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CPPT II > FINAL: UNIT 5: Heart and Lung Transplants > Flashcards

FINAL: UNIT 5: Heart and Lung Transplants Flashcards

1
Q

With organ transplants there is always a

Native Organ–belongs to pt, needs to be replaced

Donor Organ—-organ coming from somewhere/someone else

A

see pics

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2
Q

PTs Role in:

Pt waiting for transplant

Pt receiving transplant

Pt recovering from transplant

A

see pics

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3
Q

Donors can supply up to ____ organs

A

8

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4
Q

Selection Guidelines: For all transplants

*Recipients

A
  • MUST BE Ambulatory w/ Rehab potential
  • Satisfactory nutritional status w/ Normal BMI
    • ​b/w 18-30
  • Appropriate Mental State
    • ​NO intellectual disability
    • Must comprehend and accept procedure, risks an complications
    • satisfactory psychosocial profile & good support system
    • *Downs pts do NOT qualify
  • Motivated and compliant w/ tx
  • Adequate financial resources for meds and follow
    • ​$10,000 liquid in bank
  • Absence of contraindications
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5
Q

EXCLUSION Criteria

A
  • Active/Recent malignancy (<5yrs cx free)
  • Other end-organ failure or dysf
  • Current smoking or subs abuse (past 6mos)
  • Untreated psychiatric disorders
    • ​ex. Bipolar
  • Known active infection
    • ​TB, HIV, Sepsis
  • Hx of non-compliance
  • Unsatisfactory nutritional status
    • ​Obesity or severe malnutrition
  • Lack of social support
  • Poor rehab pot.—–> THIS IS WHERE PT COMES IN!!!
    • ​PT can SHOW the pt is functional and has ability to rehab
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6
Q

Hx Transplantation Milestones

A
  • 1963
    • first lung transplant
    • 18d survival
  • 1967
    • ​first heart transplant
    • 18d survival
  • 1980-1990​
    • Long term survival achieved***
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7
Q

AFTER Transplant……what is req’d???

A

Lifetime immunosuppressant*

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8
Q

Immunosuppressive Therapy for ANY transplant

3 Modalities of Therapy:

A
  1. Induction
  2. Maintenance
  3. Rejection
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9
Q

Immunosuppressive Therapy for ANY Transplant

1. Induction

A

Used in the IMMEDIATE PERI-TRANSPLANT Pd.

*when risk of rejection is HIGHEST and potent immunosuppression is needed

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10
Q

Immunosuppressive Therapy for ANY Transplant

  1. Maintenance
A

Cont’d for recipient’s lifetime w/ reduced doses of drugs

*every 12hrs vs. 2x/day

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11
Q

Immunosuppressive Therapy for ANY Transplant

3. Rejection

A

IF recognized, higher doses and potent IV immunosuppressants are used

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12
Q

Meds for ANY transplant

***

A

Immunosuppressants

  • Ex. Prednisone—–Steroid
    • ​REMEMBER W/ STEROIDS
      • ​Main MSK SE==> Myopathy

*ALL meds begin as IV and are changed to PO when approp.

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13
Q

Other Meds for ANY transplant other than immunosuppression

A
  • Antifungal prophylaxis
  • Corticosteroids

*Immunosuppression is a lifelong commitment —–> prevents rejection while min. SEs

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14
Q

Heart Transplant Eligibility:

3 Dis’s that lead to transplant:

A
  • 1. Cardiomyopathy
    • ​Dilated
    • Hypertrophic
    • Restrictive
    • Preserved EF
    • Reduced EF
  • 2. HF
    • ​Preserved EF
    • Reduced EF
  • 3. Congenital Heart Dis.
    • ​ALL UNIT 4 DIS’S
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15
Q

Heart Transplant Eligibility

Eligibilty Checklist

A
  • Adv’d HF or MAX medical therapy
  • Freq. hospitalizations
  • Deterioation of clinical status
  • Poor prognosis w/out transplant
    • agree <2 yrs to live w/out transplant
  • NO add. medical options
  • All other guidelines met
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16
Q

Evaluation Testing for Heart Transplant

FULL WORK UP

Ex’s:

A
  • 24 hr urine screen—-assess kidney function
  • chest x-ray
  • colonoscopy
  • blood tests
    • type
    • electrolytes
    • Infectious dis’s
  • mammogram
  • PSA—-Prostate Specific Antigen
  • Dental exam
  • Echo
  • cardiac cath
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17
Q

Listing System

Heart Transplant

1A:

