organ transplant Flashcards
1
Q
Transplantation
A
the process by which the tissues organs of one human are grafted into another
2
Q
United Network for Organ Sharing (UNOS)/ organizations in the US
A
private, nonprofit organization that oversees procurement and distribution of organs and maintains national wait list
- (maintains standards and regulations)
- Federal Government contractor
63 organ procurement organizations(OPO’s) organizations in the US.
- Regionally located
- Procure organs from different locations
- Assess potential donor candidates
3
Q
what is the most sought organ
A
kidneys
4
Q
types of donors
A
Deceased donor (primarily ICU):
1) Brain dead or neurological death donor – Most viable donor
- Traumatic brain injury, anoxic death
2) Non-heart-beating donor – Lesser viability –
Living donor
1) Related (parent or sibling)
2) Unrelated (spouse or friend)
3) Paired exchange: Two-way exchange occurs
4) Altruistic (most common with bone marrow)
tip: can live on 1 functioning kidney
5
Q
Graft
A
Refers to the organ that was transplanted
6
Q
Allograft
A
non-self of same species
7
Q
Autograft
A
Self (skin)
8
Q
Living donor
A
Donor is alive when giving organ to recipient, may be relative, friend or anonymous
- Bone marrow is most common
9
Q
Donor
A
person who gave organ
10
Q
Recipient
A
person receiving organ
11
Q
Calcineurin
A
- Chemical responsible for activation of T-cell
- Inhibitors include Tacrolimus and Cyclosporine
- After macrophage eats infectious material, sends signal to t-cell, which precipitates cell mediated response
- Want to inhibit!! -> part of process for organ rejection
12
Q
T-cells
A
responsible for cell-mediated response
13
Q
B-cells
A
responsible for humoral response (anti-body production)
- Lymphocytes that make antibodies
14
Q
HLA (Human Leukocyte Antigen)
A
highly adaptive proteins which help fine-tune our immune system – over 200 measurable panels as of today
- Want to get to as close match as possible
- Look to see what immunosuppressive therapy to use
15
Q
ABO Incompatibility
A
Incompatibility between donor and recipient blood types
- Formerly an absolute contraindication
16
Q
Risk of Mortality post transplant determined by
A
- the severity illness at time of transplant
- Type of transplant (kidneys easier than heart)
- Degree of human leukocyte antigen (HLA) matching allogeneic transplants
- Stem cell source
- Intensity of the condition regimen
- Ages of both the donor and the recipient
- Experience of transplant center
tip:
- People don’t immediately improve following major surgeries- Days to mobilize fluid.
- Heart more complex than kidney-
- Stem cells can be from periphery, more are seen in the bone marrow.
- The younger you are, the better you’ll do.
17
Q
Patient selection
A
- Physical and psychological health.
- Financial resources and insurance status (based off immunosuppressive therapy post surgery)
- Biological age (younger is better)
18
Q
how is the UNOs national list patient ranking used for heart transplants?
A
status 1 -> LVAD patients and inotropes (can be continuous infusions)
status 2 -> stable on oral heart failure medications
19
Q
how is the UNOs national list patient ranking used for lung transplants?
A
LAS scoring system used -> test run on patient for lung capacity
20
Q
how is the UNOs national list patient ranking used for liver transplants?
A
MELD score (predicts mortality based off liver health)
- 1 , 2A, 2Band 3
- Based on severity of disease
- S1-Death predicted within 7 days, S3 living with ESLD
- Liver failure -> awful death
21
Q
Absolute and Relative Contraindications to Solid organ Transplant
A
Malignancy (active cancer until healed)
Active Infection
Active drug, tobacco, or illicit substance use (doesn’t mean forever)
Inability to comply with medical regimen
Acquired immune deficiency syndrome-
Human immunodeficiency virus (can still receive) and
Hepatitis (relative contraindication)
Morbid Obesity (relative contraindication)
Specific Contraindications exist for each organ
22
Q
Common Complications
A
Hypertension
Post transplant Diabetes Mellitus
Renal insufficiency
Hyperlipidemia
Bone Disease
Malignancy
Infection
Rejection – several different types
23
Q
Common Medical Complications due to transplant: Hypertension
A
1) is common: caused by preexisting disease, calcineurin inhibitors and corticosteroids (both blunt inflammatory process, cause elevations in BG, BP)
2) Goal is per JNC guidelines (120/80)
3) Calcium channel blockers are medication of choice to decrease renal vascular resistance, due to calcineurin-induced vasoconstriction.
