Anesthesia for Organ Transplantation by sammyc2007

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									Anesthesia for Organ
      By Ken Martin
  Presentation Learning Objectives
At the end of this presentation, you will be able to:
 Describe the Care of Cadaveric Organ Donors.
 Describe Non-Heart Beating Organ Donors.
 Describe the Care of Living Organ Donors.
 Describe Contraindications to Solid Organ
 Describe/Discuss Pathophysiology, Preoperative,
  Intraoperative and Postoperative Management
  of Transplant Patient; Kidney, Pancreas, Liver,
  Intestine, Cardiac, and Lung.
 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
 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
 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.
              Brain Death
 Not uniformly defined between institutions
 Not one universally accepted standard
 Not one universally and consistently
  applied algorithm for determination

Traditional Cardiopulmonary Death is
  defined as Asystole and Apnea
     Neurological Determination of
          Death/Brain Death
1. Unresponsive coma
  with a known
  proximate cause and
  absence of reversible
2. Absence of centrally-
  mediated motor
3. Absent brainstem
  reflexes incl. the
  capacity to breathe
All vital organs: Heart, Lung, Liver and
      Kidney, can be supported by
       technology or replaced by

 Except the brain, it is the only organ that cannot be functionally
 supported or replaced.
                 Physiology and
   Acid-base equilibrium
   Hepatic physiology and mechanisms of hepatic drug
   Renal physiology, renal failure, and renal function tests
   The autonomic nervous system and receptor
   Hypothermia and perioperative temperature control
   Coagulation
   Reperfusion syndrome in clinical liver transplantation
   End stage liver disease and clinical manifestations
                    Clinical Skills
   Organ procurement and donation
   Anesthesia for organ donation
   Anesthesia for organ transplantation
   Transfusion medicine
   Anesthesia for patients with hepatocellular disease
   Invasive hemodynamic monitoring
   Non-invasive hemodynamic monitoring
   Shock states
   Cardiopulmonary-cerebral resuscitation
   Cardiac emergencies and their management
   Intensive care management of the liver transplant patient
   History and organization of organ transplantation
   Pancreas transplantation
   Intestinal and multiple organ transplantation
   Infectious diseases and transplantation
    Specialized training and skill
 Anesthetic management of the organ donor
 Anesthetic management for multiple visceral organ
 Advanced cardiac life support
 Central venous catheterization (femoral, internal jugular
  and subclavian veins)
 Right heart catheterization (pulmonary artery catheter
 Arterial line placement (radial and femoral)
 Management of the difficult airway
 Transesophageal echocardiography
 Arterial blood gas analysis
    Perceptions of Organ Donation
   Most people still consider organ donation as a
    gift, but many would now agree to readily share
    body parts after death. This biased population of
    well-educated people has still little knowledge of
    organ donation. The negative impact of
    ignorance surrounding religious precepts and the
    high acceptance rate of educational programs in
    schools, justify supporting an intensive
    international effort in education that should also
    include Church leaders.
An international opinion poll of well-educated people regarding awareness and
   feelings about organ donation for transplantation. Cantarovich, Felix;
   Heguilen, Ricardo; Filho, Mario Abbud; Duro-Garcia, Valter; Fitzgerald,
   Robert; Mayrhofer-Reinhartshuber, David; Lavitrano, Maria-Luisa; Esnault,
   Vincent L. M.; Cantarovich, Felix. Transplant International (0934-0874)
   6/1/2007. Vol.20,Iss.6;p.512-518.
                      Brain Death
The concept of brain death has become deeply ingrained in
  our health care system. It serves as the justification for
  the removal of vital organs like the heart and liver from
  patients who still have circulation and respiration while
  these organs maintain viability. On close examination,
  however, the concept is seen as incoherent and
  counterintuitive to our understandings of death. In order
  to abandon the concept of brain death and yet retain our
  practices in organ transplantation, we need to either
  change the definition of death or no longer maintain a
  commitment to the dead donor rule, which is an implicit
  prohibition against removing vital organs from
  individuals before they are declared dead.
Brain death - too flawed to endure, too ingrained to abandon, Truog
   RD. Journal of Law, Medicine & Ethics (1073-1105) 2007 Summer.
Health Care Professionals Attitudes
   The acceptance and application of the concept that brain death is a
    valid determination of death is the central issue in organ donation.
    However, whether attitude to brain death of health care
    professionals influences the organ procurement process has not
    been systematically studied.
   Conclusions: The understanding and acceptance of brain death as a
    valid determination of death was associated with a positive effect on
    the level of comfort of health care professionals in performing key
    donor-related tasks. Reinforcing a positive attitude to brain death
    among health care professionals may facilitate the procurement

Attitude of health care professionals to brain death: influence on the
   organ donation process. Cohen J, Ami SB, Ashkenazi T, Singer P.
   Clin Transplant 2007
    Anesthetic Mgt of Transplant Pts for Non-
               Transplant Surgery

   The number and success rate of paediatric organ transplantation
    continue to improve yearly, and the number of transplanted children
    presenting for either elective or emergency nontransplant surgery is
    expected to increase accordingly. Since anaesthetists and surgeons
    in hospitals who are not involved in transplantations, may be
    required to manage paediatric transplant recipients, the reviews of
    the existing experience in this field will be valuable tools in their

Anaesthetic and perioperative management of paediatric organ
  recipients in nontransplant surgery. Smyrniotis, V., Arkadopoulos,
  N., Contis, J., Briassoulis, G., Kostopanagiotou, E., Kostopanagiotou,
  G.. Paediatric Anaesthesia (1155-5645) 11/1/2003.
    Anesthetic management of pediatric
     living related liver and small bowel
   The anesthetic management of a pediatric living related liver and small
    bowel transplant is very challenging. Preoperatively, the focus is on the
    extensive preparation needed for these cases. Intraoperatively, fluid
    management requires maintenance of a delicate balance between low CVP
    to prevent venous congestion of the transplant and adequate blood
    pressure to maintain perfusion, especially during the reperfusion phase.
    Monitoring the coagulation status and platelets is important, in order to be
    able to react appropriately to uncontrollable bleeding; however,
    overcorrection, which can lead to hepatic or mesenteric artery thrombosis
    and graft failure, should not be risked. Temperature control is crucial in
    children independent of the surgical procedure, but poses a special
    challenge in light of large volume shifts, cold transplanted organs, and large
    surface area exposure.

