CONTINUING EDUCATION What s New in the Transplant OR?

CONTINUING EDUCATION What s New i the Trasplat OR? ANIL S. PARAMESH, MD, FACS 2.0 www.aor.org/ce Cotiuig Educatio Cotact Hours idicates that cotiuig educatio cotact hours are available for this activity. Ear the cotact hours by readig this article, reviewig the purpose/goal ad objectives, ad completig the olie Examiatio ad Learer Evaluatio at http://www.aor.org/ce. A score of 70% correct o the examiatio is required for credit. Participats receive feedback o icorrect aswers. Each applicat who successfully completes this program ca immediately prit a certificate of completio. Evet: #13511 Sessio: #0001 Fee: Members $12, Nomembers $24 The cotact hours for this article expire April 30, 2016. Purpose/Goal To eable the learer to uderstad curret advaces i orga trasplatatio. Objectives 1. Idetify types of trasplatatio procedures. 2. Describe tasks that must be accomplished before procuremet ad trasplatatio procedures. 3. Describe surgical time outs performed durig procuremet ad trasplatatio procedures. 4. Idetify iformatio that must be documeted durig procuremet ad trasplatatio procedures. 5. Idetify medicatios that may be used to prevet rejectio of trasplated orgas. Accreditatio AORN is accredited as a provider of cotiuig ursig educatio by the America Nurses Credetialig Ceter s Commissio o Accreditatio. Approvals This program meets criteria for CNOR ad CRNFA recertificatio, as well as other cotiuig educatio requiremets. AORN is provider-approved by the Califoria Board of Registered Nursig, Provider Number CEP 13019. Check with your state board of ursig for acceptace of this activity for relicesure. Coflict of Iterest Disclosures Dr Paramesh has o declared affiliatio that could be perceived as posig a potetial coflict of iterest i the publicatio of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, cliical editor, with cosultatio from Susa Bakewell, MS, RN-BC, director, Perioperative Educatio. Ms Holm ad Ms Bakewell have o declared affiliatios that could be perceived as posig potetial coflicts of iterest i the publicatio of this article. Sposorship or Commercial Support No sposorship or commercial support was received for this article. Disclaimer AORN recogizes these activities as cotiuig educatio for registered urses. This recogitio does ot imply that AORN or the America Nurses Credetialig Ceter approves or edorses products metioed i the activity. http://dx.doi.org/10.1016/j.aor.2013.01.016 Ó AORN, Ic, 2013 April 2013 Vol 97 No 4 AORN Joural j 435

What s New i the Trasplat OR? ANIL S. PARAMESH, MD, FACS 2.0 ABSTRACT Advacemets i trasplatatio offer promisig treatmet optios for a variety of diseases. Orga doatio, a essetial part of orga trasplatatio, may be performed at hospitals eve if the facility is ot a trasplat ceter; therefore, perioperative urses should be aware of developmets i trasplatatio ad the implicatios for patiet care at their facilities. Cosideratios for orga trasplat protocols iclude the type of documetatio required, the elemets of the trasplat OR time out, ad the use of itraoperative ati-rejectio medicatios. Cosideratios for orga doatio protocols iclude issues specific to a deceased door, a livig door, or a doatio after cardiac death. Newer developmets i the trasplat OR iclude laparoscopic kidey doatio ad trasplatatio, kidey paired doatio trasplatatio, other livig door procedures, ad trasplatatio procedures usig robotic techology. AORN J 97 (April 2013) 436-444. Ó AORN, Ic, 2013. http:// dx.doi.org/10.1016/j.aor.2013.01.016 Key words: orga doatio, doatio after cardiac death, trasplat time out, orga trasplatatio, orga procuremet orgaizatio. www.aor.org/ce To the uiitiated, the trasplat OR may seem like a itimidatig place to work. May trasplatatio surgeries are large ad complex, occur as uscheduled emergecy procedures, ad have a compoet of urgecy because of the eed to miimize the ischemic times of the orgas. Eve if a hospital is ot a trasplat ceter, orga procuremet (ie, doatio) procedures may be performed there, ad perioperative staff members are vital participats. Regulatig orgaizatios such as the Uited Network for Orga Sharig (UNOS) ad the Ceters for Medicare & Medicaid Services have established rules ad regulatios that must be followed by perioperative staff members. This article provides a overview of orga doatio protocols, although these protocols may vary slightly from hospital to hospital, ad a descriptio of curret regulatios ad documetatio requiremets that must be followed i the trasplat OR. Newer surgical iovatios are also discussed. This review ca serve as a primer for perioperative staff members who wat to joi or lear more about beig o a trasplat team. PROTOCOLS IN THE RECIPIENT TRANSPLANT OR Orgas that ca be recovered iclude the heart, lugs, kideys, liver, pacreas, ad itesties. http://dx.doi.org/10.1016/j.aor.2013.01.016 436 j AORN Joural April 2013 Vol 97 No 4 Ó AORN, Ic, 2013

