Transplant Patient Hot Case

GENERAL APPROACH

Considerations

  • Transplant – liver, heart, lung, heart-lung, bone marrow, renal, pancreatic
  • Phase of care – immediate post op, sepsis, rejection, respiratory failure, renal failure
  • Surgery – graft function, anatomy, anastomoses (leaks and occlusion)
  • Infection – bacterial (early), opportunistic: fungal, viral, mycobacterial (late)
  • Immunosuppression – rejection (hyperacute = alloAb, acute = T-cell, chronic), GVHD (rash, liver dysfunction, GI symptoms), drug side effects, malignancy

Cases

  • peri-operative management +/- complications: heat, heart-lung and liver transplants
  • renal or pancreatic transplant with complications
  • bone marrow transplantation e.g. sepsis and hematological malignancy

INTRODUCTION

CUBICLE

  • isolation (neutropenia, MDRO)
  • waste disposal equipment for cytotoxic agents

INFUSIONS

  • immunosuppressants: calcineurin antagonists, corticosteroids, anti-nucleotides, monoclonal antibodies
  • antibiotics
  • vasoactives
  • distributive shock (noradrenaline, vasopressin)
  • isoprenaline (e.g. chronotropy in heart transplant), dobutamine, dopamine, milrinone (cardiogenic shock)

VENTILATOR

  • mode
  • level of oxygenation: high FiO2, PEEP
    — e.g. 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)
  • ICCs
  • 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: GVHD
  • signs of underlying disease necessitating transplantation
  • IDC and urine output (hypovolemia, ACS, calcineurin inhibitors, renal graft dysfunction)

RELEVANT INVESTIGATIONS

  • graft function

-> liver: ultrasound, 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

DISCUSSION


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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