Anesthetic management of pediatric living related liver and small bowel
   transplants, Campise-Luther, R.. (2006) Clinical Transplantation 20 (s16),
                         Heart Centers
Allegheny    General Hospital, Pittsburgh, PA, PAAGTX1HR
Children's   Hospital of Philadelphia, Philadelphia, PA, PACPTX1HR
Children's   Hospital of Pittsburgh, Pittsburgh, PA, PACHTX1HR
Hahnemann      University Hospital Tenet, Philadelphia, PA, PAHMTX1HR

Hospital   of the University of Pennsylvania, Philadelphia, PA, PAUPTX1HR

Penn    State Milton S Hershey Medical Center, Hershey, PA, PAHETX1HR

St.   Christopher's Hospital for Children, Philadelphia, PA, PASCTX1HR
Temple    University Hospital, Philadelphia, PA, PATUTX1HR
The    Lankenau Hospital, Wynnewood, PA, PALHTX1HR
Thomas     Jefferson University Hospital, Philadelphia, PA, PATJTX1HR
University   of Pittsburgh Medical Center, Pittsburgh, PA, PAPTTX1HR
                       Intestine Centers

Children's   Hospital of Pittsburgh, Pittsburgh, PA, PACHTX1IN

University   of Pittsburgh Medical Center, Pittsburgh, PA, PAPTTX1IN
                          Lung Centers
Children's   Hospital of Philadelphia, Philadelphia, PA, PACPTX1LU

Children's   Hospital of Pittsburgh, Pittsburgh, PA, PACHTX1LU

Hospital   of the University of Pennsylvania, Philadelphia, PA, PAUPTX1LU

Temple   University Hospital, Philadelphia, PA, PATUTX1LU

University   of Pittsburgh Medical Center, Pittsburgh, PA, PAPTTX1LU
                  Heart-Lung Centers
Children's   Hospital of Philadelphia, Philadelphia, PA, PACPTX1HL

Children's   Hospital of Pittsburgh, Pittsburgh, PA, PACHTX1HL

Hospital   of the University of Pennsylvania, Philadelphia, PA, PAUPTX1HL

Temple   University Hospital, Philadelphia, PA, PATUTX1HL

University   of Pittsburgh Medical Center, Pittsburgh, PA, PAPTTX1HL
                          Liver Centers

Albert   Einstein Medical Center, Philadelphia, PA, PAAETX1LI
Allegheny    General Hospital, Pittsburgh, PA, PAAGTX1LI
Children's   Hospital of Philadelphia, Philadelphia, PA, PACPTX1LI
Children's   Hospital of Pittsburgh, Pittsburgh, PA, PACHTX1LI
Geisinger    Medical Center, Danville, PA, PAGMTX1LI
Hahnemann      University Hospital Tenet, Philadelphia, PA, PAHMTX1LI
Hospital   of the University of Pennsylvania, Philadelphia, PA, PAUPTX1LI
Oakland    Veterans Administration Medical Center, Pittsburgh, PA, PAPTVA1LI
Penn    State Milton S Hershey Medical Center, Hershey, PA, PAHETX1LI
St.   Christopher's Hospital for Children, Philadelphia, PA, PASCTX1LI
Thomas     Jefferson University Hospital, Philadelphia, PA, PATJTX1LI
University   of Pittsburgh Medical Center, Pittsburgh, PA, PAPTTX1LI
VA    Pittsburgh Healthcare System, Pittsburgh, PA, PAVATX1LI
                     Pancreas Centers

Albert   Einstein Medical Center, Philadelphia, PA, PAAETX1PA
Allegheny    General Hospital, Pittsburgh, PA, PAAGTX1PA
Children's   Hospital of Pittsburgh, Pittsburgh, PA, PACHTX1PA
Geisinger    Medical Center, Danville, PA, PAGMTX1PA
Hahnemann      University Hospital Tenet, Philadelphia, PA, PAHMTX1PA
Hospital   of the University of Pennsylvania, Philadelphia, PA, PAUPTX1PA
Lehigh   Valley Hospital, Allentown, PA, PALVTX1PA
Penn   State Milton S Hershey Medical Center, Hershey, PA, PAHETX1PA
Pinnacle   Health System at Harrisburg Hospital, Harrisburg, PA, PAHHTX1PA
Temple    University Hospital, Philadelphia, PA, PATUTX1PA
Thomas     Jefferson University Hospital, Philadelphia, PA, PATJTX1PA
University   of Pittsburgh Medical Center, Pittsburgh, PA, PAPTTX1PA
               Kidney Centers
Albert   Einstein Medical Center, Philadelphia, PA, PAAETX1KI

Allegheny    General Hospital, Pittsburgh, PA, PAAGTX1KI

Children's   Hospital of Philadelphia, Philadelphia, PA, PACPTX1KI

Children's   Hospital of Pittsburgh, Pittsburgh, PA, PACHTX1KI

Geisinger    Medical Center, Danville, PA, PAGMTX1KI

        Wyoming Valley Medical Ctr, Wilkes-Barre, PA,

Hahnemann      University Hospital Tenet, Philadelphia, PA,

        of the University of Pennsylvania, Philadelphia, PA,

Lehigh    Valley Hospital, Allentown, PA, PALVTX1KI
                        Kidney Centers

Oakland    Veterans Administration Medical Center, Pittsburgh, PA, PAPTVA1KI

Penn    State Milton S Hershey Medical Center, Hershey, PA, PAHETX1KI

Pinnacle    Health System at Harrisburg Hospital, Harrisburg, PA, PAHHTX1KI

St.   Christopher's Hospital for Children, Philadelphia, PA, PASCTX1KI

Temple    University Hospital, Philadelphia, PA, PATUTX1KI
The    Lankenau Hospital, Wynnewood, PA, PALHTX1KI
Thomas     Jefferson University Hospital, Philadelphia, PA, PATJTX1KI
University   of Pittsburgh Medical Center, Pittsburgh, PA, PAPTTX1KI
VA    Pittsburgh Healthcare System, Pittsburgh, PA, PAVATX1KI
              Myths Regarding Organ
   There is a severe organ shortage in this country. Despite continuing efforts
    at public education, misconceptions and inaccuracies about donation
    persist. It's a tragedy if even one person decides against donation because
    they don't know the truth. Following is a list of the most common myths
    along with the actual facts:

   Myth: If emergency room doctors know you're an organ donor, they won't
    work as hard to save you.