A

*Considered FIRST

  • Pts are HIGHEST priority
  • Must stay in hospital due to meds or machine
  • LVAD, BiVAD, ECMO
  • Vent. dependent
  • IV Inotrope (strength)
  • Limtd life expect w/out transplant
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18
Q

Listing System

Heart Transplant

1B Status

A

*Considered 2nd IF NO 1A Match

  • 2nd highest priority
  • Can live outside hospital
  • May req. sm amts of IV meds or LVAD
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19
Q

Listing System

Heart Transplants

Status 2

A

NO IV meds

NOT hospitalized

Clinically stabe BUT terminal dx

CHDs

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20
Q

Listing System

Heart Transplants

Status 7

A

Pts are listed for transplant BUT have been removed from active list

infection, life event, insurance, finances

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21
Q

Factors influencing Compatibility

Heart transplants

5:

A
    1. Blood Type, ABO compatibility
    1. Listing Status (1A, 1B, 2)
      * LONGER wait==HIGHER priority
    1. Days on waiting list
    1. Cavity Size
    1. Geographic Loc.
      * *Heart can be stored for 4-6hrs*****

*NOTE: More MEN are donors—> more risky behavior

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22
Q

2 Sx Approaches

Heart Transplant

A
    1. Anterior Axilla Approach
      * ​MOST COMMON
      * **RIB 4
    1. Sternotomy
      * ​*Sternal Precautions
      • ​NO lifting
      • NO overhead
      • NO valsalve
      • NO using just one arm to get up or move—-USE BOTH
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23
Q

What is the BIGGEST PROBLEM AFTER Heart Transplant?

A

Denervated heart****

*takes awhile for the heart to become stim’d w/out help from SA Node…..

*WARM-UP IS KEY!!!

24
Q

POST Heart Transplant Complications

Complications assoc’d w/ Sx:

A
  • Rejection
  • Infection
  • Ischemic injury
25
Q

Post Heart Transplant Complications

Comps assoc’d w/ Transplantation:

A
  • INC susceptibility to infections
  • Cx

**BOTH are bc you are on immunosuppressants for LIFE

26
Q

Post Heart Transplant Comps

Comps assoc’d w/ Immunosuppressive Drugs:

A
  • MYOPATHY***
    • PT plays huge role in this/recognizes it!!!
  • SEs of long term oral glucosteroids and other immunosuppress drugs (SEE ABOVE)
    • ​Osteroporosis/penia
27
Q

PTs Role in Heart Transplant

Rehab Phases

POST-Transplant

In general key points

A
  • Expect a blunted HR response to EX due to lack of SNS activation/denervation of heart—–> WARMUPS!!!
    • ​DELAYED sinus tachy
    • DELAYED INC SBP
    • DELAYED tolerance to ex.
  • Pts CAN obtain partial reinnervation of the ANS over time*
  • CONSTANTLY check for s/s of infection/rejection
  • ADDRESS WHOLE PATIENT!!!!!
28
Q

PTs Role in Heart Transplant

Rehab Phases

POST-Transplant

Other key things to remember Dr. Macfarlane mentioned

A
  • Only terminate Warm-up when you see an INC in HR
    • ​means the heart is finally stimulated
  • *remember the heart will act like the body is RESTING when its NOT
  • We NEED an INC in HR to INC blood flow to body*
  • ADDRESS WHOLE PATIENT, not just endurance
    • EX. Quad strength in CV pts linked to long-term success!!!
29
Q

Explain this slide

Denervated Heart vs. Innervated Heart

A
  • Denervated Heart
    • ​expect blunted HR response —-> just like BetaBlockers
  • *REMEMBER
    • ​The denervated heart is now going to rely on circulating Epi and NE to attach to the SA node receptors bc ANS NOT ATTACHED TO SA Node
  • Catecholamines: Wait to kick SA node in
  • Expect Delayed recover after Ex. ***
30
Q

S/S of Rejection/Infection

Heart Transplant

SIGNS ARE THE SAME—-this is what makes it difficult and why it is IMPERATIVE you monitor this!!!

