Pneumonia in Heart-Lung Transplant

OVERVIEW

  • pulmonary infections = most frequent complication with high mortality
  • requires aggressive, early, broad spectrum antimicrobial therapy
  • close consultation and even transport to transplant unit may be indicated

PATIENT

  • severity of pneumonia
  • co-morbidities: ischaemic heart disease, pacemaker, hypertension, DM, renal function, graft vs host disease
  • severity of immunosuppression
  • medications: discussion with transplantation team about how to manage
  • smoking history

TRANSPLANT

Cardiac

  • heart is denervated -> only responsive to direct acting drugs/hormones in circulation
  • requires careful titration of intravascular volume
  • requires invasive monitoring
  • altered ECG and rhythm strips
  • premature obliterative coronary atherosclerosis -> LV dysfunction
  • arrhythmia management

Respiratory

  • exercise capacity
  • premorbid lung function
  • impaired cough and clearance of secretions
  • impaired function from obliterative bronchiolitis (chronic rejection)
  • bronchial or tracheal stenosis relating to original anastomotic site

PNEUMONIA

Opportunistic Infections

  • requires early aggressive investigation (CXR, bronchoscopy, CT chest, open lung biopsy)
  • early aggressive broad spectrum anti-microbial cover
  • community acquired bacterial organisms (cefuroxime + erythromycin -> imipenem)
  • Aspergillus and Candida (caspofungin)
  • CMV (foscarnet, ganciclovir)
  • Pneumocystis jiroveci (co-trimoxazole)
  • Cryptococcus neoformans (amphotericin B)
  • consider steroids early

Adrenal Issues

  • secondary to steroid use
  • requires increased steroids to cover illness

DISPOSITION

  • isolation
  • early referral and possible retrieval
  • early discussion with patient and family about risk
  • may need advanced oxygenation techniques:
    -> nitric oxide
    -> prostacycline
    -> prone ventilation
    -> high frequency oscillation
    -> ECMO

CONCLUSION

  • requires decisive, aggressive management
  • involvement of quaternary level services

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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