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Anaesthesiology
Transplant Anesthesia
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
10 sections · 194 slides
Overview
- Scope of this topic
- Roadmap
- Organ supply, demand and allocation in the United States
- Cold ischemia time
- Cold ischemia limits by organ
- Transplant activity by organ (2020)
- Reading the transplant activity figures
- Patient survival by organ and years after transplant
- Survival patterns and widening the donor pool
Anesthetic management of organ donors
- Declaration and clinical findings of brain death
- Two hemodynamic stages of brain death
- Hormonal chaos of brain death and resuscitation goals
- Fluid strategy conflicts between organs
- Hormone replacement in the brain-dead donor
- Ventilation and monitoring targets during procurement
- Vulnerability, assessment and matching of donor lungs
- Assessment of the heart donor and marginal features
- Surgical steps of heart retrieval
- Sharing one thoracic donor between three recipients
- Policy background and the decision to withdraw treatment
- Predicting death within an hour of withdrawal
- Criteria for predicting death within 60 minutes of withdrawal of life-sustaining treatment
- Criteria for predicting death within 60 minutes of withdrawal of life-sustaining treatment (continued)
- Outcomes of circulatory-death grafts
- Selection and surgical approach for living kidney donors
- Pain, complications and recovery after kidney donation
- Indications for living liver donation
- Left lateral segment living donor liver transplantation
- Right hepatectomy for adult-to-adult donation
- Right lobe living donor liver transplantation
- Mortality and morbidity after liver donation
- Blood conservation, recovery and analgesia after liver donation
- Corneal transplantation: types and anesthetic goals
- Anesthetic technique choices for keratoplasty
- General versus regional anesthesia for keratoplasty
Renal transplantation
- Burden of kidney failure and waiting list outcomes
- Effects of the kidney allocation system
- Diagnoses of kidney transplant recipients
- Recipient diagnoses and cardiovascular risk
- Exclusion criteria and dialysis before transplant surgery
- Induction, relaxants and preparation before incision
- Opioid pharmacology in end-stage renal disease
- Fluid choice and renal vasoactive drugs
- Induction immunosuppression in kidney transplantation
- Maintenance immunosuppression and glucose control
- Analgesia after kidney transplantation
Liver transplantation
- Share 35 and the MELD and MELD-Na scores
- Continuing refinement of liver allocation
- Multisystem complications of end-stage liver disease
- Multisystem complications of end-stage liver disease (continued)
- Why liver failure is a whole-body disease
- Diagnoses leading to liver transplantation in adults
- Changing indications for liver transplantation
- Cardiac tests and functional assessment before liver transplantation
- Diagnosis and screening of portopulmonary hypertension
- Drug treatment of portopulmonary hypertension
- Transplant risk in hepatopulmonary syndrome, and terlipressin
- Duration, access and monitoring in liver transplantation
- The three phases of liver transplantation
- The dissection phase and massive ascites at incision
- Plasma, calcium and platelet transfusion targets
- Poor hemostasis and rebalanced coagulation in cirrhosis
- Antifibrinolytic drugs in liver transplantation
- Diagnostic criteria for hepatorenal syndrome versus other causes of renal dysfunction
- Renal dysfunction and hepatorenal syndrome
- Drug support of renal function in liver disease
- Caval-sparing technique, reperfusion and postreperfusion syndrome
- Preparation for the moment of portal reperfusion
- Cardiac events and preconditioning at graft reperfusion
- Kidney, clotting and completion of the liver transplant
- Intraoperative hazards and hepatic artery flow in children
- Acute liver failure and intracranial pressure monitoring
- Initial management and lowering intracranial pressure
- Anesthetic drug choice in acute liver failure
Pancreas, islet, bowel and composite tissue transplantation
- Patterns of pancreas transplantation and the shift to islets
- Assessment and glucose control in pancreas transplantation
- Implanted insulin pumps and the Edmonton protocol
- Indications for intestinal and combined liver-intestine transplantation
- Vascular access and perioperative issues in intestinal failure
- Reperfusion of the intestinal graft
- Composite tissue allografts and retrieval of a face graft
- Limb transplantation and composite tissue immunology
- Complications of face transplantation
Lung transplantation
- Scale and survival after lung transplantation
- Changing indications for lung transplantation
- Surgical options and the single versus double choice
- When one lung will not do, and mechanical support
