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)