TRANSPLANT OR www.aorjoural.org Tissues that ca be recovered iclude coreas, heart valves, boes, fascia, ad sapheous veis. Whe settig up a recipiet trasplat OR, the OR maager should cosider the followig: What kid of documetatio is required durig the procedure? What is differet about a trasplat OR time out? What ati-rejectio medicies are give itraoperatively? What is the back table procedure? Itraoperative Documetatio Curret regulatios stipulate that the details of the trasplatatio must be verified before the surgery occurs. 1,2 This requires that two health care professioals, usually the RN circulator ad surgeo, cofirm the recipiet s ame, orga type, blood type compatibility, ad UNOS door idetificatio umber with the UNOS database. Frequetly, this is accomplished via a telephoe coferece as a portio of The two most importat times that the RN circulator must documet for a orga trasplatatio are out-of-ice time ad reperfusio time. the surgical time out with a trasplat coordiator who has access to the UNOS web site. The RN circulator ad surgeo must documet the telephoic verificatio coferece o a siged form that becomes part of the patiet s medical record. The documetatio form must iclude the time of the verificatio ad a ote that it was performed before orga implatatio. Oe of the more cofusig issues for perioperative urses is documetatio of ischemic times. Although differet hospitals ad differet orgas may have several times that must be documeted (eg, times of cardiopulmoary bypass for heart/ lug/liver trasplatatios), the two most importat times that the RN circulator must documet for a orga trasplatatio are out-of-ice time (ie, the time the orga is take out of the cold storage to start the vascular aastomoses) ad reperfusio time (ie, the time that blood is allowed to flow ito the orga). Durig the door surgical procedure, the RN circulator documets cross-clamp time (ie, the time the blood flow stopped i those orgas), but this is ot part of the recipiet surgical procedure. The ischemic times are legths of time that are calculated from these three time values. Cold ischemic time is the time from cross-clamp of the orga s blood flow durig the doatio procedure to the out-of-ice time, which reflects the legth of time the orga spet i cold storage. Warm ischemic time is from out-of-ice time to reperfusio, which reflects the legth of time betwee whe the orga was removed from cold storage ad the vascular aastomoseswereperformed to allow blood flow back ito the orga. Although warm ischemic times are usually short (ie, less tha oe hour), cold ischemic times vary (eg, typically less tha six hours for the heart or lugs ad more tha 18 hours for kideys). This is because may orgas are trasported across the coutry after they have bee procured. Trasplat OR Time Out The uiversal time out is curretly practiced i ORs across the Uited States as a method to miimize errors by idetifyig the patiet, the scheduled surgical procedure, ad the surgical site ad cofirmig proper use of preoperative atibiotics. A additioal beefit of the time out is to help foster team uity i the OR through itroductio of all members of the team. AORN Joural j 437

April 2013 Vol 97 No 4 PARAMESH The trasplat OR time out has these compoets with some additios; the team must cocur that the door ad recipiet blood types have bee cofirmed with a UNOS idetificatio umber. 1,2 Furthermore, i additio to preoperative atibiotics, ay ati-rejectio medicatios to be give are discussed. Durig a trasplatatio procedure, there ca be less clarity about the site of surgery tha durig other types of procedures. For istace, typically, liver ad heart trasplatatios are orthotopic (ie, the orga is placed i the same locatio as the orga beig replaced). Both the liver ad heart are aturally located at approximately the midlie of the body. Kideys ad pacreas grafts, however, are typically heterotopic (ie, these orgas are placed i a locatio away from the primary orga, which may ot be removed). The site of implatatio ca vary; for example, a right door kidey ca go ito the left groi or vice versa. I additio, the site of iteded implatatio ca vary based o itraoperative fidigs. For example, the surgeo may have origially iteded to place a kidey i the patiet s right groi but o itraoperative surgical exploratio determies that the patiet s right groi vessels are usuitable for use. The surgeo may therefore have to place the kidey i the patiet s left groi istead. Thus, durig the time out, the surgeo may state the site of iteded implatatio with the kowledge