TRANSESOPHAGEAL ECHOCARDIOGRAPHY
(TEE)
Transducer
TEE Ultrasound Machine
Description
Performed to assist in the diagnosis of cardiovascular
disorders when noninvasive echocardiography is contraindicated or
does not reveal enough information to confirm a diagnosis. TEE
provides a better view of the posterior aspect of the heart, including
the atrium and aorta. It is done with a transducer attached to a
gastroscope that is inserted into the esophagus.
Indication
 Confirm diagnosis if conventional echocardiography does not
correlate with other findings.
 Detect and evaluate congenital heart disorders.
 Detect atrial tumors (myxomas).
 Detect or determine the severity of valvular abnormalities and
regurgitation.
 Detect subaortic stenosis as evidenced by displacement of the
anterior atrial leaflet and reduction in aortic valve flow,
depending on the obstruction.
 Detect thoracic aortic dissection and CAD.
 Detect ventricular or atrial mural thrombi and evaluate cardiac
wall motion after myocardial infarction.
 Determine the presence of pericardial effusion.
 Evaluate aneurysms and ventricular thrombus.



Evaluate or monitor biological and prosthetic valve function.
Evaluate septal defects.
Measure the size of the heart’s chambers and determine if
hypertrophic cardiomyopathy or heart failure is present.
Procedure
1. The client is placed on the examination table in a left side-lying
position.
2. The pharyngeal site is anesthetized, and a bite device is plaed
in the mouth to prevent damage to the scope if the client bites
down.
3. The endoscope with the ultrasound device attached to its tip s
inserted 30 to 50 cm to the posterior portion of the heart as in
any esophagoscopy procedure.
4. The depth is determined to achieve the position behind the
heart.
5. The client is requested to swallow to facilitate placement of the
tube as the scope is inserted.
6. When the transducer is in place, the scope is manipulated by
controls on the handle to obtain various views of the heart
structure.
7. Scanning is provided in real-time images of heart motion and
recordings of the images for viewing.
8. Actual scanning is usually limited to 15 minutes or until the
desired number of image planes are obtained at different
depths of the scope.
9. When the study is completed, the scope is removed and the
client is placed in the semi-Fowler’s position to prevent
aspiration until the gag reflex returns.
Nursing Responsibilities
Before the Procedure
 Explain that transesophageal echocardiography allows visual
examination of heart function and structures.
 Tell the patient who will perform the test, when it’s
scheduled, and that he’ll need to fast for 6 hours before the
test.
 Review the patient’s medical history for possible
contraindications to the test.
 Ask the patient about allergies and note them on the chart.
 Before the test, have the patient remove dentures or oral
prostheses and note any loose teeth.
 Explain to the patient that his throat will be sprayed with a
topical anesthetic and that he may gag when the tube is
inserted.
 Tell the patient that an I.V. line will be inserted to administer
sedation before the procedure and that he may feel slight
discomfort from the tourniquet and needle puncture.
 Reassure him that he’ll be made as comfortable as possible
and that his blood pressure and heart rate will be monitored
continuously.
 Make sure that the patient or a responsible family member
has signed an informed consent form.
During the Procedure
 Confirm the patient’s identity using two patient identifiers
according to facility policy.
 Connect the patient to a cardiac monitor, the automated
blood pressure cuff, and pulse oximetry probe so that all
parameters can be assessed during the procedure.
 Help the patient lie down on his left side and administer the
prescribed sedative.
 The back of the patient’s throat is sprayed with a topical
anesthetic.
 A bite block is placed in his mouth, and he’s instructed to
close his lips around it.
 A gastroscope is introduced and advanced 12” to 14” (30 to
35 cm) to the level of the right atrium. To visualize the left
ventricle, the scope is advanced 16” to 18” (40 to 45 cm).
After the Procedure
 Ultrasound images are recorded and then reviewed after the
procedure.
 Monitor the patient’s vital signs and oxygen levels for any
changes.
 Keep the patient in a supine position until the sedative wears
off.
 Encourage the patient to cough after the procedure while
lying on his side or sitting upright.
TRANSTHORACIC ECHOCARDIOGRAPHY (TTE)
Transducer
TTE Ultrasound Machine
Description
A noninvasive ultrasound procedure that is used to measure
the ejection fraction and examine the size, shape, and motion of
cardiac structures. Uses high-frequency sound waves of various
intensities to assist in diagnosing cardiovascular disorders. The
procedure records the echoes created by the deflection of an
ultrasonic beam off the cardiac structures and allows visualization of
the size, shape, position, thickness, and movement of all four valves,
atria, ventricular and atria septa, papillary muscles, chordae
tendineae, and ventricles. This procedure can also determine bloodflow velocity and direction and the presence of pericardial effusion
during the movement of the transducer over areas of the chest.
Indication
 Detect atrial tumors (myxomas).
 Detect subaortic stenosis
 Detect ventricular or atrial mural thrombi and evaluate
cardiac wall motion after myocardial infarction.
 Determine the presence of pericardial effusion, tamponade,
and pericarditis.
 Determine the severity of valvular abnormalities such as
stenosis, prolapse, and regurgitation.

Indication
 Evaluate congenital heart disorders.
 Evaluate endocarditis.
 Evaluate or monitor prosthetic valve function.
 Evaluate the presence of shunt flow and continuity of the
aorta and pulmonary artery.
 Evaluate unexplained chest pain, electrocardiographic
changes, and abnormal chest x-ray
 Evaluate ventricular aneurysms and/or thrombus.
 Measure the size of the heart’s chambers and determine if
hypertrophic cardiomyopathy or heart failure is present.