   Fact: If you are sick or injured and admitted to the hospital, the number
    one priority is to save your life. Organ donation can only be considered
    after brain death has been declared by a physician. Many states have
    adopted legislation allowing individuals to legally designate their wish to be
    a donor should brain death occur, although in many states Organ
    Procurement Organizations also require consent from the donor's family.
    UNOS Ethics Committee Position
 Financial Incentives for Organ Donation
 Convicted Criminals and Transplant Evaluation
 Ethics of Organ Donation From Condemned
 Living Non-directed Organ Donation
 Preferred Status For Organ Donors
 Life Expectancy
 Organ Failure Caused by Behavior
 Compliance/Adherence
 Repeat Transplantation
 Alternative Therapies
 Split Vs. Whole Liver Transplantation
    Patient Alert: New Study Finds Most Organ
     Transplant Patients are Unaware of their
          Increased Risk for Skin Cancer

   SAN ANTONIO (Feb. 1, 2008) - As the number of
    organ transplants continues to increase throughout the
    world, so too are the number of organ transplant
    recipients developing skin cancer. Due in large part to
    the immunosuppressive medications required to prevent
    organ rejection, skin cancer among patients receiving
    solid organ transplants - such as kidney, heart, liver, or
    lung, among other organs - also tends to be more
    aggressive and spreads more quickly than in other
    patients. Now, new research demonstrates the need for
    more comprehensive patient education and management
    of skin disease in transplant patients to try to reverse
    these rising skin cancer rates.
    Organ Transplant in the Media
   Egypt's thriving organ trade
    Mar 14, 2008 (LA Times) The country has no laws regarding transplants and little oversight. A
    kidney can go for as much as $7300 in Egypt.

   Boston hospital gets OK for face transplants
    Mar 05, 2008 (Boston Globe) The New England Organ Bank authorized Brigham and Women's
    hospital to perform partial face transplants. The first candidates will be recipients of donated
    kidneys because those patients are already on immunosuppressant drugs.

   Two lungs are better than one
    Feb 28, 2008 (AFP) A paper in the Lancet reports that COPD patients who receive two
    transplanted lungs, instead of one, live on median about two years longer. The problem: there
    aren't enough donor lungs to go around.

   Woman donates kidney after seeing flyer
    Feb 27, 2008 (AP) The recipient was an 8-year-old. The donor saw the flier at the school where
    her children and the recipient all attend.

   Hearings begin in organ harvesting case
    Feb 27, 2008 (NYT) A California doctor is accused of speeding the death of patient so a
    transplant team could retrieve the patient's organs. The president of the American Society of
    Transplant Surgeons called the case unprecedented.

   Who wants to buy a pancreas?
    Feb 12, 2008 (Canadian Press) A Quebec man with a rare condition is trying to sell his pancreas
    online. The man reportedly decided to market his organ after a Montreal hospital told him it
    would not release the organ to him following a pancreatectomy. He seems to have found no
    takers, so far.
    Uniform Anatomical Gift Act
   The UAGA provides individuals who are 18
    years of age or older the right to donate
    organs and tissue for transplantation. A
    written document of your wish includes a
    signed donor card or indication on your
    driver's license. All states have enacted
    some form of the UAGA.
        Organ Transplant History
   Researchers began experimenting with organ
    transplantation on animals and humans in the 18th
    century. Over the years, scientists have experienced
    many failures, but by the mid-20th century, they were
    performing successful organ transplants. Transplants of
    kidneys, livers, hearts, pancreata, intestine, lungs, and
    heart-lungs are now considered routine medical
   Unfortunately, the need for organ transplants continues
    to exceed the supply of organs. But as medical
    technology improves and more donors become available,
    the number of people who live longer and healthier lives
    continues to increase each year.
         Significant Milestones in
    Organ Donation and Transplantation
   1869 — First "transplant" which was a skin graft.
   1906 — First transplant of a cornea
   1954 — First kidney transplant - the living donor
    donated to his identical twin.
   1962/1963 — First kidney, lung, and liver transplants
    from deceased donors.
   1967/1968 — First heart transplant (in South Africa)
    and first U.S. heart transplant.
   1968 — Congress passes the Uniform Anatomical Gift
    Act (not a U.S. Government Web site) and makes
    donating organs and tissues legal.
   1968 — First pancreas transplant.
   1981 — First heart/lung transplant.
    Timeline of Historical Events
 1983 — The Federal Food and Drug Administration
  approves cyclosporine which reduces rejection of
  transplanted organs or tissues.
 1983/1984 — First successful lung and heart/liver
 1984 — Congress passes the National Organ Transplant
  Act, which prohibits the selling of organs and tissues and
  establishes the Organ Procurement and Transplantation
  Network (to ensure fair and equitable allocation of
  donated organ and tissues.)
 1986 — The United Network for Organ Sharing (UNOS)
  (not a U.S. Government Web site) provides services for
  equitable access and allocation of organs and sets the
  membership criteria and standards for transplant centers
  in the U.S. through a contract with the Division of
  Transplantation, HRSA/HHS.
    Timeline of Historical Events
 1987 — Medicare pays for heart transplants performed
  at hospitals that meet criteria set by the Health Care
  Financing Administration.
 1988 — The Joint Commission on Accreditation of
  Health Care Organizations (JCAHO) sets donor standards
  and requires hospital policies and procedures for organ
  and tissue procurement.
 1990 — Medicare pays for liver transplants (that meet
  specific medical criteria) performed at approved
 1990 — Nobel Prize awarded to Drs. Joseph E. Murray
  and Dr. E. Donnall Thomas pioneers in kidney and bone
  marrow transplants respectively.
 1991 — First successful small intestine transplant.
 1996 — Congress authorizes mailing organ and tissue
  donation information with income tax refunds (sent to
  approximately 70 million households).
Timeline of Historical Events
   2002 — Up-to-the-minute data on the number of people
    waiting for organ transplants in the United States are
    now available online through the OPTN.
   2003 — Secretary Tommy G. Thompson, Secretary of
    the U.S. Department of Health and Human Services
    designates April as National Donate Life Month.
   2005 — First successful partial face transplant (France)
   2006 — First successful penis transplant (China)
Consent for Organ Donation — Balancing Conflicting
                Ethical Obligations

In the March 20, 2008 edition of The New England Journal of
   Medicine (Volume 358:1209-1211) Robert D. Truog, M.D.