that this may eed to be chaged itraoperatively. Ati-rejectio Medicatios I additio to preoperative atibiotics, most trasplat recipiets receive oe or more ati-rejectio medicatios either at the start of or durig the procedure. The most commoly used ati-rejectio medicatios are steroids (eg, a methylpredisoloe sodium succiate bolus is ifused). May trasplat recipiets also receive iductio therapy, which are medicatios admiistered at the start of the trasplatatio procedure. May of these are atibody preparatios, which work by destroyig or iactivatig lymphocytes i the recipiet, prevetig lymphocyte-iduced rejectio ad allowig better acceptace of the graft. Some of the more commoly used agets are alemtuzumab, atithymocyte globuli, ad basiliximab, although cliical trials are uder way for a host of ew agets. May of these agets are classified as chemotherapeutic agets, ad may of them are actually used as such. These medicatios preset the risk of causig the patiet to have a aaphylactic reactio as a result of cytokie release. Typically, the aesthesia professioal admiisters these medicatios usig a ifusio pump. May of these medicatios require that the patiet be premedicated with steroids; thus, a methylpredisoloe sodium succiate bolus is admiistrated before this ifusio. Typically, the patiet is itubated by the time the aesthesia professioal starts the medicatio ifusio. These medicatios are very expesive to prepare; therefore, the pharmacist may ot prepare or release these medicatios to the OR util it is cofirmed that the trasplatatio procedure is actually goig to happe. The RN circulator may ot receive the medicatio util the patiet is i the room ad the trasplatatio procedure is about to start. It is importat for the surgical team to work cooperatively with pharmacy persoel i this regard. Back Table Preparatio Most orgas require preparatio before implatatio. This is typically doe with istrumets o a separate table away from the mai OR table. It is importat to realize that util the orga is ready to be trasplated ito the recipiet, istrumets should ot be allowed to cross-cotamiate. The possibility always exists that a problem may be ecoutered itraoperatively that would preclude the patiet from receivig the orga. The orga, therefore, may eed to go to aother recipiet. To prevet cross-cotamiatio, the orga is packed i a sterile cotaier util the surgeo is ready to implat it. Most trasplat ceters have a desigated list of istrumets for each orga. The orga preparatio 438 j AORN Joural

TRANSPLANT OR www.aorjoural.org is cosidered a separate procedure ad must be hadled as such. The back table preparatio may require cleaig fat off the orga, recostructig vessels, or flushig the vessels with additioal preservative solutio. The preparatio is performed i a ice basi, ad although the orga is removed from its cotaier, the time required to perform back table preparatio is still cosidered part of the cold ischemic time. Aother importat part of the back table procedure is hadlig of the door blood vessels. May orgas (eg, pacreas, liver) are set with a portio of the door iliac or carotid vessels for vascular recostructio. These vessels are ot always used but are typically stored i a desigated refrigerator after they have bee labeled with the appropriate blood type. These vessels are viable for several days ad may be used for a vascular procedure or aother trasplatatio i lieu of a graft if the door ad recipiet blood types are compatible. However, because of the risk of crossifectio, typically these vessels are segregated, ad importat door serological results, such as hepatitis, must be documeted. PROTOCOLS IN THE DONOR TRANSPLANT OR Whe settig up a door trasplat OR, the OR maager should cosider the followig: May orgas are set with a portio of the door iliac or carotid vessels for vascular recostructio. These vessels are stored i a desigated refrigerator after beig labeled with the appropriate blood type. How does orga doatio work i the Uited States? What is eeded to set up a deceased door OR? What is differet about a deceased door OR time out? What issues are specific to a livig door OR? What issues are specific to doatio after cardiac death (DCD)? Orga Doatios i the Uited States The orga allocatio system is maitaied by UNOS uder a US Departmet of Health ad Huma Services cotract. The system has become detailed ad complicated over the years with respect to each orga trasplated. The Uited States (icludig Puerto Rico) is divided ito 11 regios for orga allocatio. These regios are further divided ito separate door service areas. Each door service area is serviced by a orga procuremet orgaizatio (OPO) that has a cotract with UNOS to provide orga doatio services. There are 58 OPOs i the Uited States. Medicare Coditios of Participatio madate that every patiet i the coutry for whom death is immiet (eg, with a Glasgow Coma Score 5) must be referred to the local OPO for possible orga doatio. 