Procedure
1. A conductive gel is applied to the chest. A transducer is then
placed on the chest surface along the left sternal border, the
subxiphoid area, suprasternal notch, and supraclavicular
areas to obtain views and tracings of the portions of the
heart. These areas are scanned by systematically moving
the probe in a perpendicular position to direct the ultrasound
waves to each part of the heart.
2. Different views or information can be obtained about heart
function by positioning the patient on the left side and/ or
sitting up, or requesting the patient breathe slowly or hold
his or her breath during the procedure. To evaluate
heartfunction changes, the patient may be asked to inhale
amyl nitrate (vasodilator).
3. Contrast medium may be administered if ordered. A second
series of images is obtained.
4. Once the study is completed, the needle is removed and a
pressure dressing is applied over the puncture site.
Nursing Responsibilities
Before the Procedure
 Inform the patient this procedure can assist in assessing heart
function.
 Review the procedure with the patient. Address concerns
about pain and explain that there may be some moments of
discomfort or pain experienced when the IV line is inserted to
allow infusion of fluids such as saline, anesthetics, sedatives,
contrast, medications used in the procedure, or emergency
medications.
 Instruct the patient to remove jewelry and other metallic
objects from the area to be examined.
 Positioning for this study is in a supine position on a flat table
with foam wedges to help maintain position and immobilization
 Explain that the chest will be exposed to allow attachment of
electrocardiogram leads for simultaneous tracings, if desired.
During the Procedure
 Evaluate for the presence of other risk factors, such as family
history of heart disease, smoking, obesity, diet, lack of
physical activity, hypertension, diabetes, previous myocardial
infarction (MI), and previous vascular disease, which should
be investigated.
 Understanding genetics assists in identifying those who may
benefit from additional education, risk assessment, and
counseling.
After the Procedure
 Activity: Pace activities to match energy stores and provide
assistance to complete activities of daily living. Assess current
level of activity to determine a baseline, and assess response
to activity. Evaluate oxygen needs in relation to activity.
Encourage the use of assistive devices.
 Excess Fluid Volume: Administer ordered diuretics and weigh
every day at the same time. Evaluate for edema in the
extremities; assess breath sounds for congestion (crackles),
shortness of breath, use of accessory muscles, and nasal
flare. Limit fluid as ordered.
 Inadequate Cardiac Output: Monitor vital signs: heart rate,
blood pressure, and respiratory rate. Monitor for ECG
changes, decreased urinary output, changes in level of
consciousness, shortness of breath, cyanosis, pallor, and cool
skin. Complete a daily weight, pace activities, use pulse
oximetry to monitor oxygenation and administer oxygen as
ordered.
CONTINUOUS RENAL REPLACEMENT THERAPY
(CRRT)
Description:
The critical care nurse will monitor CRRT, a continuous
therapy that may last for many days and is a slower kind of dialysis
that is less taxing on the heart. For unstable patients in the ICU whose
bodies cannot withstand routine dialysis. In order to prevent clotting
in the dialysis circuit, specific anticoagulation is required. CRRT is
accomplished by insertion of a large-gauge double-lumen catheter
into the internal jugular, subclavian, or femoral vein.
Indications:
• Uremia
• Encephalopathy
• Metabolic Acidosis • Volume Overload
• Pericarditis
• Hyperkalemia
• Drug & Toxin Removal
• Hemodynamic Instability
Procedures:
1. Perform hand hygiene, don appropriate PPE including mask
with face shield.
2. Ensure CRRT circuit has been primed and flow rates
programmed.
3. Don non-sterile gloves and remove gauze and tape that is
surrounding the catheter limbs and discard. Place a nonsterile waterproof pad under the dialysis limbs to protect the
bed linen.
5. Prepare the catheter by applying gloves and using 4x4 sterile
gauze.
6. Cleanse the catheter.
7. Clean the sterile field. With your dominant hand, grab the blue
sterile towel by the edge and open it up. Place it on top of the
waterproof (white) towel. Discard the gauze. Rest the limbs on the
sterile towel.
9. Prepare Access Limb. Ensure that the clamp on the access limb
(red) is closed.
10. Withdraw Blood. Open the clamp and vigorously aspirate 5 mL of
blood.
11. Reclamp the limb and check for clots.
12. Confirm adequacy of flow rate and flushes with saline.
13. Repeat for return limb.
14. Connect the Circuit
Nursing Responsibilities:
 Respiratory: Dialysis can cause changes in a patient’s fluid
balance; therefore, it is important to closely monitor:
respiratory effort, the use of accessory muscles, signs of
tachypnea, distress, fatigue and signs of infection
 Positioning: Patients still need to be turned at least every 2
hours to maintain good skin integrity. They are often at a
higher risk of pressure ulcers due to their compromised state.
 Neuro: Assess for reduced levels of consciousness, increased
restlessness, agitation and aggression are indications of
neurological status changes. These changes result from
raised creatinine levels, slow excretion of sedatives and levels
of pain.
 Cardio: Accurate recording of fluid levels is important, to
ensure that the patient does not become hyper - or hypovolemic; the patient relies on external forces to control their
internal environment.
 Psychosocial: A patient undergoing CRRT will be concerned,
and possibly anxious, about the machine. The presence of
uncontrolled pain will add to these fears, as will the lack of
control over what is happening to their body. Regular
education of the patient and family is of utmost importance.
CRANIOTOMY
Description:
Craniotomy is the surgical opening of the skull to gain access
to intracranial structures to perform a biopsy, remove a tumor, relieve
increased ICP, evacuate a blood clot, evaluate and treat the means
of burr holes (made with a drill or hand tools) or by making a bony
flap.