  Organ transplantation is truly one of the miracles of
  modern medicine, saving the lives of many patients and
  improving the quality of life for many more. Given the
  ever-increasing gap between the number of organs
  needed and the supply, clinicians have an ethical
  obligation to help ensure that the desires of people who
  want to donate organs are respected. The Department
  of Health and Human Services took up this challenge in
  2003, when it collaborated with leading transplantation
  organizations to launch the Breakthrough Collaborative,
  calling on all hospitals to increase their organ-donation
  rates to 75% or higher.
Key Elements of the Standard Approach and the Presumptive Approach
               to Counseling Potential Organ Donors.

Perioperative Blood Use in Adult Organ
 Transplantation at the University of
Organ            RBC* Plasma* Platelets*   Cryo*
Kidney N=250     0-2    0         0            0
Intestine n=40   7      3         0            0
Lung, double     7      2         8            0
Lung, single     0-2    0          0          0
Heart n=51       4     5           10         0
Liver n=110      12    13          10         0

         Heme oxygenase (HO)-1
 Oxidative stresses associated with ischemia/reperfusion, neutrophil
  activation, and anesthesia with certain volatile agents, etc., are thought to
  play an important role in the development of acute organ failure in critical
  illnesses, such as acute lung injury, acute coronary artery insufficiency,
  acute liver failure, acute renal failure, and multiple organ dysfunction
  syndrome. Such oxidative stressors provoke a set of cellular responses,
  particularly those that participate in the defense against tissue injuries. Free
  heme, which can be rapidly released from hemeproteins, may constitute a
  major threat in the oxidant stress because it catalyzes the formation of
  reactive oxygen species. To counteract such insults, cells respond by
  inducing the 33-kDa heat shock protein, heme oxygenase (HO)-1, the rate-
  limiting enzyme in heme degradation. Induced HO-1 as such removes free
  heme by an enzymatic process. In addition, HO-1 induction itself confers
  protection to tissues from further oxidative injuries. In contrast, the
  abrogation of HO-1 induction, or chemical ablation of HO activity abolishes
  the beneficial effect of HO-1, and results in the aggravation of tissue
Heme oxygenase-1: a new drug target in oxidative tissue injuries in
  critically ill conditions. Takahashi, T., Shimizu, H., Akagi, R., Morita, K.,
  & Sassa, S.. Drug Dev. Res. 67:130-153, 2006.
                 CO2 Management
   Is there a carbon dioxide concentration range that provides
    optimum benefit to the patient intraoperatively. It includes the
    physiological effects of carbon dioxide on various organ systems in
    awake and anesthetized individuals and its clinical effects in the
    ischemia/reperfusion setting.
   Overall, the benefits of managing carbon dioxide concentration
    intraoperatively for the maintenance of cardiac output, tissue
    oxygenation, perfusion, intracranial pressure, and cerebrovascular
    reactivity are well defined.

Optimizing the intraoperative management of carbon dioxide
  concentration. Akca O. Current Opinion in Anaesthesiology
  (CINAHL) (0952-7907) 2006 Feb. Vol.19,Iss.1;p.19-25
              Survival Statistics
   Survival statistics depend greatly on the age of
    donor, age of recipient, skill of the transplant
    center, compliance of the recipient, whether the
    organ came from a living or cadaveric donor and
    overall health of the recipient. Median survival
    rates can be quite misleading, especially for the
    relatively small sample that is available for these
    organs. Survival rates improve almost yearly,
    due to improved techniques and medications.
    This example is from the United Network of
    Organ Sharing (UNOS), the USA umbrella
    organization for transplant centers. Up-to-date
    data can be obtained from the UNOS website.
    Organ Donation and Utilization in
     the United States, 1997-2006
   Deceased organ donation has increased rapidly
    since 2002, coinciding with implementation of the
    Organ Donation Breakthrough Collaborative. The
    increase in donors has resulted in a
    corresponding increase in the numbers of kidney,
    liver, lung and intestinal transplants. Current
    efforts of the collaborative have focused on
    differentiating ORPD and OTPD targets by donor
    type (standard and expanded criteria donors and
    donors after cardiac death), utilization of the
    OPTN regional structure and enlisting centers to
    increase transplants to match increasing organ
    availability. R. S. Sung, J. Galloway, J. E. Tuttle-
    Newhall, T. Mone, R. Laeng, C. E. Freise, P. S. Rao
Kidney and Pancreas Transplantation in the United
   States, 1997-2006: The HRSA Breakthrough
    Collaboratives and the 58 DSA Challenge
   Growth in the number of active patients on the
    kidney transplant waiting list has slowed.
    Projections based on the most recent 5-year data
    suggest the total waiting list will grow at a rate of
    4138 registrations per year, whereas the active
    waiting list will increase at less than one-sixth
    that rate, or 663 registrations per year. The last 5
    years have seen a small trend toward improved
    unadjusted allograft survival for living and
    deceased donor kidneys. Since 2004 the overall
    number of pancreas transplants has declined.
    Among pancreas recipients, those with
    simultaneous kidney-pancreas transplants
    experienced the highest pancreas graft survival
Liver and Intestine Transplantation
  in the United States, 1997-2006
   Liver transplantation in 2006 generally resembled
    previous years, with fewer candidates waiting for
    deceased donor liver transplants (DDLT),
    continuing a trend initiated with the
    implementation of the model for end-stage liver
    disease (MELD). Candidate age distribution
    continued to skew toward older ages with fewer
    children listed in 2006 than in any prior year.
    Total transplants increased due to more DDLT
    with slightly fewer living donor liver transplants
    (LDLT). Survival rates have increased over time.
    Small children waiting for intestine grafts
    continue to have the highest waiting list
    Transplants in Foreign Countries Among Patients
     Removed from the US Transplant Waiting List

