    • Donation After Cardiac Death (DCD):
      • Introduced to address organ shortages and meet transplant demands.
      • Ethical concerns about the timing of death present challenges and hinder widespread acceptance.
    • Living Donor Transplants:
      • Living individuals donate organs to other people (family, friends, or strangers).
      • Thousands are performed annually, primarily kidney transplants.
      • In 2019, the US recorded a record 7,397 living donor transplants, highlighting its significance.

    Organ Transplantation Considerations

    • Organ donation is an accepted medical treatment for patients with end-stage organ failure.
    • Approximately 80 people receive organ transplants daily, but 20 people die daily while waiting for a transplant.
    • The number of transplants and donors continues to steadily rise.
    • In 2019, a record 39,718 transplants were performed in the US.
    • Despite this increase, over 112,500 patients remained on the waiting list in 2019.
    • The national organ transplant list is maintained by UNOS (United Network for Organ Sharing).
    • UNOS enforces strict standards for fair and ethical organ distribution.
    • Criteria considered for organ allocation include:
      • Blood/tissue matching
      • Organ size
      • Medical urgency
      • Wait time
      • Geographic location of donor and recipient.

    Organ Donor Statistics

    • Over 120 million people in the US are identified as organ donors.
    • A single donor can save up to 8 lives through organ donation.
    • Only 3 out of every 1000 people are estimated to die in a way that allows for organ donation.

    Consideration of Alternative Donation Methods

    • Due to the limited availability of organs based on DBD criteria, guidelines for DCD and living donor donation have been developed.
    • These methods aim to expand the pool of potential donors and save more lives.

    Renal Transplant

    • The first kidney transplant occurred in 1954, with a living donor providing a kidney to his identical twin.
    • Renal transplants gained momentum in the 1960s with the development of immunosuppression.
    • It is the most common solid organ transplant procedure and offers improved quality of life and higher survival rates compared to dialysis.
    • Five-year post-transplant survival rates are impressive:
      • 91% for recipients of live donor grafts.
      • 83% for deceased donor recipients who did not receive extended criteria donor (ECD) grafts.
      • 70% for recipients of grafts from ECDs.

    End-Stage Renal Disease (ESRD)

    • Defined as a decrease in kidney function to less than 10% of normal capacity.
    • Decline is measured using Glomerular Filtration Rate (GFR). A GFR below 15% necessitates renal replacement therapy.
    • ESRD impacts society significantly in terms of cost and resource allocation.
    • ESRD patients often have multiple comorbidities and may require hemodialysis (HD).
    • The incidence steadily increased from 1980 to 2001 but has plateaued in recent years.
    • Factors contributing to the rise include diabetes and hypertension.

    Recipient Risk Factors for Rejection

    • Previous blood transfusions, particularly if recent.
    • Previous pregnancies, particularly if multiple.
    • Previous allograft, particularly if rejected early.
    • African ethnicity.
    • cPRA (calculated panel reactive antibody) greater than 20%.
    • Donor-specific antibody (current or historic).

    Anesthetic Considerations

    • General anesthesia (GETA) is the standard for kidney transplant surgery.
    • Goals include:
      • Maintaining an appropriate depth of anesthesia.
      • Achieving muscle relaxation.
      • Ensuring hemodynamic stability.
    • ESRD patients are at risk of aspiration due to gastroparesis, making rapid sequence induction (RSI) important.
    • Succinylcholine may be used cautiously, with attention to potassium levels.
    • Rocuronium is an alternative for RSI in high-risk patients.
    • Cisatracurium is often preferred due to its intermediate duration of action.
    • Close neuromuscular blockade monitoring is crucial for appropriate management and reversal.

    Intraoperative Monitoring

    • Standard, noninvasive monitoring is usually sufficient for younger, healthier transplant recipients.
    • An arterial line is useful for patients with coronary artery disease (CAD) and uncontrolled hypertension.
    • Central venous pressure (CVP) monitoring is beneficial when assessing cardiovascular function is necessary.
    • A central venous line (CVL) is common due to the administration of immunosuppressive and vasoactive medications.
    • In some cases, a pulmonary artery catheter and transesophageal echocardiogram (TEE) may be needed.
    • Large-bore peripheral intravenous (PIV) lines are essential but challenging due to arteriovenous fistulas and potential venous thrombosis.