Indications:
• Tumors
• Brain Aneurysm • Depressed Skull fracture
• Volume Overload • CSF leak repair • Vascular Malformations
• Brain Abscess
• Intracranial foreign bodies
Procedures:
1. Once the patient is under anesthesia, the correct position of
the head is fixed depending on the approach to be utilized. It
is of utmost importance to avoid any pressure points on
vulnerable body areas by adequately padding throughout. The
location of the incision for the craniotomy depends on the part
of the brain to be operated on. If the surgical craniotomy is
assisted by neuronavigation, anatomical points are confirmed
before the incision at this time.
2. After the skin incision is made, the muscles below the scalp
are dissected to expose the skull. Retractors can be placed on
the edges of the incision to have adequate exposure to the
surgical area to be focused on. Alternatively, fish hook
retractors or sutures can be used to hold the scalp flap. The
pericranium can be separated to be used as a dural substitute
if necessary, during the closure.
Several burr holes are made into the skull utilizing the
craniotome or cranial drill. Caution has to be employed to
avoid plunging the craniotome into the brain tissue.
3. The holes are cleaned from any bone fragment, and the
dura is separated with a Freer elevator or Penfield dissector.
The burr holes are connected with a craniotome saw, and a
bone flap is elevated after carefully separating it from the dura
matter below. The bone flap is held in the surgical instrument
table until the closure portion of the surgery. For the intradural
procedure, the dura is cut and retracted, exposing the brain
4. Once the surgery on the brain concludes, the bone is
reattached in position with plates and screws. Adequate
hemostasis should be obtained before closing the scalp. The
overlying tissues are reattached, and the scalp is then sutured
in anatomical layers. Depending on the surgeon’s preference,
a subdural or subgaleal drain can be left in place to drain the
accumulated blood products.
Nursing Responsibilities:
 Respiratory status is assessed by monitoring rate, depth, and
pattern of respirations. A patent airway is maintained.
 Vital signs and neurologic status are monitored using a facilitybased neurologic assessment tool; findings are documented.
Arterial line may be used for blood pressure monitoring.
 Pharmacologic agents may be prescribed to control increased
ICP.
 Incisional and headache pain may be controlled with analgesic
such as an opioid or acetaminophen, as prescribed. Monitor
response to medications.
 Position head of bed at 15 to 30 degrees, or per clinical status
of the patient, to promote venous drainage.
 Turn side to side every 2 hours; positioning restrictions will be
ordered by the health care provider (craniectomy patients
should not be turned on the side of the cranial defect).
 CT scan of the brain is performed if the patient’s status
deteriorates.
MECHANICAL VENTILATION
Description
A mechanical ventilator is a machine that helps a patient
breath (ventilate) when they are having surgery or cannot breathe on
their own due to a critical illness. The purpose of positive-pressure
mechanical ventilation is to improve gas exchange in the lungs by
producing positive intrathoracic pressure and positive airway
pressure and decrease the work of breathing.
Indication
 respiratory or ventilatory failure evidenced by:
 hypoxemia
 metabolic acidosis
 respiratory acidosis
 inadequate tissue oxygenation
 Surgical procedures
Procedure
1. Verify the practitioner’s order.
2. If the patient isn’t already intubated, prepare the patient for
intubation.
3.
intubation
3. Gather and prepare the necessary equipment.
4. Perform hand hygiene.
5. Assist with intubation (if necessary) and then connect the ET
tube to the ventilator circuit. Trace the ventilator circuit from
the patient to its point of origin
6. Observe for chest expansion, and auscultate for bilateral
breath sounds to verify that the patient is being ventilated.
7. Position the patient with the head of the bed elevated 30 to
45 degrees, unless contraindicated by the patient’s condition.
If the patient can’t bend at the waist, use reverse
Trendelenburg position
8. Suction the patient’s airway when necessary to maintain
airway patency
Nursing Responsibilities
Before the Procedure
 Verify the practitioner’s order.
 Gather and prepare the necessary equipment.
 Put on gloves and other personal protective equipment as
needed to comply with standard precautions.
 As the patient’s condition allows, perform a complete physical
assessment, and obtain blood
During the Procedure
 Trace the ventilator circuit from the patient to its point of origin
to make sure it’s connected properly.
 Observe for chest expansion, and auscultate for bilateral
breath sounds to verify that the patient is being ventilated
After the Procedure
 Position the patient with the head of the bed elevated 30 to 45
degrees, unless contraindicated by the patient’s condition, to
reduce the risk of aspiration and consequent ventilatorassociated pneumonia (VAP).
 Confirm that written informed consent has been obtained by
 Monitor the patient’s oxygen saturation level by pulse
oximetry; make sure that the alarm limits are set
appropriately for the patient’s current condition.
 Check the ventilator tubing frequently for condensation,
which can cause resistance to airflow and which the patient
may aspirate staff.
 Monitor the patient’s ABG values
 Change, clean, or dispose of the ventilator tubing and
equipment when it’s visibly soiled or malfunctioning
 Perform hand hygiene.
 Clean and disinfect your stethoscope using a disinfectant
pad.
 Perform hand hygiene.
 Document the procedure
INTRA-AORTIC BALLOON PUMP (IABP)
THERAPY
Description
Also called Intra-Aortic Balloon Counterpulsation. It is a
mechanical circulatory support device which temporarily supports
cardiac function, allowing the heart to gradually recover by decreasing
myocardial workload and oxygen demand and increasing perfusion of
the coronary arteries.