3 Failure to do so is a violatio of the Ceters for Medicare & Medicaid Services ad Joit Commissio guidelies. The local OPO will the sed a represetative who will review the case ad approach the family to discuss orga doatio. 4 It is ot the resposibility of hospital admiistrative persoel, physicias, or urses to discuss orga doatio with the patiet s family because this may be see as a coflict of iterest i the eyes of the patiet s family members. If the family agrees ad the door appears appropriate, the OPO coordiator will assume maagemet of the patiet ad perform the appropriate testig for doatio. The UNOS orga allocatio system is complicated ad varies for differet orgas. Certai OPOs or regios also have allocatio variaces that further complicate the system. Geerally, most orgas stay locally withi the OPO if AORN Joural j 439

April 2013 Vol 97 No 4 PARAMESH there is availability of a local trasplat ceter to perform the orga trasplatatio. The most importat door testig that occurs is blood type ad huma leukocyte atige geetic typig. For several orgas (eg, liver, lugs, heart), there are scorig systems that allocate poits to the sickest patiets so that the patiet with the highest score is the first to be cosidered whe a orga is available. The kideys ad pacreas are allocated by a scorig system that takes ito accout the geetic match ad the wait time of the potetial recipiet. To prevet a orga from beig wasted, may trasplat ceters will brig i backup recipiets for the orgas i the evet that the iteded recipiet is foud ot to be eligible for the orga. Settig up a Deceased Door OR It may seem dautig that a potetial door will eed ope heart, lug, ad abdomial surgery all at the same time. However, the istrumet sets for all deceased doatio surgeries are similar ad most OPOs have a stadard checklist of eeded items, all of which are ormally used i a major laparotomy pack. I most istaces, the OPO or the specific trasplat team will brig some istrumets, such as retractors (eg, chest, abdome), staplers, caulas, preservative fluid, ad packig boxes. Usually, there is also a urse coordiator who either scrubs i or helps circulate i the room. The hospital may eed to assig a RN circulator or scrub perso to the procedure. I additio to the basic istrumets, a steral saw usually is required, alog with ice slush i which to pack the orgas, although the trasplat team may brig these also. I rare istaces, imagig equipmet such as fluoroscopy may be required. Time i the OR ca vary, depedig o the availability of the teams ad other uforesee circumstaces such as weather; some teams may eed to fly i from out of state. The door OR procedure typically lasts a few hours, with all the orga teams operatig simultaeously to dissect out their respective orgas. After dissectio is complete, the surgeo cross-clamps the aorta to stop blood flow ad the uses preservative fluid to flush out all of the door s blood. After the aorta is cross-clamped, the aesthesia professioal turs the aesthesia machie off, ad team members remove ad pack the idividual orgas. I certai istaces, tissue recovery teams may arrive after the orgas have bee recovered. The surgical team closes the icisios ad the RN circulator ad scrub perso prepare the door body before sedig it to the morgue. If it is ot a coroer s case, the urse ad scrub perso remove all tubig ad catheters, wipe dow the body to remove all blood stais, ad the place the body ito a body bag. If it is a coroer s case, the coroer s office may give specific istructios to the OPO team (eg, place the body i a body bag with the edotracheal tube ad cetral lies i place). The OPO team commuicates these istructios to the OR team. Deceased Door OR Time Out The preprocedure time out may be differet i a door OR. Perhaps most otable is the fact that the surgeos performig the procuremet procedures may ot kow the ame of the patiet, ad they are ot required to kow. The door is assiged a UNOS idetificatio umber, ad that is the umber that must be cofirmed, alog with the blood type ad the orgas that are to be recovered. 1,2 May OPO teams ask for a momet of silece or message of respect at the start of the procedure, recogizig that the door ad family have coseted to doate orgas to save the lives of others. This ca be helpful to ursig ad aesthesia team members because staff members may ot be comfortable that a potetial patiet is there to die, ad aesthesia staff members may ot be comfortable turig off the machies durig surgery. The poit of the procedure is ot to save the door s life but to save the lives of the may recipiets who will receive the doated orgas. 440 j AORN Joural