   Transplant tourism, where patients travel to
    foreign countries specifically to receive a
    transplant, is poorly characterized. This study
    examined national data to determine the
    minimum scope of this practice. US national
    waiting list removal data were analyzed. Waiting
    list removals for transplant without a
    corresponding US transplant in the database were
    reviewed via a data validation query to transplant
    centers to identify foreign transplants. Recipients
    from 34 states, plus the District of Columbia,
    received foreign transplants in 35 countries, led
    by China, the Philippines and India. Transplants in
    foreign countries among waitlisted candidates in
    the US are increasingly performed.
     Calculating Life Years from Transplant
    (LYFT): Methods for Kidney and Kidney-
              Pancreas Candidates
   The Organ Procurement and Transplantation
    Network (OPTN) Kidney Committee is considering
    a proposal for a new deceased donor kidney
    allocation system. Among the components under
    consideration is a strategy to rank candidates in
    part by the estimated incremental years of life
    that are expected to be achieved with a
    transplant from a specific available deceased
    donor, computed as the difference in expected
    median lifespan with that transplant compared
    with remaining on dialysis. Prioritizing candidates
    with higher LYFT scores for each available kidney
    could substantially increase total years of life
    among both transplant candidates and recipients.
    LYFT is also a powerful metric for assessing
    trends in allocation outcomes and for comparing
    alternative allocation systems.
      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 Reality of Black Market Organs
    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
    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
   Body weight less than 80% or greater than 120% of
   Inability to carry out the responsibilities necessary to
    maintain a healthy lifestyle and remain compliant with all
    Most Transplant Patients...

 Are in surgery approximately 3-7 hours
 Spend 1 day on the breathing machine
 Spend 1-2 days in the intensive care unit
 Are discharged 7-12 days after their
               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.
            Management of liver
 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
 Administer calcium for signs of
 List EKG signs of hyperkalemia
 Administer epinephrine for hypotension
 Judicious volume infusion to avoid
  distended liver
     Preoperative Assessment
   General Physical Status
          1 = Outpatient
          2 = Inpatient
          3 = ICU
          4 = Acute fulminant hepatic failure
   CNS – Rule out diseases mimicking hepatic encephalopathy
   Cardiovascular – LV function, CAD, valves
   Pulmonary – CXR, ABG, PFTs as indicated
   Hepatic – etiology of liver failure, hepatitis serology
   Coagulation – INR, PT, PTT, platelets, fibrinogen
   Renal – BUN, creatinine, electrolytes
   Vascular access –Lines/transducer set-up! A minimum is: two 8.5F introducer
    sheaths for the RIS, one radial arterial line, one right femoral arterial line, and an
    oximetric (consider RIF) pulmonary artery catheter. The following areas should be
    left untouched: the left groin and the axillas for veno-venous bypass, the right
    subclavian for a post-operative Hickman catheter. The left radial artery can be used
    even if the arm is used for the bypass. 18F IV in hand for drugs.
 Anesthesiology is responsible for the basic set-up of the anesthesia
  machine, transducers, monitors, TEE, warming blanket, rapid infusion
  system, upper body and lower body Gaymar warmers, and lines and stop-
  cocks on the special headboard. Before the start of the case,
  anesthesiology will also ascertain that a large number of labels, lab
  requisition forms and anesthesia records have been imprinted with the
  patient’s name and Medical Records number on them.
 During the transplantation procedure any free member of the anesthesia
  team will help with transportation of blood, blood products, and blood
  samples. When the transplantation procedure is completed, and the patient
  has left the room, it is the responsibility of the blood bank staff to collect
  empty blood and blood product bags, and the unused blood and blood
  products. Anesthesiology will bring the unused blood components and the
  empty bags to the OR Laboratory and notify the blood bank staff when to
  come to the OR to retrieve these. On each occasion when blood is drawn
  in blue tops and sent to the OR Stat Lab for analysis, there will be two blue
  tops delivered. The lab will know how to handle these.
   Transplantation stages
   Stage I: Pre-anhepatic
   Stage II: Anhepatic
   Stage III: Post-anhepatic
   Rapid Infusion System
   The RIS/Belmont rapid infusion system is primed with
    500 ml of Normosol-R, two units of packed red blood
    cells, and two units of fresh frozen plasma. During the
    case, the RIS is filled with increments of 500 ml
    Normosol-R plus two units of packed red blood cells and
    two units of fresh frozen plasma. Use the extensions
    from the RIS as part of the intravenous set, then the RIS
    can just plug into a stopcock.
    Blood and Blood Products
   The blood bank will initially deliver 20
    units of blood. FFP will initially be
    delivered as four bags, each containing
    five units of FFP, i.e., 4 x 1,000 ml.
    Thereafter one bag will be delivered every
    time FFP is requested. Platelets and
    cryoprecipitate will be supplied as three
    pools of 10 units.
    Temperature Maintenance
   The patient will be placed on a heating blanket. In
    addition, the arms will be wrapped in plastic bags and
    foam pads. The patient’s head will be covered with a
    plastic bag. Patient temperature will be monitored with
    the usual esophageal temperature probe plus a Foley
    catheter with a temperature sensor. The patient should
    be kept at normal body temperature. In order to
    maintain normal body temperature, a heating coil in the
    veno-venous bypass and an upper and lower body
    Gaymar warmer will be used. If needed: heat the
    operating room! Make certain that infusate temperature
    is adequate. The infusate will cool when not running,
    thus run the RIS in ―re-circulate mode‖ for a few
    seconds to put warm fluid in the line. Fluids delivered
    through peripheral IVs will be heated through the
    standard blood warmers.
      Thrombelastographs and
   Three thrombelastographs will be
    available. Coagulopathies should be
    treated as indicated by TEG data.
    Platelets, amicar, and protamine will be
    given based on TEG results. Heparin
    effect is common in Stage III. Platelet
    levels should preferably not be lower than
    50K. Risk of platelet transfusion:
    sensitization to future platelet
         Arterial blood gases and
   Acidosis: will be treated with either bicarbonate or THAM
    (preferably given only to patients who are on low salt diet or have
    hypernatremia), or both. Acidosis is common in Stage II. The
    tendency is to be very aggressive with treatment before
    unclamping. The advantage of THAM is two-fold: it will move
    intracellularly and it does not perturb the Na balance. Keep BE
    close to zero prior to unclamping.

   Calcium chloride: can be given liberally, about 500 mg per every
    1,500 ml from RIS. Ca2+ should be checked frequently (‹4.5 mg/dl
    or ›0.8 mmol/l).

   Potassium: increased potassium levels should be treated
    aggressively except during initial reperfusion during which a
    transitory K+ peak will be seen. This usually will normalize
    spontaneously. Begin to treat in Stage II if K+ › 4.0; try to
    decrease K+ to ‹ 4.0 before unclamping.