Indication
 Acute Myocardial Infarction
 Refractory Left Ventricular Failure
 Cardiogenic Shock
 Refractory Ventricular Arrhythmias
 Acute Mitral Regurgitation and Ventricular Septal Defect
 Cardiomyopathies
 Sepsis
 Refractory Unstable Angina
 Complex Cardiac Anomalies (In Infants and Children)
 Cardiac Surgery
 Cardiac Catheterization and Angioplasty
 Weaning from Cardiopulmonary Bypass.
Procedure
1. Prepare patient in the room
2. Shave the patient’s groin.
3. Place the bed side table in an appropriate position for the
procedure
4. Before the provider is at the bed side, the nurse may set up
the console and prepare the appropriate equipment.
 Single transducer
 Saline
 Pressure Bag
 Mask
 Bonnet
 Gauze
 Leads
 Central insertion kit
 Gloves
 Balloon Pump Kit
5. Plug in the balloon pump console and position it out of the
way but accessible
6. Turn on the machine.
7. Place the EKG leads on the patient as soon as possible.
(This is imperative that this be completed prior to the
provider draping the patient and preparing the sterile field)
8. Ensure that the leads are connected to the console.
9. Prime and hang a single transducer set-up. Untangle the
tubing and hang it for it to be accessible when the provider
is ready to connect.
10. Connect the transducer cables between tubing and console
11. Zero the transducer to get a pressure reading.
12. Take note that there is no need to level if using a fiber-optic
balloon.
13. Ensure the setup is in Auto and one-to-one configuration.
14. Console is automatically in standby and can stay for hours.
15. Do not press ‘Start’
16. Assess patient’s needs prior to the time of insertion.
 Assist on setting up the ultrasound opposite to the provider.
 Put on a cap, a mask with a face shield or a mask and
goggles, a sterile gown, and sterile gloves to comply with
maximal barrier precautions.
 The practitioner puts on a cap, a mask with a face shield or a
mask and goggles, a sterile gown, and sterile gloves. The
practitioner then cleans the site with chlorhexidine based
antiseptic solution and drapes the patient using a sterile
drape and observing maximal barrier precautions.
 Assist the practitioner in placing the probe cover on the
ultrasound probe in a sterile manner. Remember to not touch
the inner contents.
 Afterwards, the nurse will provide the inner contents of the
balloon pump kit to the practitioner.
 Connect the pressure tubing. This is where it comes in key
that the nurse will hang the tubing accessible. Do not make
contact to the practitioner’s tubing
 Flush at the direction of the practitioner of the provider.
 While the practitioner is on the balloon pump, the nurse
should remain on alert for any assistance that is required.
 Monitor the patient for discomfort and his hemodynamic
stability.
 Connect the fiber-optic line to the balloon console
 Flush the pressure the line.
 Make sure the monitor is viewable
Nursing Responsibilities
Before the Procedure
 Verify the practitioner’s order.
 Gather and prepare the appropriate equipment.
 Make sure that the emergency equipment, suction setup, and
temporary pacemaker setup are readily available in case the
patient develops complication (such as an arrhythmia) during
insertion.
 practitioner and that the signed consent form is in the
patient’s medical record.
 Conduct a preprocedure verification to make sure that all
relevant documentation, related information, and equipment
are available and correctly identified to the patient’s
identifiers.
 Verify that a complete blood count, coagulation studies, and
other ordered studies have been completed as ordered to
check for conditions that may increase the risk of bleeding.
Ensure that the results are in the patient’s medical record.
 Notify the practitioner of unexpected results.
 Confirm the patient’s identity using at least two patient
identifiers
 Provide client privacy.
 Raise the bed to waist level when providing patient care to
prevent caregiver back strain
During the Procedure
 Obtain the patient’s baseline vital signs and oxygen saturation
by pulse oximetry for baseline comparison.
 Administer supplemental oxygen as ordered and as
necessary.
 Remove excess hair from the intended insertion site, if
needed, using a single-patient-use scissors.
 Assess and record the patient’s peripheral leg pulses and
document sensation, movement, color, and temperature of
the legs to help determine peripheral circulation status and
the best insertion site.
 Administer a sedative or an analgesic, as ordered, following
safe medication administration practices.
 Position the patient supine with access to the insertion site.
 Perform hand hygiene.
 Make sure the health care team follows infection prevention
practices; use an insertion checklist to guide the insertion
 process to reduce the risk of infection.
process to reduce the risk of infection.
After the Procedure
 Monitor the patient’s vital signs, hemodynamic parameters,
and clinical status at a frequency determined by your facility
and the patient’s condition
 Return the bed to the lowest position to prevent falls and
maintain patient safety.
 Discard used supplies appropriately.
 Remove and discard your personal protective equipment.
 Perform hand hygiene.
KIDNEY TRANSPLANT
Description
Kidney transplantation has significantly improved the quality
of life for many patients with chronic renal disease. Patients may
choose to accept transplantation rather than remain on hemodialysis
for the rest of their lives.
Indication
 Indication for transplantation is end-stage renal disease, most
often glomerulonephritis, pyelonephritis, polycystic disease,
or nephrosclerosis
Procedure
TRANSPLANT FROM LIVING DONOR
Open Approach
1. The donor nephrectomy procedure is as described for
nephrectomy; however, the ureter and renal vein and artery require
meticulous dissection.
2. Maximum length of the ureter is achieved by dividing it at or below
the pelvic rim if possible. To preserve adequate ureteral
vascularization, the surgeon is cautious not to skeletonize the ureter.
Procedure
3. Particular care is taken to remove the maximum length of the renal
vein and artery. Obtaining the maximum length of the left renal vein
sometimes requires partial occlusion of the inferior vena cava with a
Satinsky clamp and dissection of a portion of the inferior vena cava.
This is done after the ureter has been freed.
