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

• Indications for organ transplant
• Assessing new infiltrates in a lung transplant patient: Pneumonia in the Immunocompromised,  Pneumonia in the Heart-Lung Transplant Patient
• Acute transplant issues: Acute rejection, Acute Graft Versus Host Disease
• Complications of immune suppression: Infections in the Immunocompromised, Infections occurring post-transplantation
• Prognosis
• Organ donation
• Different types of transplant: Bone Marrow Transplantation, Heart Transplant Patient, Liver Transplantation, Renal Transplant Patient, Lung Transplant