TRANSPLANT OR www.aorjoural.org Livig Door OR Livig doatio has icreased the availability of orgas aroud the world. May coutries do ot have the elaborate system of orga allocatio or brai death laws that the Uited States has. Therefore, deceased doatio may ot be a optio, ad livig doatio may be the oly way trasplatatios ca occur. Curretly, livig doatio is possible for the kideys, liver, pacreas, lugs, ad itesties. Although the cause of livig door trasplatatio has bee advaced i recet years, the overridig cocer will always be the safety of the door. The livig door OR time out is similar to the stadard time out, with the additio of team members cofirmig ad documetig the UNOS idetificatio umber ad blood type compatibility before the procedure begis. Orga laterality must also be oted if applicable. I may istaces, retrieval of the orga from the livig door may occur simultaeously Livig doatio has icreased the availability of orgas aroud the world. Curretly, livig doatio is possible for the kideys, liver, pacreas, lugs, ad itesties. with the recipiet s procedure, so perioperative staff members i both rooms may eed to coordiate efforts. It is imperative that either team goes beyod a poit of o retur without otifyig the team i the other room. For example, if the recipiet caot udergo the trasplatatio because of a itraoperative fidig (eg, abormal aatomy, icidetal discovery of a tumor), the door team must be otified before the kidey is removed. Similarly, if the door is foud to have a itraoperative issue (eg, abormal aatomy, icidetal tumor, aesthesia complicatios, iadvertet ijury durig the surgery), the recipiet surgery must be delayed. DONATION AFTER CARDIAC DEATH Most istaces of orga doatio occur i a sceario i which the door has bee declared brai dead but the heart is still beatig. Thus, surgical dissectio is performed while the orgas are still beig perfused, ad the heart is oly stopped whe the dissectio is complete ad the orgas are ready to be flushed. Oe of the ewer treds i doatio has bee to obtai orgas from a door whose heart has stopped beatig. The cocept of DCD has bee advaced i the past few years as aother mechaism to icrease orga doatio. May patiets i the Uited States are o life support systems but are ot brai dead. Ofte, their families make the difficult decisio to tur off life support. I those istaces, orga doatio is possible after the heart has stopped beatig. Approximately 5% to 10% of all orga doatios are DCD. The protocol for pursuig DCD varies. 5 Although the local OPO may have a protocol, if the door hospital has a protocol, the hospital protocol is usually followed. This is because hospital admiistrative persoel at the door hospital may have created their ow protocol based o what they believe will make their staff members ad patiets most comfortable. Perioperative team members must kow whether their hospital has a existig protocol for DCD. For DCD, the door is extubated ad life support stopped, ofte with the family at the bedside. The door is the allowed a period of time to progress to asystole, which usually occurs withi oe to two hours. Whe the patiet becomes asystolic, a additioal two to five miutes is allowed to esure o retur of the heartbeat. Family members (if preset) are asked to leave, ad the procuremet team eters to recover the orgas. It is importat to recogize that the OPO caot be ivolved i the withdrawal-of-care process. This is typically performed by a hospital physicia (eg, critical care physicia, aesthesiologist) with a facility urse documetig asystole. AORN Joural j 441

April 2013 Vol 97 No 4 PARAMESH The DCD procedure is cosidered somewhat cotroversial, ad because of this, protocols vary. The extubatio may occur i the itesive care uit, i the postaesthesia care uit, or i the OR. The patiet s family members may or may ot be allowed to come ito the OR for this part of the process. Although measures are allowed to make the patiet comfortable, the use of hepari boluses or placemet of caulas is ot well defied. To prevet coagulatio durig asystole, the door is give a large hepari bolus either at the start of the procedure or at the time of asystole. Some facilities will ot allow the bolus to be give at the start of the procedure for fear that this may haste death from itracraial bleedig. Some facilities allow catheters to be placed i the femoral artery ad vei at the start of the procedure so that preservative fluid ca be flushed i quickly as soo as asystole is declared. It is illegal to give the patiet medicatios to haste asystole. If the patiet does ot progress to asystole i the determied time frame, the procedure is cosidered termiated ad the patiet is take back to the itesive care uit ad allowed to die there. Some cotroversy surrouds DCD, because some studies have show that these orgas may ot fuctio as well as orgas retrieved i the stadard fashio. 6,7 However, DCD remais a importat additive modality to icrease orga doatio ad must be viewed as part of the larger picture of orga shortage i the Uited States. Aother recet developmet is ucotrolled DCD procuremet, 8 which relates to situatios of cardiac arrest i the hospital, emergecy departmet, or ambulace for which resuscitatio is ot successful. After the patiet is declared dead ad if the patiet s ad family members wishes reflect cosideratio for orga doatio, cardiopulmoary resuscitatio ca be reiitiated to allow some perfusio of the orgas util the OPO team ca arrive to perform the procuremet procedure. NEWER TRANSPLANTATION PROCEDURES I additio to stadard trasplatatio procedures, ewer procedures are beig perfected i a effort to improve orga doatio rates. Some of these procedures iclude laparoscopic kidey doatio ad trasplatatio, kidey paired doatio trasplatatio, other livig door trasplatatio procedures, ad trasplatatio procedures usig robotic techology. Laparoscopic Kidey Doatio ad Trasplatatio There is little doubt that laparoscopic kidey doatio has helped improve orga doatio rates 9 because it is less ivasive i ature, causes less pai, ad decreases recovery time. As a result, laparoscope kidey doatio ad trasplatatio has become the stadard of care i most istitutios. Laparoscopic kidey trasplatatios are ow beig reported aroud the world. 9,10 I a report from Idia, Modi et al 10 described four cases of laparoscopic placemet of trasplated kideys i the iliac fossae. Although the aastomotic time was loger tha would be expected with a ope procedure, the log-term outcomes for these kideys were equivalet to those placed durig a ope procedure. 10 Kidey Paired Doatio Trasplatatios Although livig doatio is advocated to help patiets receive a good orga i a timely fashio, as may as 25% of willig doors are icompatible with their iteded recipiet. 11 Oe of the ew, iovative ways to overcome this problem is to swap doors betwee icompatible pairs, so that more livig doatio ca occur. 12 The swap etails fidig multiple pairs of willig but icompatible door/recipiet pairs ad the orchestratig a swap betwee as may groups as it takes to esure every recipiet is paired with a compatible door. Kidey swaps may occur withi oe hospital or may be part of a regioal sharig system. A atioal kidey paired doatio program has bee started by UNOS. From a surgical perspective, this obviously requires much preplaig. 442 j AORN Joural

TRANSPLANT OR www.aorjoural.org Typically, the door procuremet procedures are performed simultaeously, with the two ORs coordiatig o the telephoe, sometimes across the coutry, to esure that icisios are made at the same time. This is doe so that the paired doatio does ot fall apart if oe door decides to cacel the procedure at the last miute. If a paired doatio is performed i the same hospital, the door ad recipiet idetities usually are kept cofidetial. To accomplish this, the patiets, their family members, ad the postaesthesia care uit ad hospital rooms are segregated to maitai cofidetiality. The OR team members eed to kow that they should ot metio ames of doors ad recipiets i the presece of the patiets or family members. Other Livig Door Trasplatatios Although livig doatio is typically associated with kidey trasplatatios, other orgas ca be trasplated from livig doors. A very elaborate ad expesive system of orga allocatio does ot exist i may parts of the world, ad it may be cost prohibitive to keep deceased doors o life support or to fly orgas aroud the coutry. Cultural biases may also play a part; i parts of the world, brai death is ot accepted as death ad, hece, doatio caot occur. I these scearios, livig doatio may be the oly optio for trasplatatio to occur. Livig liver doatio has progressed from a child beig able to receive a portio of the left lobe (25% volume) of a paret s liver to a much more complex procedure i which a adult ca doate the right lobe (60% volume) of his or her liver to aother adult. Livig door hepatectomies are ow beig performed laparoscopically as well. 13 I additio to livig liver ad kidey doatio, livig door lug, 14 pacreas, 15 ad itestie 16 trasplatatios have also bee reported. I all situatios, door safety is the priority ad these procedures are stopped if there is a chace of risk to the door. Robotic Procedures Use of a robotic surgical system has revolutioized urologic ad gyecologic surgery because of the icreased ability to perform itricate maeuvers i very small areas. Iterest cotiues i determiig additioal surgical procedures that could feasibly be performed with the robotic system. I the past few years, robotic kidey 17 ad liver 18 doatio, alog with robotic kidey 19 ad pacreas 20 trasplatatio, have bee reported as sigle case series (ie, a sigle author or istitutio reportig experiece with a procedure). CONCLUSIONS Orga trasplatatio saves lives ad gives hope to may people. Today, advacemets i trasplatatio offer promisig treatmet optios for a variety of diseases. Trasplatatio is a excitig ad growig surgical specialty. Perioperative care durig trasplatatio procedures exposes staff members to ovel protocols, ethical challeges, ad iovative surgical procedures. As with may other complex surgical procedures, a team approach with dedicated members usually leads to the best outcomes for patiets. Refereces 1. Orga distributio: defiitios: trasplat ceter. Orga Procuremet ad Trasplatatio Network. Health Resources ad Services Admiistratio. http://opt.trasplat.hrsa.gov/policiesadbylaws2/policies/pdfs/ Policy_3.Pdf. Accessed November 12, 2012. 2. Stadardized packagig, labelig ad trasportig of orgas, vessels, ad tissue typig materials: verificatio of iformatio upo receipt of orga. Orga Procuremet ad Trasplatatio Network. Health Resources ad Services Admiistratio. http://opt.trasplat.hrsa.gov/policiesadbylaws2/policies/pdfs/policy_17.pdf. Accessed November 12, 2012. 3. Medicare coditios of participatio for orga doatio: a early assessmet of the ew doatio rule. US Departmet of Health ad Huma Services. Office of Ispector Geeral. http://www.hhs.gov/oig/oei. Accessed November 12, 2012. 4. Miimum procuremet stadards for a orga procuremet orgaizatio (OPO). Orga Procuremet ad Trasplatatio Network. Health Resources ad Services Admiistratio. http://opt.trasplat.hrsa.gov/policiesad Bylaws2/policies/pdfs/policy_2.pdf. Accessed November 12, 2012. AORN Joural j 443

April 2013 Vol 97 No 4 PARAMESH 5. Reich DJ, Mulliga DC, Abt PL, et al. ASTS Stadards o Orga Trasplatatio Committee. ASTS recommeded practice guidelies for cotrolled doatio after cardiac death orga procuremet ad trasplatatio. Am J Trasplat. 2009;9(9):2004-2011. 6. D Alessadro AM, Hoffma RM, Kechtle SJ, et al. Liver trasplatatio from cotrolled o-heart-beatig doors. Surgery. 2000;128(4):579-588. 7. Brook NR, Waller JR, Nicholso ML. Noheart-beatig kidey doatio: curret practice ad future developmets. Kidey It. 2003;63(4):1516-1529. 8. Roberts KJ, Bramhall S, Mayer D, Muiesa P. Ucotrolled orga doatio followig prehospital cardiac arrest: a potetial solutio to the shortage of orga doors i the Uited Kigdom? Traspl It. 2011;24(5):477-481. 9. Rater LE, Hiller J, Sroka M, et al. Laparoscopic live door ephrectomy removes disicetives to live doatio. Trasplat Proc. 1997;29(8):3402-3403. 10. Modi P, Rizvi J, Pal B, et al. Laparoscopic kidey trasplatatio: a iitial experiece. Am J Trasplat. 2011;11(6):1320-1324. 11. Paramesh AS, Killackey MT, Zhag R, et al. Livig door kidey trasplatatio: medical, legal, ad ethical cosideratios. South Med J. 2007;100(12):1208-1213. 12. Delmoico FL. Exchagig kideysdadvaces i livigdoor trasplatatio. N Egl J Med. 2004;350(18): 1812-1814. 13. Theappa A, Jha RC, Fishbei T, et al. Liver allograft outcomes after laparoscopic-assisted ad miimal access live door hepatectomy for trasplatatio. Am J Surg. 2011;201(4):450-455. 14. Che F, Fujiaga T, Shoji T, et al. Outcomes ad pulmoary fuctio i livig lobar lug trasplat doors. Traspl It. 2012;25(2):153-157. 15. Sutherlad DE, Radosevich D, Gruesser R, Gruesser A, Kadaswamy R. Pushig the evelope: livig door pacreas trasplatatio. Curr Opi Orga Trasplat. 2012;17(1):106-115. 16. Tzvetaov IG, Oberholzer J, Beedetti E. Curret status of livig door small bowel trasplatatio. Curr Opi Orga Trasplat. 2010;15(3):346-348. 17. Pietrabissa A, Abelli M, Spiillo A. Robotic-assisted laparoscopic door ephrectomy with trasvagial extractio of the kidey. Am J Trasplat. 2010;10(12): 2708-2711. 18. Giuliaotti PC, Tzvetaov I, Jeo H, et al. Robot-assisted right lobe door hepatectomy. Traspl It. 2012;25(1): e5-e9. 19. Boggi U, Vistoli F, Sigori S, et al. Robotic real trasplatatio: first Europea case. Traspl It. 2011;24(2): 213-218. 20. Boggi U, Sigori S, Vistoli F. Laparoscopic robotassisted pacreas trasplatatio: first world experiece. Trasplatatio. 2012;93(2):201-206. Ail S. Paramesh, MD, FACS, is a associate professor of surgery ad urology at Tulae Trasplat Istitute, Tulae Uiversity School of Medicie, New Orleas, LA. Dr Paramesh has o declared affiliatio that could be perceived as posig a potetial coflict of iterest i the publicatio of this article. 444 j AORN Joural

EXAMINATION CONTINUING EDUCATION PROGRAM What s New i the Trasplat OR? 2.0 www.aor.org/ce PURPOSE/GOAL To eable the learer to uderstad curret advaces i orga trasplatatio. OBJECTIVES 1. Idetify types of trasplatatio procedures. 2. Describe tasks that must be accomplished before procuremet ad trasplatatio procedures. 3. Describe surgical time outs performed durig procuremet ad trasplatatio procedures. 4. Idetify iformatio that must be documeted durig procuremet ad trasplatatio procedures. 5. Idetify medicatios that may be used to prevet rejectio of trasplated orgas. The Examiatio ad Learer Evaluatio are prited here for your coveiece. To receive cotiuig educatio credit, you must complete the Examiatio ad Learer Evaluatio olie at http://www.aor.org/ce. QUESTIONS 1. Before the trasplatatio occurs, two health care professioals must verify the details of the trasplatatio with the Uited Network for Orga Sharig database, ad this may be accomplished via a telephoe coferece. a. true b. false 2. Durig the recipiet portio of a orga trasplatatio procedure, the RN circulator must documet 1. cross-clamp time. 2. out-of-ice time. 3. reperfusio time. a. 1 ad 2 b. 1 ad 3 c. 2 ad 3 d. 1, 2, ad 3 3. The time betwee whe the orga was removed from cold storage ad the vascular aastomoses were performed to allow blood flow back ito the orga is called the a. cold ischemic time. b. warm ischemic time. 4. The trasplat OR time out icludes 1. cofirmig proper use of preoperative atibiotics. 2. cocurrig that the door ad recipiet blood types have bee cofirmed with a UNOS idetificatio umber. 3. idetifyig ati-rejectio medicatios to be give. 4. idetifyig the patiet ad the scheduled surgical procedure. 5. idetifyig the surgical site ad the site of iteded implatatio. 6. itroducig all surgical team members. a. 1, 3, ad 5 b. 2, 4, ad 6 c. 2, 3, 5, ad 6 d. 1,2,3,4,5,ad6 Ó AORN, Ic, 2013 April 2013 Vol 97 No 4 AORN Joural j 445

April 2013 Vol 97 No 4 CE EXAMINATION 5. A trasplatatio is whe a orga is placed i a locatio away from the primary orga. a. orthotopic b. heterotopic 6. May ati-rejectio medicatios are classified as chemotherapeutic agets. a. true b. false 7. Whe the patiet has a Glasgow Coma Score 5, hospital admiistrative persoel are resposible for discussig orga doatio with the patiet s family members. a. true b. false 8. The most importat door testig that occurs is 1. blood typig. 2. geotypig. 3. huma leukocyte atige geetic typig. 4. pheotypig. a. 1 ad 3 b. 2 ad 4 c. 1, 2, ad 4 d. 1, 2, 3, ad 4 9. Laparoscopic kidey doatio has helped improve orga doatio rates because it 1. causes less pai. 2. decreases recovery time. 3. is less ivasive i ature. a. 1 ad 2 b. 1 ad 3 c. 2 ad 3 d. 1, 2, ad 3 10. Orgas that ca be trasplated via livig orga doatio ad trasplatatio iclude the 1. itestie. 2. kidey. 3. liver. 4. lug. 5. pacreas. a. 1 ad 3 b. 2, 4, ad 5 c. 1, 2, 4, ad 5 d. 1,2,3,4,ad5 446 j AORN Joural

LEARNER EVALUATION CONTINUING EDUCATION PROGRAM What s New i the Trasplat OR? 2.0 www.aor.org/ce This evaluatio is used to determie the extet to which this cotiuig educatio program met your learig eeds. Rate the items as described below. OBJECTIVES To what extet were the followig objectives of this cotiuig educatio program achieved? 1. Idetify types of trasplatatio procedures. 2. Describe tasks that must be accomplished before procuremet ad trasplatatio procedures. 3. Describe surgical time outs performed durig procuremet ad trasplatatio procedures. 4. Idetify iformatio that must be documeted durig procuremet ad trasplatatio procedures. 5. Idetify medicatios that may be used to prevet rejectio of trasplated orgas. CONTENT 6. To what extet did this article icrease your kowledge of the subject matter? 7. To what extet were your idividual objectives met? 8. Will you be able to use the iformatio from this article i your work settig? 1. Yes 2. No 9. Will you chage your practice as a result of readig this article? (If yes, aswer questio #9A. If o, aswer questio #9B.) 9A. How will you chage your practice? (Select all that apply) 1. I will provide educatio to my team regardig why chage is eeded. 2. I will work with maagemet to chage/ implemet a policy ad procedure. 3. I will pla a iformatioal meetig with physicias to seek their iput ad acceptace of the eed for chage. 4. I will implemet chage ad evaluate the effect of the chage at regular itervals util the chage is icorporated as best practice. 5. Other: 9B. If you will ot chage your practice as a result of readig this article, why? (Select all that apply) 1. The cotet of the article is ot relevat to my practice. 2. I do ot have eough time to teach others about the purpose of the eeded chage. 3. I do ot have maagemet support to make a chage. 4. Other: 10. Our accreditig body requires that we verify the time you eeded to complete the 2.0 cotiuig educatio cotact hour (120-miute) program: Ó AORN, Ic, 2013 April 2013 Vol 97 No 4 AORN Joural j 447