4. Repair of the inferior vena cava is made with a continuous 4- 0 or
5-0 vascular suture.
5. Five minutes before the surgeon clamps the renal vessels, 5000
units of heparin sodium and 12.5 g of mannitol are systemically
administered to the patient to prevent intravascular clotting and
maximize diuresis.
6. Furosemide, mannitol, and IV fluids are administered to the donor
to maintain adequate urinary output from the donor's remaining kidney.
7. Gentle handling of the kidney is essential. Team members must
prevent undue traction on the vascular pedicle, which may induce
vasospasm and reduce perfusion of the kidney.
8. To reduce warm ischemia time the surgeon double-clamps the vein
and the artery, excises the kidney, and immediately places it in iced
saline solution on a sterile back table, where the kidney is flushed with
the designated electrolyte solution. Warm ischemia time (from the
clamping of renal vessels to a point at which the kidney is perfused
with cold electrolyte solution) should be kept to a minimum to prevent
acute tubular necrosis and to maintain maximum renal function after
transplantation.
9. Gerald forceps are used to expose the renal artery to permit
insertion of an olive tip or. smooth Christmas tree cannula. The cold
electrolyte solution passes through the IV tubing and the needle
catheter, flushing any remaining donor's blood from the kidney. This
also decreases the kidney's metabolic rate by lowering its
temperature. Flushing time is usually 2 to 5 minutes.
10. After flushing the surgeon may trim the vessels of adventitia to
facilitate the vascular anastomosis to the recipient's iliac vessels.
11. The kidney, in iced saline solution and HTK or UW solution, is
covered with sterile drapes and taken by the surgeon to the room in
which the recipient's iliac vessels have been exposed.
12. Wound closure for the donor is as described for nephrectomy.
Hand-Assisted Laparoscopic Approach.
1. The surgeon creates a supraumbilical incision for the hand
port. After the hand-port is placed, a 10-mm trocar is placed
through the hand-port to introduce pneumoperitoneum. A
camera is introduced through the trocar to directly visualize
the placement of the 5-mm working port, approximately two
fingerbreadths cephalad to the hand-port. The 10-mm camera
port is placed three fingerbreadths inferior to the xiphoid. An
additional 5-mm trocar may be placed in the flank at the
convex border of the kidney if extra retraction is necessary.
2. A bipolar ESU is used to incise the left lateral peritoneal
reflection.
3. The descending colon is reflected medially from the beginning
of the splenic flexure down to the level of the sigmoid colon,
incising the phrenocolic ligaments completely. Care is taken
to ensure no bowel injury or mesenteric defect occurs.
4. The surgeon divides the lienorenal and splenocolic ligaments
at the inferior border of the spleen, allowing the spleen to be
retracted superiorly and to mobilize the splenic flexure
medially.
5. Gerota fascia is exposed by mobilizing the descending colon
medially.
6. The plane is developed between Gerota fascia and the
mesentery, adjacent to the lower pole of the kidney.
7. The plane medial to the gonadal vein and the ureter is
developed and the structures are dissected off the psoas
muscle, taking care not to devascularize the ureter.
8. The surgeon continues to dissect the medial aspect of the
upper pole of the kidney, which is mobilized until the upper
pole is completely free.
9. The left renal vein is then freed from its adventitial attachments
and the adrenal and lumbar veins are identified, doubly
clipped on both sides, and divided between clips.
10. After elevating the kidney, the surgeon performs
additional dissection, usually posteriorly to the renal vein
to identify and isolate the renal artery and after dividing the
fibro-fatty and lymphatic tissue around the vessels.
11. The renal artery is dissected out, taking care to ensure
there is space to pass the endovascular gastrointestinal
anastomosis (GIA) stapler around the artery and vein.
12. The entire kidney is then freed of all its adventitial
attachments.
13. The anesthesia provider administers 40 mg of furosemide
(Lasix) and 12.5 mg of mannitol and 3000 units of heparin
via the patient's IV.
14. Next the gonadal vein is double clipped and divided and
the ureter is triple clipped and divided at the level of the
iliac vessels.
15. After 3 minutes of systemic heparinization, the renal artery
and vein are transected individually and sequentially with
the endovascular GIA stapler.
16. The kidney is placed in the large basin with iced saline and
flushed on the back table with 1 L of cold HTK or UW
solution.
17. After the kidney is flushed, as described in the open donor
nephrectomy, the kidney basin is covered with a drape and
taken to the recipient OR.
18. The surgeon irrigates the peritoneum and achieves
hemostasis. A drain may be inserted into the peritoneal
space for a short time postoperatively.
19. The wounds are sutured and dressings applied.
TRANSPLANT FROM CADAVERIC DONOR
1. The surgeon makes a midline incision from the xiphoid
process to the symphysis pubis with bilateral supraumbilical
transverse extensions through the skin, subcutaneous layer,
fascia, and muscle.
2. Hemostasis is obtained with clamps, ties, suture ligatures, and
the ESU.
3. The kidney, renal vessels, and ureter are carefully dissected
with Metzenbaum scissors, DeBakey forceps, and Dean
hemostatic forceps.
4. The anesthesia provider administers 15,000 units of heparin
sodium IV 5 to 10 minutes before the renal vessels are
clamped.
5. The usual method of resection is en bloc resection (harvesting
of donor kidneys) which involves the removal of sections of
the inferior vena cava and aorta with both kidneys in continuity
6. The surgeon makes an incision along the route of the small
bowel mesentery up to the esophageal hiatus.
7. Next, the surgeon mobilizes the entire GI tract, spleen, and
inferior portion of the pancreas dividing the celiac axis and the
superior mesenteric artery, exposing the entire retroperitoneal
region.