   Hematocrit: keep 25 – 30 for patients without CAD.
          Blood Sampling times
   Blood samples will be drawn for TEG’s at:
   Baseline
   I:     + 60 min
   II:    - 30 min (30 min before bypass)
   II:    + 10 min (10 min after bypass)
   III: - 5 min
   III: + 5 min
   III: + 30 min
   III: BR – 5 min (5 min before start of biliary reconstruction)
   End sample
   OR as needed!
   Coagulation studies
   PT, PTT, and Fibrinogen (two blue tops) and Platelets (one purple top) should be
    drawn every 60 min throughout the case. One set of coags should also be
    drawn 10 min into the anhepatic phase.
   Other studies
   Ca2, K2, and Na+ are automatically analyzed with the ABG sample.
   Lactate (black screw top) and glucose (small red top) will be drawn as needed.
     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.
      Drugs mixed in syringes
   Ephedrine 1 x 5 mg/ml
   Epinephrine 1 x 10 ug/ml
   Epinephrine 1 x 100 ug/ml
   Two sets of specially prepared medications are now in the Liver
    Transplant cart:
   Calcium chloride 10% for injection, three bottles of 250 ml each.
   Sodium bicarbonate 1 m/Eq/ml for injection, three bottles of 250 ml
   Dopamine 5 mg/cc in 50 cc Baxter pump
   Lidocaine 0.8% in D5W, one 500 ml bag.
   Vecuronium 20 mg vial, five vials, D5W, one 100 ml bag (the
    vecuronium vials and bag of D5W are placed together in a zip-lock
    bag.) Pancuronium 10 mg vial, five vials.
         Fluid Management
   Normosol-R/NS will be used as a primary
    intravenous fluid. Limited amounts should
    be given (usually 1,000 ml, maximally
    1,500 ml), mainly to keep peripheral IVs
    open. Do not deliberately fill the patient
    up with volume before reperfusion. There
    may be a transient drop in
    volume/pressure with reperfusion, but this
    is usually immediately followed by
    increases in filling pressures.
      Hemodynamics and Mixed
        Venous Oxygenation
   Patients with abnormal ejection fractions (EF) are usually
    not accepted for transplantation. Circulation before
    transplantation should be hyperdynamic with an EF in
    the 65- 75% range; an EF of 55% is considered
    abnormally low.
   During the case the liver index should be 4 – 5
    l/min/m2. 3 – 4 l/min/m2 is considered low and may
    warrant therapy with dopamine. As in other patients,
    numbers should not be treated per se.
   Fenoldapam or Dopamine may also be started for low
    urinary output. Mixed venous oxyhemoglobin saturation
    can be expected to be 80 – 90. It usually drifts upwards
    through Stage I
   Transesophageal Echocardiography
   As indicated, TEE will be used to access liver status of
    the patient along with other monitors.
   Anesthesia record
   The anesthesia record should include the GA record flow
    sheet for rapid infusion (fluids with blood and blood
    products) and the flow sheet of lab values.
   Transfer of patient to ICU
   The ICU fellow will come to the OR 1 hour to 1½ hours
    before the surgical ending time. He/she will be
    appraised of the case and a report will be given in the
    OR before patient transport. The patient will then be
    transferred to the SICU by both the anesthesiologist and
    the surgeons with full monitoring.
   1)
              Surgical time points
   2)    Bypass started (if used)
   3)    Portal vein clamped
   4)    Hepatic artery clamped
   5)    Infrahepatic vena cava clamped
   6)    Suprahepatic vena cava clamped
   7)    Diseased liver removed
   8)    Donor liver removed from ice
   9)    Removal of portal cannula
   10)   Portal vein unclamped
   11)   Infrahepatic vena cava unclamped
   12)   Suprahepatic vena cava unclamped
   13)   Initial flow restored
                       a) Venous (portal vein)
                       b) Cross-clamp aorta (if applicable)
                       c) Arterial (hepatic artery)
   14)   Complete flow restored a) Venous                  b) Arterial
   15)   Off bypass (if used)
   16)   Flow interrupted
                       a) Portal vein
                       b) Hepatic artery
   17)   Flow restarted
                       a) Portal vein
                       b) Hepatic artery
   18)   Start biliary anastomosis
   19)   End biliary anastomosis
   20)   Close incision
             Living Liver Donor
   In our experience, donor hepatectomy
    was not an entirely safe procedure;
    therefore, extreme care should always be
    given by the transplant teams to living
    donors to avoid any distressing morbidity
    or even, the less likely but more
    catastrophic, mortality.
Donor Outcome After Living Liver Donation: A Single-
  Center Experience. Khalaf, H.; Al-Sofayan, M.; El-Sheikh,
  Y.; Al-Bahili, H.; Al-Sagheir, M.; Al-Sebayel, M.; Khalaf,
  H. Transplantation Proceedings (0041-1345) 5/1/2007.
Anesthetic risks for donors in living-
   related liver transplantation
   Liver transplantation involving living-related
    donors has been adopted in many centers as a
    way of relieving organ shortage. Maximal efforts
    must be applied in the anesthetic approach to
    minimize donor complications in living-related
    liver transplantation; however, this will not
    completely eliminate some risks to the donor.

Anesthetic risks for donors in living-related liver
  transplantation: analysis of 30 cases.
  Akpek, E.A., Arslan, G., Erkaya, C., Torgay, A.,
  Dönmez, A., Kayhan, Z., Karakayali, H. (2003)
  Transplant International 16 (8), 584–588.
              Living Donor (LD) vs
              Diseased Liver (DZ)
The LD procedure took longer to perform because of the
  time required for hilar dissection. The difference in
  intraoperative transfusions is attributable to use of cell
  salvage and retransfusion of salvaged blood for all
  donors; this was not routine for DZ procedures.
  Perioperative outcomes were similar in all other respects.
  The LD procedure has similar outcomes to those of the
  DZ procedure.

Right hepatectomy for living liver donation vs right
   hepatectomy for disease: intraoperative and immediate
   postoperative comparison. Gali B;Findlay JY;Plevak DJ;Rosen
   CB;Dierkhising R;Nagorney DM. Arch Surg (0004-0010) 2007 May.
   Vol.142,Iss.5;p.467-71; discussion 471-2
Extracorporeal Life Support
        (eg. ECMO)
           Porto-pulmonary HTN
   Pulmonary hypertension in the setting of cirrhosis and
    portal hypertension is known as portopulmonary
    hypertension (PPHTN). Moderate or severe PPHTN is
    uncommon, but has a poor prognosis and is considered
    to be a contraindication to liver transplantation Effective
    pharmacologic control of PPHTN before liver transplant is
    associated with excellent posttransplant survival that is
    similar to patients transplanted for other indications.