A
  • HEART Specifically:
    • ​S3 gallop–> Lub, Dub, Dub​
      • ​S3 sound blood hits walls of HEART, not VALVES
    • Arrhythmias
    • JVD
  • OTHER:
    • Fever >100 degs/fever/chills
    • Changes in BP
    • Resp distress
    • Dyspnea
    • Fatigue
    • DECd EX tolerance and capacity
    • Wt. gain
    • Edema

**Remember these all look A LOT like signs of infection/sickness too!!!

31
Q

Lung Transplantation Eligibility

Broken down by Categories of Diseases

32
Q

Lung Transplant Eligibilty

General List

A
  • End Stage lung dis. on max med. therapy
  • FREQ. hospitalizations
  • Deterioration of clinical status/ADL
  • O2 dependency
  • Poor prognosis W/OUT transplant
  • NO add. medical options
  • All other guidelines met

see pics for guidelines broken down by Dis. Category

33
Q

Lung Transplant

Listing System

PT Eval

What are the components of this?

A
  • Ht
  • Wt
  • Lung Dx code
  • Functional status and 6MWT—PT
  • assisted ventilation
  • Supp. O2
  • Current ABG
34
Q

Lung Transplant

Listing System uses what score?

A

Lung Allocation Score LAS

HIGHER score===HIGHER on list

35
Q

Lung Transplant

Listing System

Disease specific categories

A
  • COPD:
    • ​%Predicted FVC: <60% w/ hypoxemia
    • FEV1 <25%
    • NOTE: Obstructive, LOOW
  • Pulm HTN: remember NORM Pulm aa SBP <25
    • >55mmHg w/ life exp <3yrs
    • Pulm AA mean press & systolic press
  • IPF: Idiopathic Pulm Fibrosis
    • ​<60% Vital Capacity
36
Q

Factors influencing Compatibility

Lung Transplant

A
    1. Blood type, ABO compat.
    1. Listing status (LAS score)
    1. Days on waiting list
    1. Thoracic cavity size
    1. Geographic Loc.
37
Q

Lung Transplant

Sx approaches

A
    1. Clamshell Incision
      * ONLY RESTRICTION post transplant is NO driving and NO sitting in front of air bag for 6mos
    1. Mediansternotomy
      * *Sternal Precautions
      • ​NO lifting >10lbs
      • NO valsalve
      • NO bending/twisting
      • NO using just one arm to get up, USE BOTH
38
Q

Post Lung Transplant Comps

Comps assoc’d w/ Sx:

A
  • Rejection
  • Infection
  • Ischemic injury
  • Bronchial issues
    • ​anastomoses dysf—–no collateral blood supply
  • Atrial arrhythmias
    • ​A-fib COMMON***
39
Q

Post Lung Transplant Comps

Comps assoc’d w/ Transplant:

A
  • INC susceptibility to infections (PNA)
  • Cx
  • Diaphragmatic dysf
  • SLT: Single Lung Transplant–Complications*
    • Initially dec perfusion to donor lung
    • Chronic native lung hyperinflation causing displaced mediastinum, DEC V/Q of donor lung
40
Q

Post Lung Transplant Comps

Comps assoc’d w/ Immunosuppressive Drugs

A
  • SEs of long term oral glucosteroids and other immunosuppress. drugs
    • ​MYOPATHY!!!
    • osteoporosis/penia
41
Q

PTs Role in Lung Transplant

Rehab Phases

POST-Transplant

In general key points

A
  • LUNGS ARE NOW DENERVATED
  • DELAY in bronchodilation w/ onset of exertion due to denervation nature of the lung
    • ​*USUALLY DO NOT obtain partial reinnervation of the ANS like the heart
  • CONSTANTLY check for s/s of infection/rejection
    • ​same as heart except now INC in sputum prod.
  • ADDRESS WHOLE PATIENT, not just endurance
    • ​*90% anxiety in lung patho’s
      • ​pts scared
42
Q

PTs Role in Lung Transplant

Rehab Phases

POST-Transplant

Other key things to remember Dr. Macfarlane mentioned

A
  • WARM-UPS are ESSENTIAL for Lung Transplant
    • Warmup must be LOWER MET lvl than your intended Ex. MET lvl
  • *remember LUNGS are now deinnervated
  • WARMUP
    • 2-5mins
    • LOWER intensity exercise as warmup
      • some endurance component
43
Q

S/S Rejection/Infection

Post Lung Transplant

LUNG IS GENERAL

A
  • Sputum production
  • DECd lung function
  • O2 desat
  • Altered ABG
  • Hypoxemia—-> LOW O2
  • Hypercapnia—-> HIGH CO2
  • ***Lung biopsy via bronchoscopy===> GOLD STANDARD for dx of rejection
44
Q

S/S Rejection/Infection

Lungs

Gen. List

*Remember these s/s look similar!!!!!