8. Using vascular clamps, the surgeon clamps and divides the
inferior vena cava and aorta below the renal vessels.
9. The surgeon secures the lumbar tributaries with metal clips
and divides them.
10. The kidneys and ureters are freed from their surrounding soft
tissues.
11. The ureters are divided distally at the pelvic brim.
12. The surgeon clamps and divides the suprarenal aorta and
inferior vena cava at the level of the diaphragm, close to the
bifurcation.
13. The surgeon severs the vessels and kidney and ligates the
aorta and vena cava.
14.
14. After removal of the kidneys, immediate perfusion with cold
(4°C [29.2°F]) UW or electrolyte solution is performed. The
kidneys are placed in a container of cold saline solution and
surrounded by saline slush in an insulated carrier or placed on
a hypothermic pulsatile perfusion machine for transport. While
kidney perfusion is begun, the abdominal lymph nodes and
spleen are removed for use in tissue typing.
15. The incision is closed with interrupted sutures, and the
patient's artificial life-support systems are terminated. The
perioperative nurse cares for the patient's body, preserving
privacy and dignity at the patient's death.
TRANSPLANT RECIPIENT
1. The surgeon makes a curved right lower quadrant incision
through the skin, subcutaneous layer, fascia, and muscle.
2. Bleeding is controlled with clamps, ties, and an ESU.
3. The inferior epigastric vessels are divided between suture
ligatures.
4. Retroperitoneal dissection is performed by mobilizing the
peritoneum superiorly and medially.
5. A self-retaining Bookwalter retractor is placed once exposure
is attained.
6. Using Metzenbaum scissors and DeBakey forceps, the
surgeon dissects along the entire length of the hypogastric
artery and the external and common iliac arteries to the
bifurcation of the aorta, continuing down the internal iliac
artery.
7. The internal iliac artery is ligated distally and divided, with
proximal control maintained by a vascular clamp
8. The iliac vein may be dissected free by ligating and dividing
the internal iliac venous branches with 3-0 nonabsorbable
sutures or ligating clips. More commonly, only the
hypogastric artery and that portion of iliac vein to be
anastomosed are dissected free.
9. The donor kidney is brought into the operative field in a large
basin of iced saline and HTK or UW solution.
10. The surgeon uses mosquito hemostats, 4-inch DeBakey
forceps, and curved and straight fine scissors to make the
necessary alterations on the donor kidney vessels to
facilitate the anastomoses.
11. A Lambert Kay clamp is placed on the internal iliac vein.
12. A #11 blade is used to make a 1-cm incision in the iliac
vein between the clamps.
13. The vessel is rinsed with heparin sodium solution (10
units/mL) in a 30-mL syringe with an olive tip.
14. Angled Potts scissors are used to extend the incision to
accommodate the donor renal vein.
15. The surgeon performs the anastomosis of the donor
kidney renal vein to the side of the recipient's iliac vein with
5-0 double armed vascular sutures.
16. In like manner the renal artery is anastomosed end-to-end
with the proximal portion of the internal iliac artery using 50 vascular sutures.
17. Before placing the final sutures, the vessels are irrigated
proximally and distally with heparin sodium solution with a
30-mL syringe with an olive tip.
18. The Lambert Kay clamps are removed from the venous
vessels, and the anastomosis is checked for leakage.
19. The clamp on the internal iliac artery is then released, and
the anastomosis is checked.
20. Meticulous inspection is made of the hilum and surface of
the kidney for bleeding and infarction.
21. The
anesthesia
provider
administers
diuretics
intravenously as needed.
22. Attention is then directed to the ureter and bladder.
23. Two Gerald forceps are used to grasp the anterior bladder
wall.
24. Using a scalpel with a #10 blade, the surgeon makes a 4cm anterior incision.
25. The ureter is passed through the bladder wall and
tunneled suburothelially for 2 to 2.5 cm.
26. The surgeon sutures the spatulated end of the ureter into
the bladder urothelium with four to six 5-0 atraumatic
absorbable sutures, creating a ureteroneocystostomy.
27. A
6F
ureteral
stent
is
passed
through
the
ureteroneocystostomy, up to the renal pelvis, and out through
the urethra with the Foley catheter. This stenting catheter will
remain in place for 36 to 48 hours to ensure ureteral patency
during a period in which ureteral edema may occur.
28. Retractors are removed, and the bladder is closed with 5-0
atraumatic absorbable suture.
29. The renal anastomoses are again checked for bleeding.
30. The cystoscopy tubing is disconnected from the Foley catheter
and a urometer is attached to the Foley catheter to monitor
postoperative urine output.
31. The surgeon inserts closed-wound suction drains into the
wound, exteriorizes them through the skin laterally, and
secures the tubing with 2-0 nonabsorbable suture on a cutting
needle.
32. Muscle and fascial layers are closed with a single layer of 0
nonabsorbable sutures on a large atraumatic needle.
33. The subcutaneous layer is closed with 3-0 absorbable sutures
on an atraumatic needle.
34. Skin closure is accomplished with skin staples, and
dressings are applied.
NURSING RESPONSIBILITIES
TRANSPLANT DONOR
 Two adjacent ORs are prepared for the procedures because
surgery on the donor and surgery on the recipient proceed
simultaneously.
 Usually the left kidney is chosen for removal because the left renal
vein is longer than the right renal vein.
 Two IV lines and a Foley catheter are required.
 The patient is placed on a beanbag positioning device and moved
into a modified flank position with the torso in a 30-degree lateral
decubitus position with the right side down after endotracheal
intubation. The lower arm is positioned





extended outward on a well-padded armboard at a right angle to
the torso; the upper arm is positioned on an elevated lateral
armboard. The patient’s hips are rolled slightly posteriorly to
allow exposure of the lower abdominal midline.