    Induction and Maintenance

    • Induction:
      • Propofol is safe and effective in ESRD patients (monitor ejection fraction).
      • Etomidate is commonly used.
    • Maintenance:
      • Typically combines volatile anesthetic agents and intravenous agents.
      • Desflurane, isoflurane, and sevoflurane are considered safe in ESRD patients.
      • All inhalation agents decrease renal blood flow (RBF) and glomerular filtration rate (GFR) in a dose-dependent fashion.
      • Renoprotective effects of inhalation agents are under investigation.

    Pain Management

    • Careful analgesic use is crucial in ESRD patients due to metabolite accumulation.
    • Morphine's effects may be prolonged due to the morphine-6-glucuronide metabolite.
    • Meperidine should be avoided due to its metabolite, normeperidine, which increases the risk of central nervous system (CNS) excitatory effects and seizures.

    IV Fluids and Pharmacologic Considerations

    • Maintenance of IV volume is crucial for transplanted kidney performance.
    • Avoid lactated Ringer's solution due to its potassium content. Prefer PlasmaLyte and normal saline (NS).
    • Caution: Hyperchloremic metabolic acidosis from excessive NS can worsen hyperkalemia.
    • Colloids like albumin can help maintain IV volume while avoiding acidosis.
    • Maintain hemodynamic stability without compromising RBF. Agents like dopamine, dobutamine, and fenoldopam can be used.
    • Osmotic and loop diuretics may be used to increase urine output.

    Immunosuppressive Therapy

    • Most US kidney transplant recipients receive tacrolimus, mycophenolate mofetil (MMF), and often corticosteroids.
    • Immunotherapy regimens depend on patient factors, organ quality, and vulnerability to side effects.
    • Strategies include induction and maintenance therapy.
    • Induction aims for rapid immunosuppression at transplant, while maintenance utilizes oral agents.
    • Induction therapy varies but may include antibodies or interleukin-2 receptor antagonists.
    • Immunotherapy initiation typically begins with corticosteroid administration and then antilymphocyte agents immediately prior to kidney reperfusion.

    Postoperative Considerations

    • Close monitoring of hemodynamic parameters (blood pressure and heart rate) is essential to assess RBF.
    • Any acute changes in urine output should be evaluated for cause and treated appropriately.
      • May require aggressive fluid therapy if the cause is prerenal.
      • Postrenal causes, such as ureteral kinking or technical issues, may necessitate surgical exploration and intervention.

    Anesthetic Considerations: Short-Hand Summary

    • Preoperative:
      • ABO and cross-match blood typing.
      • Complete blood count (CBC), hemoglobin and hematocrit (H/H), prothrombin time/partial thromboplastin time/international normalized ratio (PT/PTT/INR), etc.
    • Anesthetic:
      • GETA + rapid sequence induction (RSI).
      • Cisatracurium or rocuronium for maintenance along with volatile anesthetics (VA).
    • IV Access:
      • 18G PIV preferred.
    • Hemodynamic Goals:
      • CVP greater than 12 cmH2O.
      • Mean arterial pressure (MAP) 90-110 mmHg.
      • Hemoglobin (Hgb) greater than 8 g/dL.
    • Invasive Lines:
      • Central venous line (CVL, triple lumen) after induction.
      • Arterial line (if CAD).
    • Avoid Hypotension:
      • Avoid α1 agonists like norepinephrine or epinephrine.
      • Use dopamine at 1-5 mcg/kg/min.
    • Fluids:
      • Isolyte preferred.
      • Normal saline (NS) with caution to avoid excessive administration.
      • Usually no lactated Ringer's solution.
      • Colloids may be suitable.
    • Immunosuppression:
      • Solumedrol 500 mg started preoperatively or immediately after induction.
      • Plus...
        • Thymoglobulin (1.5 mg/kg) via CVL over 6 hours, plus alemtuzumab (30 mg over 4 hours) ... or ...
        • Foley catheter.
      • Or...
        • Solumedrol 500 mg started preoperatively or immediately after induction.
        • Plus...
          • Thymoglobulin (1.5 mg/kg) via CVL over 6 hours, plus alemtuzumab (30 mg over 4 hours).
        • Or...
          • Foley catheter.

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    Description

    This quiz covers essential intraoperative considerations for patients with end-stage liver disease (ESLD). Key areas include monitoring and hemostasis, induction of anesthesia, and pharmacokinetic factors. Prepare to answer questions related to coagulopathies, drug metabolism, and management of hypotension during surgery.

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