The Impact of Treatment of Portopulmonary Hypertension on
  Survival Following Liver Transplantation. Ashfaq, M.;
  Chinnakotla, S.; Rogers, L.; Ausloos, K.; Saadeh, S.; Klintmalm, G.
  B.; Ramsay, M.; Davis, G. L.; Ashfaq, M.. American Journal of
  Transplantation (1600-6135) 5/1/2007. Vol.7,Iss.5;p.1258-1264
       Split and Living Related Liver
   Split liver transplants (SLTs) and living related liver
    transplants (LRLTs) were developed to increase the
    number of available organs for adult recipients. We
    review our experience in performing both the split
    procedure and the 2-graft transplant at the same
   Conclusion: A "simultaneous" transplant of 2 liver grafts
    at the same center may increase graft quality and
    improve organ survival. Conversely, it requires excellent
    technical facilities and organizational skills. This
    approach has the potential to decrease mortality on the
    adult waiting list, to optimize LT timing with outcome
    improvement, and to decrease the need for LRLDs.
Simultaneous adult-to-adult (A/A) split liver transplants. F.
  Panaro, E. Andorno, F. Ravazzoni, S. Di Domenico, D. Ghinolfi, M.
  Miggino, N. Morelli, G. Bottino, M. Casaccia, U. Valente (2006).
  Clinical Transplantation 20 (s16), 31–31.
               Tissue Oxygenation
   Liver transplantation has become a gold standard treatment for
    irreversible liver disease. Conventional measures of oxygenation are
    inadequate to understand the dynamics of regional oxygen
    metabolism during liver transplantation because they represent
    global markers of tissue dysoxia. A statistically significant (P < 0.05)
    decrease of P50 in groups B and C compared with group A was
    observed 30 minutes after reperfusion in the systemic circulation,
    hepatic, and renal veins. This coincided with a decrease in animal
    temperature 30 minutes after reperfusion. Regarding group C, after
    reperfusion of the newly transplanted liver there was a significant
    increase of P50 in the small bowel in comparison to baseline values.
    In conclusion, these changes in P50 may suggest the occurrence of
    abnormal tissue oxygenation after reperfusion.

Changes in oxyhemoglobin dissociation curve in intrabdominal
  organs during pig experimental orthotopic liver
  transplantation Kostopanagiotou, G., Theodoraki, K., Pandazi, A.,
  Arkadopoulos, N., Costopanagiotou, C., Smyrniotis, V.. Liver Transpl
Renal Transplant Physiology
    Steroids for Renal Protection?
  Subclinical renal dysfunction is thought to occur as a
   systemic manifestation of ischaemia-reperfusion injury of
   other organs. Liver transplantation is associated with
   major ischaemia-reperfusion injury. The data confirm
   increased proximal tubular lysosomal turnover,
   consistent with an increased tubular protein load,
   following liver transplantation, and suggest that
   methylprednisolone protects against renal and hepatic
Effect of perioperative steroids on renal function after liver
   transplantation. Dhamarajah, S.; Bosomworth, M.;
   Bellamy, M. C.; Turner, S.. Anaesthesia (0003-2409)
   3/1/2006. Vol.61,Iss.3;p.253-259.
               Sevoflurane for
           Renal Transplant Patient
   It was concluded that sevoflurane did not
    aggravate renal impairment in measured
    parameters (serum creatinine, blood urea
    nitrogen and creatinine clearence) of renal
    function and did not change the time for
    hemodialysis in the patient with renal

Sevoflurane Anaesthesia in a Patient with Renal Transplantation: Case
   Report and Literature Review. Eroglu, Ahmet; Erturk, Engin; Bostan,
   Habib; Eroglu, Ahmet. Internet Journal of Anesthesiology (1092-
   406X) 7/1/2007. Vol.13,Iss.1;p.30-30.
    The use of N2O anesthetic causes bowel
    distention in 50% of abdominal
    laparoscopic donor nephrectomy
    operations. The distention was severe
    enough to interfere with the progress of
    surgery in 25% of cases and the use of
    N2O had to be discontinued.

Anesthesia for laparoscopic donor nephrectomy: is nitrous oxide contraindicated? El-Galley
    R;Hammontree L;Urban D;Pierce A;Sakawi Y. J Urol (0022-5347) 2007 Jul. Vol.178,Iss.1;p.225-7
            Nephroprotective Rxs
 Fenoldopam    compared with
   dopamine resulted in better
   nephroprotective effects. No adverse
   events were recorded, and side
   effects were minimal.

Sorbello, M.; Morello, G.; Paratore, A.; Cutuli, M.; Mistretta, G.;
   Belluoccio, A.A.; Veroux, M.; Veroux, P.; Macarone, M.; Gagliano,
   M.; Mangianeli, S.; Sorbello, M.. Transplantation Proceedings (0041-
   1345) 7/1/2007. Vol.39,Iss.6;p.1794-1796
       Early Complication of Kidney
   Our results suggest that living donor
    nephrectomy is safe and is associated with
    minor complications causing little
    morbidity and no mortality.

Early results and complications of 210 living donor nephrectomies.
   Shamsa A;Rasulian H;Mahdi MP;Kadkhodayan A;Yarmohammadi
   AA;Parizadeh R. Saudi J Kidney Dis Transpl (1319-2442) 2003
   October-December. Vol.14,Iss.4;p.481-6
          General vs Regional
   Various general and regional anesthesia
    methods are used successfully in living-
    donor kidney transplantation. This study
    compared kidney graft function after
    general versus combined spinal-epidural
    anesthesia for donor nephrectomy. The
    results suggest that GA and CSE for donor
    nephrectomy have similar effects on
    kidney graft function in recipients.
    Notable Kidney Transplant
 Steven Cojocaru
 Gary Coleman
 Aron Eisenberg
 Sean Elliott
 George Lopez
 Jennifer Harman
 Ken Howard
 Alonzo Mourning
 Kerry Packer
 Neil Simon
 Billy Preston
 Ron Springs
               Heart Transplants
   Heart transplants are the third most common (corneas
    and kidneys are the most common) transplant
    operations in the U.S. (over 1,500 cases per year). A
    healthy heart is obtained from a donor who has suffered
    brain death but remains on life-support. The healthy
    heart is transported in a special solution that preserves
    the organ. While the patient is under general anesthesia,
    an incision is made through the sternum. The patient's
    blood is re-routed through tubes to a bypass machine to
    keep the blood oxygen-rich and circulating. The patient's
    diseased heart is removed and the donor heart is
    stitched in place.
          Artificial Heart Implant

