Anesthesia for Organ Transplantation

1
Anesthesia for Organ Transplantation

• By Anselmo Serna
• Greg McMichael

2
(No Transcript)
3
All vital organs Heart, Lung, Liver and Kidney,
can be supported by technology or replaced by
transplantation.
Except the brain, it is the only
organ that cannot be functionally supported or
replaced.
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
(No Transcript)
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

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
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
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 (lt 4.0) Discuss at least 4 ways to reduce
  potassium
• Replace calcium to ensure normal (gt 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

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 (contd)

• 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 HP 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 (contd)

• 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

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

39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
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

49
(No Transcript)
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 lt88) or a sudden
  increase in PA pressures.

52
(No Transcript)
53
CPB for one lung

• When CPB is necessary, femoral-vein-to-femoral-art
  ery 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 lt60.
• Methylprednisolone is usually given prior to
  release of vascular clamps.

58
Renal Transplantation
59
Renal Transplant Physiology
60
(No Transcript)
61
(No Transcript)
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 (8090) 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
  (gt60) 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 (2448 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.

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 TC 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

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

70
Question 2

• What is the most transplanted organ?
• A. Liver
• B. Heart
• C. Kidney
• D. Pancreas
• E. Lung

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

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

73
Question 5

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