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

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