   Of the patients with end-stage cardiomyopathy on a
    heart transplant list, 95% do not receive a donor heart.
    Due to this severe shortage of donor organs, an artificial
    replacement heart has been pursued for several
    decades. Hemodyanamic stabilization before
    cardiopulmonary bypass is extremely challenging, and
    the postbypass period creates a unique situation in
    which the only control the anesthesia provider has on
    the hemodynamics is management of the systemic
    vascular resistance.

  Hobbs, C., Thielmeier, K., Barber, D.. AANA Journal (0094-6354)
  12/1/2003. Vol.71,Iss.6;p.431-439.
     Notable Heart transplant
Robert Altman (1925 – 2006) Film Director.
 Announced the transplant at the 78th Academy
 Awards in 2005 while accepting his Lifetime
 Achievement Oscar. Altman said, "I'm here
 under false pretenses … Eleven years ago I had
 a heart transplant, a total heart transplant. I got
 the heart of, I think, a young woman who was
 in about in her late thirties. By that kind of
 calculation you may be giving this award too
 early because I think I've got about 40 years
 left.― He lived for 11 years with his new heart.
      Notable Heart transplant
Robert P. Casey (1932 – 2000) 41st Governor of
  Pennsylvania. Announced that he needed a rare
  heart/liver transplant due to a rare condition that
  allowed the body's antibodies to attack vital organs.
  Shortly after the announcement, Casey received the
  heart and liver from a 35-year old African-American male
  who was killed in an auto accident near Erie,
  Pennsylvania. The short time between the
  announcement and the operation lead to accusations
  that Casey was secretly placed on the top of the waiting
  list, along with sparking an urban legend that the donor
  was "killed" by the Pennsylvania State Police in order to
  "harvest" the organs. He lived for six years with his new
            Lung Transplantation
   Substantial changes in preoperative selection and
    preparation of lung transplant recipients; these include
    donation after cardiac death, and improved lung-
    preservation solutions. Newer immunosuppression
    regimens have been successfully evaluated in clinical
    trials. Particular advances in anesthesia include
    endorsement of fluid restriction in thoracic surgery,
    greater use of transesophageal echocardiography, and
    postoperative extracorporeal membrane oxygenation.

Lung transplantation. Myles PS; Myles PS; Snell GI; Westall
  GP. Current Opinion in Anaesthesiology (CINAHL) (0952-
  7907) 2007 Feb. Vol.20,Iss.1;p.21-6.
Pancreas Transplant Indications
                         Real-Life Issues
   You are the CRNA on call at a community hospital. You are informed that
    there is to be an organ donation. The donor is currently in the ICU,
    ventilator-dependent and minimally conscious. You are asked to provide
    I.V. sedation and monitoring while ventilation support is withdrawn. After
    the patient’s heart stops, you will declare death, and organ donation will
    proceed five minutes thereafter. The family wishes to be present for
    withdrawal of life-support. The donor is 33-year-old woman who was
    admitted to the ICU following surgery to stabilize a cervical fracture
    sustained during an equestrian accident. Other injuries include a right
    humeral fracture and cerebral contusion. She is otherwise healthy but is
    ventilator-dependent. Initial evaluation indicated that prognosis for recovery
    of ventilatory function is poor. She has left a living will directing that she
    would not want mechanical ventilation unless there was a ―reasonable
    likelihood‖ of recovery. Her husband indicates that he wants to have
    ventilation withdrawn and, in accordance with her wishes, to donate her
    vital organs.

Ethics Clinical Forum: Ethics Issues: Brain Death and Organ Donation.
    Moderator: Gail A. Van Norman, M.D., University of Washington, Seattle, Washington.
Donate Life
                  Donate Life
   Talk to your family about donating life.
   One donor can save or enhance the lives of
    more than 50 people.
   An average of 18 people per day die due to a
    lack of available organs.
   Approximately 96,860 men, women and children
    currently await life-saving organ transplants in
    the United States.
   Last year 28,932 organ transplants were
             IMPORTANT FACTS
   People of all ages and medical histories should consider
    themselves potential donors.
   Your medical condition at the time of death will
    determine what organs and tissue can be donated.
   There is no cost to the donor’s family or estate for organ
    and tissue donation. Funeral costs remain the
    responsibility of the family.
   All major religions approve of organ and tissue donation
    and consider donation the greatest gift.
   An open casket funeral is possible for organ and tissue
             SHARE YOUR LIFE.
   Decide to be a donor. Your commitment to organ and
   tissue donation can save lives. Please complete the
   organ donor card printed below, AND . . .
   The most important part of deciding to be a
   donor is telling your family. Most Americans
   support donation, but few have told family members of their
    decision to donate. Talking
   about donation doesn’t mean talking about death. It is talking about
    the opportunity to give
   another person a second chance at LIFE. Even if you have signed a
    donor card or indicated
   your wish to donate on your driver’s license, you need to tell your
    family since they will be
   consulted before donation can take place.
              Question 1
 What is the most transplanted organ?
 A. Liver
 B. Heart
 C. Kidney
 D. Pancreas
 E. Lung
              Question 2
 Which organization oversees Organ
  Donation in the U. S.?
 A. Department of Interior
 B. National Institute of Health
 C. United Network for Organ Sharing
 D. Internal Revenue Service
 E. Department of Homeland Security
              Question 3
 Which of the following organs cannot be
  transplanted at this time?
 A. Liver
 B. Kidney
 C. Heart
 D. Lung
 E. Brain
             Question 4
 Which anesthetic agent is not
  recommended for kidney transplant?
 A. STP
 B. Etomidate
 C. Nitrous Oxide
 D. Sevoflurane
 E. Isoflurane
                   Question 5
   Which of the following individuals do not make
    the best candidates to receive a lung transplant?
   A. Cancer
   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
             Any Questions?
   Thank you for your attention

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