- General criteria for lung transplant candidacy
- Lung recipient selection guidelines
- Risk factors for poor lung transplant outcomes
- The lung allocation score
- Evaluation, age and infection in lung recipient selection
- Reassessment and premedication of the lung candidate
- Aspiration prophylaxis and induction for lung transplantation
- Airway management for lung transplantation
- Double-lumen tube versus bronchial blocker
- Choice of side for the double-lumen tube
- Monitoring and maintenance of anesthesia in lung transplantation
- Nitrous oxide, antibiotics and immunosuppression in lung transplantation
- Ventilation before and during one-lung ventilation
- Hypoxemia strategies and indications for mechanical support
- Hemodynamic instability and right ventricular support
- Fluid strategy and choosing a mechanical support device
- Advantages reported for venoarterial ECMO over bypass
- Surgical sequence after pneumonectomy
- Reinflation and reperfusion of the lung graft
- Airway pressures, oxygen and tube exchange
- Recovery and analgesia after lung transplantation
- Single-lung transplantation and positioning for support
- Double-lung technique: en bloc versus bilateral sequential
- Order of implantation and pain after the clamshell incision
- Pediatric lung transplantation and its outcomes
- Complications and grading of primary graft dysfunction
- Risk factors and management of primary graft dysfunction
- Pharmacology of inhaled nitric oxide
- Arguments for and against routine inhaled nitric oxide
- Other effects and recommended use of nitric oxide
- Heart-lung transplantation: scale, indications and management
Heart transplantation and mechanical circulatory support
- Scale and indications for heart transplantation
- Mortality in congestive heart failure
- Roles of mechanical circulatory support
- Categories of mechanical circulatory support device
- Intra-aortic balloon pump and the Impella device
- Percutaneous ventricular assist device
- ECMO as circulatory support and how assist devices differ
- Three generations of left ventricular assist device
- First and second generation ventricular assist devices
- Axial and centrifugal flow ventricular assist devices
- Third generation devices and comparative trial data
- Biventricular support and anesthesia for device placement
- Assessment and blood pressure measurement with an assist device
- Device parameters and hemodynamic goals
- Pressure target and medical therapy while awaiting a heart
- Cardiac resynchronization therapy
- Heart failure population and referral criteria
- Guideline changes and functional capacity as a prognostic marker
- Pulmonary hypertension as a barrier, and optimising it
- Noncardiac contraindications to heart transplantation
- Timing and issues needing special attention in the heart recipient
- Continuing support and assessing anticoagulation
- Antibiotics, devices, and differences from routine open-heart surgery
- Monitoring, access and induction for heart transplantation
- Preparation for repeat sternotomy and femoral access
- Maintenance and echocardiography in heart transplantation
- Biatrial versus bicaval orthotopic heart transplantation
- Anatomy of bicaval orthotopic heart transplantation
- Cannulation, bypass and catheter handling
- Ischemic time and assessment before weaning from bypass
- Denervation of the donor heart and two P waves
- Right heart failure and graft dysfunction on weaning
- End of the procedure, and pediatric heart transplantation
- Trends, outcomes and anesthesia in pediatric heart transplantation
- Marginal donors and ABO-incompatible grafts in infants
- Cardiac transplantation from donation after circulatory death
- Two mechanisms of procuring a circulatory-death heart
- Procurement methods and roles in circulatory-death heart donation
The transplant patient for nontransplant surgery
- Meeting a transplant recipient, and drug choice
- Monitoring choices and masked infection
- Continuity of antimicrobial and immunosuppressive regimens
- Immunosuppressive agents: mechanism and example drugs
- Immunosuppressive agents: side effects and perioperative considerations
- Immunosuppressive agents: side effects and perioperative considerations (continued)
- Three phases of immunosuppression
- Perioperative implications of immunosuppressive drugs
- Drug level monitoring and analgesic choice
- Anesthetic choice and airway issues in lung recipients
- Detecting rejection and deciding whether to proceed
- Pharmacology of the denervated heart and drug choice
- Electrocardiogram findings and preoperative evaluation
- Monitoring options in the heart transplant recipient
Key points
- Key points on organ donation
- Key points on kidney and liver transplantation
- Key points on thoracic transplantation
References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition