The Transplant Patient
21/4/11
Examinations Book
GENERAL APPROACH
Transplant – liver, heart, lung, heart-lung, bone marrow, renal, pancreatitic
Phase of care – immediate post op, sepsis, rejection, respiratory failure, renal failure
Surgery – graft function, anatomy, anastomoses
Infection – bacterial (early), opportunistic: fungal, viral, mycobacterial (late)
Immunosuppression – rejection, GVHD, drug side effects, malignancy
INTRODUCTION
CUBICLE
- isolation (neutropenia, MDRO)
- special waste disposal equipment for cytotoxic agents
INFUSIONS
- immunosuppressants: calcineurin antagonists, corticosteroids, anti-nucleotides, monoclonal
antibodies)
- antibiotics
- vasoactives
- distributive shock (noradrenaline, vasopressin)
- isoprenaline, dobutamine, dopamine, milrinone (cardiogenic shock)
VENTILATOR
- mode
- level of oxygenation: high FiO2, PEEP (cardiogenic pulmonary oedema, atelectasis, ARDS,
VILI, nosocomial pneumonia, aspiration, reperfusion/rejection of lung transplant, respiratory
failure in post-bone marrow transplantation patient)
MONITOR
- fever: sepsis, SIRS, drug fever
- CVP: high in RV dysfunction (common after heart and lung transplants), prominent V wave
in TR
- ECG: paced rhythm and conduction disturbances
- haemodynamics: invasive BP, PAC, PiCCO
EQUIPMENT
- drains: location and drainage (blood)
- ICC’s
Jeremy Fernando (2011)
- mediastinal, pleural, pericardial drains post heart transplant
- abdominal drains after liver transplant (billary drain if a T-tube is inserted)
- IDC and wound drain for renal transplant
- epidural for analgesia for clamp shell incision
- PAC
- epicardial pacing post cardiac transplant
- RIJ vein spared from lines with cardiac transplants (permits subsequent endocardial
biopsies)
QUESTION SPECIFIC EXAMINATION
- hands/arms -> head -> chest -> abdo -> legs/feet -> back
-> general:
-> cardiovascular:
-> respiratory:
-> abdominal:
- neurological: as able
- surgical incisions: heart = sternotomy, lung + heart = sternotomy/clamshell, Mercedes Benz
= liver, lazy S to iliac fossa = kidneys
- rashes: graft vs host
- signs of underlying disease necessitating transplantation
- IDC and urine output
RELEVANT INVESTIGATIONS
- graft function
-> liver: U/S, LFTs, stability of glucose, coagulopathy
-> lung: bronchoscopy
-> heart: ECHO
-> kidney: ultrasound including duplex
- graft tissue biopsies and results
- drain biochemisty and culture
OPENING STATEMENT
=
Global statement
Transplant – function
Complications
How to progress from here
Jeremy Fernando (2011)