Three pillows are placed between the patient's legs, and the
ankles and feet are appropriately padded. An axillary roll is also
placed and the radial pulse is confirmed in the right wrist.
The bed is flexed to 30 degrees, and the upper portion is angled
downward to approximately 140 degrees.
The skin is prepped from midchest to pubis and draped to
expose the flank area.
An electrolyte solution of histidine-tryptophan-ketoglutarate
(HTK) or University of Wisconsin (UW) solution that contains
10,000 units of heparin is used to flush the harvested kidney
TRANSPLANT RECIPIENT




The perioperative nurse places the patient in the supine position
and inserts a Foley catheter into the bladder.
Approximately 100 mL of antibiotic mixed in an IV bag of 0.9%
normal saline is instilled into the bladder through cystoscopy
tubing.
The bladder is filled and drained four times.
The fifth instillation of 100 mL is left in the bladder and the
cystoscopy tubing is clamped until the time of the ureteral
anastomosis.
The patient is prepped from nipples to groin and draped.
LIVER TRANSPLANT
Description
Liver transplantation is implantation of a liver from a donor
into a recipient. The procedure includes retrieving or procuring the
liver from a donor, transporting the donor liver to the recipient's
hospital, performing a hepatectomy on the recipient, and then
implanting the donor liver
Indication
 Liver transplantation is indicated for patients with chronic
hepatocellular disease, chronic cholestatic disease, metabolic
liver disease, primary hepatic cancer, acute fulminant liver
disease, and inborn errors of metabolism. When malignancies
are the cause of end-stage liver disease, the right upper
quadrant
may
be
radiated
intraoperatively—after
hepatectomy and before transplantation
Procedure
1. Bilateral subcostal incisions are made with a midline incision
extended toward the umbilicus. If necessary, the xiphoid is removed.
The right side of the chest is entered if additional exposure is needed.
2. Initial dissection of the underlying tissues is achieved with
electrosurgery and suture ligatures.
3. Isolation of all hilar structures and dissection to mobilize the lobes
of the native liver are performed.
4. The retrohepatic vena cava is skeletonized, as are the hepatic
artery, portal vein, common bile duct, and inferior vena cava.
5. The donor liver is examined.
6. Preparations may be made at this time for venovenous bypass
using an extracorporeal assist device if the patient is unstable.
7. The infrahepatic vena cava and the suprahepatic vena cava are
clamped, as are the portal vein, the hepatic artery, and the common
bile duct.
8. Native hepatectomy is then performed.
9. The donor liver is placed in the right upper abdomen, and
revascularization of the donor organ begins with end-to-end
anastomoses in the vena cava and portal vein, with double-armed fine
vascular suture.
10. At this point the clamps on the portal vein, suprahepatic vena
cava, and infrahepatic vena cava are released slowly, and blood flow
through the vena cava and portal vein is restored.
11. The anastomosis sites are checked for leaks.
12. If it was used, venovenous bypass is discontinued, and the
cannulation sites are closed.
13. The postrevascularization phase focuses on achieving
hemostasis. Complete hemostasis may require extensive time at this
point. Bleeding may be exacerbated by a fibrinolytic episode
associated with the reperfusion of the donor organ. The liver is
monitored for a change in color from dusky to pink. An intraoperative
Doppler may be used to confirm patency of the blood supply.
14. The anastomosis of the hepatic artery is then commenced,
followed by bile duct reconstruction. This varies with the status of the
recipient’s biliary tract. If biliary atresia is the cause of the patient's
end-stage liver disease, choledochoenterostomy into a Roux-en-Y
loop of jejunum is performed.
15. The anastomoses are checked for leaks.
16. Drains are placed behind and in front of the liver and exteriorized.
The abdomen is then closed.
Nursing Responsibilities
Communication Among Teams.
Patient Positioning.
-
-
-
-
-
The patient is placed supine with knees slightly flexed and
padded.
An indwelling urinary catheter is inserted after induction of
anesthesia. Accurate body alignment is essential.
A gel pad that is the length of the OR bed or a pressure-reducing
OR bed mattress is used, with attention to all potential pressure
areas.
Heel protectors are applied and IPCDs are placed on the
patient's legs.
The safety strap is placed over the lower part of the thighs and
secured.
A forced-air warming device is applied over the upper body,
neck, and head to assist in maintaining normothermia.
Fluid warmers are used to warm blood products and IV
solutions.
Skin Preparation.
-
-
The patient is prepped from the neck to midthigh, bedline to
bedline. Prep solution should not pool at the bedline or wet the
sheets on the OR bed.
Fire safety precautions for prep solutions are followed.
Blood Loss and Replacement.
-
-
-
Blood loss may be extensive and replacement must be timely.
The perioperative nurse confirms that blood products are
available at the beginning of the procedure (this may be
incorporated into the time-out). These include 10 units each of
packed red blood cells (RBCs) and fresh frozen plasma (FFP)
and 1 unit of pooled donor platelets.
The perioperative nurse remains available to assist the
anesthesia provider during the insertion of peripheral and arterial
lines. An autologous cell-saver device may be used to assist in
blood replacement by way of autotransfusion.
The perioperative nurse ensures that communication occurs
among teams.
Coordination among the procurement team, anesthesia team,
and surgical teams is essential for a successful transplant
procedure.
Perioperative nursing responsibilities also include monitoring and
communicating blood-loss volume in suction canisters and on
sponges, the availability of blood and blood products, laboratory
results, time of organ arrival, ischemic time, and other events as
they unfold in preparation for and during the transplant procedure
LUNG TRANSPLANT
Description
Lung transplantation currently offers the only definitive
treatment for CF. Lung transplantation lengthens lifespan and
improves quality of life. Single-lung, double-lung and heart–lung
trans plants have been successfully completed. Because the donor
lungs do not have the CF geneimplanting the donor liver
Indication
 Indications for single-lung transplantation (SLT) include
restrictive
lung
disease,
emphysema,
pulmonary
hypertension, and other nonseptic end-stage pulmonary
diseases. Double-lung transplantation (DLT) can be
performed for many of these indications and is specifically
indicated for patients with cystic fibrosis or patients with a
chronic infection in end-stage pulmonary failure
Procedure
DONOR HARVESTING
1. The patient's skin is prepped from chin to knees and laterally to
the midaxillary line. A median sternotomy incision is most commonly
used. A thoracotomy may also be used.
2. The surgeon opens the pleura longitudinally posterior to the
sternum, and divides the pericardium back to the hilum on both
adhesions are incised, and the proximal pulmonary arteries are
dissected at their origin.
The inferior pulmonary ligament is dissected, pleural adhesions are
incised, and the proximal pulmonary arteries are dissected at their
origin.
pericardially; the pulmonary artery is isolated as close to the lung as
possible. The surgeon may ligate and divide the azygos vein for
additional exposure; the pulmonary artery is dissected.
3. After heparinization and hypotensive anesthesia, the superior vena
cava is ligated and divided and heavy silk ties are placed around each
vessel.
3. If the left lung is being removed, the ligamentum arteriosum is
divided.
4. The surgeon dissects the aortic arch free, and divides the
ligamentum arteriosum. The anterior and inferior margins of the
pulmonary artery are separated from the main artery and ascending
aorta. Umbilical tapes are placed around the pulmonary artery and
aorta. A purse-string suture is placed for infusion of the cardioplegia
solution in the heart.
5. After cardioplegia and pulmoplegia are established, the heart is
prepared for removal; veins and arteries are separated, and the heart
is removed and placed in cold preservation solution.
4. The anesthesia provider collapses the lung to be removed, and
the proximal pulmonary artery is occluded. If instability occurs after
occlusion, CPB may be required. In some cases femoral bypass is
initiated. If the patient remains stable, the pneumonectomy is
performed.
5. Pulmonary veins are divided extrapericardially. The first branch of
the pulmonary artery and descending branch are separated. The
blood supply to the bronchus is preserved by not dissecting tissue
around the bronchus.
6. Using blunt and sharp dissection, the surgeon dissects the
pulmonary arteries free from the mediastinum to the hilum anteriorly
and then posteriorly to the anterior aorta and hilum. The trachea is
dissected free. The lungs are inflated before stapling and dissection.
The lungs are removed and immersed in cold preservation solution.
6. The surgeon divides the bronchus and removes the lung. The
pericardium is opened around the pulmonary veins to allow room for
the atrial clamp.
7. The team provides postmortem care for the donor.
8. Three anastomoses are completed for an SLT: bronchus to
bronchus, pulmonary artery to pulmonary artery, and recipient
pulmonary veins to donor atrial cuff. Techniques used to minimize
bronchial anastomotic complications include shortening the donor
bronchial stump, reinforcing the anastomosis with a vascularized
tissue pedicle such as omentum or intercostal muscle pedicle flap,
or using an intussuscepting bronchial anastomosis technique.
RECIPIENT PREPARATION AND TRANSPLANTATION
1. The perioperative nurse assists with positioning the patient laterally
for SLTs or in the supine position for bilateral lung transplants. The
nurse also performs a wide skin prep for exposure of the chest and
abdomen (nipple line to knees).
2. An incision is made. Usually a thoracotomy is created for SLTs.
Bilateral lung transplants may be performed through bilateral
thoracotomies, median sternotomy, or a clamshell incision. The
conduct of the procedure depends on which lung is to be removed. If
the right lung is being removed, the pulmonary vein is isolated extra
7. Inferior and superior pulmonary veins are incised and joined.
9. After anastomoses and restoration of circulation, the lung is fully
inflated and observed. Chest tubes are placed and secured.
10. After closure of the chest the surgeon performs a bronchoscopy
to remove secretions and to ensure that the anastomosis is intact.
Nursing Responsibilities
-
-
-
-
-
Reverse isolation procedures are not necessary unless the
neutrophil count is very low (< 500/mm3 ).
Use good hand washing and standard precautions at all times
and aseptic technique for dressing changes, IV starts and site care,
and other invasive procedures (such as urinary catheterisation).
Do not allow caregivers or visitors with URTI to have contact
with the person; a mask may be provided for short visits if contact
is unavoidable.
Skin surveillance and care is vital following transplant. Intact skin
reduces the risk of infection; however, corticosteroid therapy
increases the risk of skin tears and breakdown.
The effect of all medications on immunosuppressive therapy and
the transplanted organ(s) should be carefully investigated prior to
administration. Some antibiotics and other drugs can affect blood
levels of immunosuppressants.
Particular attention must be paid to respiratory hygiene.
Regularly scheduled coughing and deep breathing, and the use
of vibration, percussion and postural drainage, are important to
prevent accumulation of secretions
RIB INSTRUMENTS
A. Strippers/rasps
B. Shears
C. Approximator/
Contractor
Self- Retaining Chest
Retractor/ Rib Spreader
Thoracic Tissue Forceps
A. Bronchus Clamps
B. Lung Forceps
Specialty Lung and Thoracic Retractors - are used to hold lung tissue
and displace the bones of the shoulder girdle
Basic Laparotomy Set