A
  • Fever>100degs/fever/chills
  • Changes in BP
  • Resp distress
  • Dyspnea
  • Fatigue
  • DEC Ex tolerance and capacity
  • Wt Gain
  • Edema
45
Q

LUNG/HEART Transplant

If LESS THAN 3yr Life Expectancy

What things should you incorporate?

A
  • EDUCATE
  • Functional mobility
  • ID mm imbalances and strength
  • Strengthen MAJOR MM GROUPS—Glutes/Quads
  • MM endurance
    • ​those awaiting heart transplant—> “Cardiac Rehab parameters—REVIEW THESE
  • Optimize breathing patterns
  • Address anxiety/depression
  • yoga/mobilization w/ breathing
  • Prevent sedentary lifestyle despite progressive deterioration of lungs
    • ​DEC strength and diaphragmatic impairments adversely affect ex. capacity
46
Q

POST-OP Transplant

Heart and Lung

Acute Care:

A
  • Monitor VITALS
    • ​Conditional Breathlessness Dyspnea–> usually related to mm fatigue and anxiety
  • Skin care
  • Pulm mgmt/Chest PT/Segmental breathing
    • ​diaphragmatic breathing
    • INSP. hold—-count insp, pause, exhale
    • biofeedback
    • pursed lip
    • airway clear. techs
      • aspiration common—-> assess BEFORE trendelenberg pos
  • functional mobility
  • assist in weaning process off mech. vent.
  • strength train
  • EDUCATE
    • ​anxiety, coping mechs, breathing w/ mobility
47
Q

POST-OP Heart/Lung Transplant

Acute Care:

BED POSITIONING

A
  • HOB >30degs to prevent aspiration
  • IF unable to get OOB, place bed in chair pos when hemodynamically stable
48
Q

POST-OP Heart/Lung Transplant

Acute Care:

SLT POSITIONING (Single Lung Transplant)

A
  • Pos. pt w/ donor lung side UP, native lung DOWN to promote DRAINAGE
    • ​ex. L. lung transplant—lay on R. side
49
Q

POST-OP Heart/Lung Transplant

Acute Care:

DLT: Double Lung Transplant

POSITIONING

A
  • Pos. pt supine for and rotate ASAP, every 2hrs
    • ​SAME W/ HEART TRANSPLANT
50
Q

POST-OP Heart/Lung Transplant

Acute Care:

POSITIONING DURING REJECTION

A

Donor lung DOWN to optimize perfusion

51
Q

Acute Care

POST-OP Heart/Lung Transplant

POSITIOINING in gen.

A

OUT OF BED AS SOON AS MEDICALLY STABLE

52
Q

Post-Op Heart/Lung Transplant

In-pt rehab

A
  • pts function optimized @ 3-6mos post-transplant
  • Functional mob.
  • UE/LE mm endurance/strength
  • posture training/scapular strength
  • Chest PT
  • Pt specific impairs
53
Q

POST-OP Heart/Lung Transplant

Home PT

A

*Transition to OP PT ASAP bc pts function is optimized @ 3-6mos post-transplant

*so after 3-6mos you want to get them into OP PT bc they are at the best their going to be w/ other PT methods

54
Q

Post-Op Heart/Lung Transplant

Outpatient PT

A
  • Scar mgmt
    • ​avoid ST restrict/dec rib mob/chronic pain
  • STM and rib mobs of T/S and ribcage
  • *mult studies have found DEC FEV1, DEC VO2max and DEC daily activity compared to healthy people of same age, ADDRESS IT
    • DO NOT UNDERDOSE!!!
  • EXERCISE PRESCRIPTION:
    • ​Progressing aerobic endurance ex
    • INC mm strength
      • *LE weakness is one of primary cause of ex limitations—-NOT dyspnea
    • INC endurance tol and ADL function
    • spirometry vol’s
  • GOALS:
    • community acts w/out fatigue
  • *Risk of re-admission is high——- optimize function and pulm status as early as possible
55
Q

Phys Activity Levels After Lung Transplant

A

*Take Home Message: Ceiling effect reached 3-6mos

*DO NOT UNDERDOSE——ALWAYS ROOM FOR PROGRESSION!!!

SEE STUDY BELOW

56
Q

POST-OP Care

Heart/Lung transplant

Infection Control

A
  • Infection control is KEY
    • ​hand washing
    • Staff wears a mask in pt environment
      • ​*LUNG transplant
    • avoid flowers & plants in room
    • NO lab jackets/coats in room

**65% of pts post-op transplant will get an infection**

CPPT II (6 decks)

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