4) Single agent is usually not sufficient-avoid hypotension in renal transplant
24
Q
Common Medical Complications: Post transplant diabetes mellitus (PTDM)
A
1) PTDM may be directly related to corticosteroids that enhance glyconeogensis and to calcineurin inhibitors + corticosteroids
- Increased insulin resistance
- Directly affect release of insulin from beta cells
2) PTDM is associated with higher organ rejection
3) Tight glycemic control is indicated -> high grafted organs don’t go well with uncontrolled BG
4) Treatment options
- Alterations in immunosuppressive regimen
- SubQ Insulin, metformin, sulfonylurea’s, insulin secretogogues, alpha-glucosidase inhibitors, & thiazolidinediones
tip:
Adverse reactions to SUBq insulin -> hypoglycemia
- no ceiling effect (can increase if needed)
- oral insulin have worse side effects
25
Common Medical Complications: Renal Insufficiency
1) May be seen in all solid organ transplant recipients regardless because of nephrotoxicity associated with calcineurin inhibitors
2) Treat by reduction in calcineurin dose
3) Manage DM
4) Manage HTN
5) Limiting medications that cause nephrotoxicity
- NSAIDS
- Diuretics
- Certain Antibiotics (vanco + gentamycin)
26
Common Medical Complications: Hyperlipidemia
1) Contributes to cardiovascular disease and to chronic allograft nephropathy
2) Pathogenesis of Hyperlipidemia found to be associated with immunosuppressive agents, most notably Sirolimus
3) Treatment
- Diet modification + exercise if tolerated
- Bile acid sequestrants (Questran)
- Nicotinic acid (Niacin)
- HMG-CoA reductase inhibitors:
---- Increased incidence of myopathy reported in cardiac recipients who are taking Cyclosporine & HMG-CoA reductase inhibitor
---- Can change to different statin if needed
---- AVOID grapefruit juice if taking statin
27
Common Medical Complications: bone disease
1) Osteoporosis is common
2) Related to corticosteroids with maximum amount of bone loss in first 3 months. (ex. COPD population)
3) Baseline and annual bone scans are indicated
4) Treatment minimization of corticosteroid, supplemental calcium (before developing bone disease), bisphosphnates, and hormone replacement.
5) Hard to treat, easier to prevent
28
Common Medical Complications: Malignancy
1) Increased incidence of lymphoma, skin cancer and Kaposi’s sarcoma
2) Lymphomas are primarily B-cell non-Hodgkin’s type, related to Epstein-Barr virus (looks and feels like common cold and remains dormant, can identify with HLA panel), most common in seronegative recipients with positive organs
- Post transplant lymphomas have been associated with higher does of cyclosporine and tacrolimus and with repeated anti-lymphocyte antibody therapy
3) Treatment: minimize or cessation of Immunosuppression, chemotherapy, and radiation therapy
4) Overall poor prognosis (huge rise for infection, use of immunosuppressive therapy + bone marrow regimen will lead to poor outcomes)
tip:
Can make changes to immunosuppressive therapy
29
Common Medical Complications: infections
1) Leading cause of death in solid organ recipients
2) Highest risk for infection during the first 6 months post transplant
3) Immunosuppressive medication alters the inflammatory response
- fever and increased WBC count may not be as pronounced
- fever in transplant recipient may signal rejection rather than infection: Malaise, fatigue, etc.
30
Common Medical Complications: Fungal: Candida, Aspergillus, Cryptococcus, Pneumocystis jiroveci
Oral fluconazole or itraconazole is frequently prescribed for fungal prophylaxis, and Bactrim is given for Pneumocystis jiroveci prophylaxis
Where: Mouth (candida thrush), PCP pneumonia (AIDs patients)
31
Common Medical Complications: Bacterial: Mycobacterium tuberculosis, Pseudomonal aeruginosa, Legionella, Listeria, Nocardia asteroides, Gram-negative bacteria
Most common among transplant patients
Types and causes of bacterial infection differ according to the organ transplanted
- Intra-abdominal infections are seen in liver, pancreas, and intestinal transplant recipients
- Pneumonia – Nosocomially in heart and lung recipients
- Renal recipients and the pancreas recipient with urinary drainage of exocrine secretions, urinary tract infections
32
Common Medical Complications: Rejection
Occurs when the recipient’s immune system recognizes the graft is “nonself”
Rejection involves local and systemic immune responses that leads to local inflammation, deterioration of the graft function and eventual necrosis
33
Organ rejection: hyperacute
rare, occurs within minutes, humorally mediated, rapid tissue necrosis (missed in HLA panel)
34
Organ rejection: Accelerated acute
occurs 1-5 days postoperatively; cellularly and humorally mediated; difficult to treat, rare
35
Organ rejection: Acute
cellularly mediated in 90%; typically occurs within first few months but may occur at any time; amenable to treatment
36
Organ rejection: Chronic
cell-mediated and humorally initiated injury to the endothelium and vascular sclerosis (organ will sclerosis and cause necrosis); occurs slowly and leads to eventual graft loss; no definitive treatment
37
Treatment of Rejection (increase regimen):
Increase Steroids
Increase Immunosuppressive medications
If necrosis occurs, organ has to be removed
38
Immunosuppression Therapy
Immunosuppression: the pharmacologic manipulation of the immune system performed to prevent or suppress rejection
Induction therapy: administered both before and after transplantation to delay the onset of the first rejection episode or to help limit the initial quantity of calcineurin (T-cell mediator); induction therapy typically consist of monoclonal or polyclonal anti-lymphocyte antibodies/globulin (ALG)
Maintenance therapy typically is calcineurin inhibitor, a corticosteroid (go to), and antimetabolite; maintenance therapy MUST be provided for the life of the allograft
39
Immunosuppression Therapy - Calcineurin inhibitors
metabolized via the cytochrome P450 enzyme (in liver); thus, other medications metabolized via this route may alter drug concentrations
Conversion between generic and brand forms of cyclosporine requires careful trough monitoring
Grapefruit juice be avoided by patients on calcineurin inhibitors
tip:
Monitored via trough levels
Avoid st. john worts
40
types of Calcineurin inhibitors
Inhibits IL-2secretion
Tacrolimus (Prograf): Prophylaxis of rejection, monitored by trough levels, and can cause renal dysfunction, hyperglycemia, tremors
Cyclosporine (Neoral): Prophylaxis of rejection, monitored by trough levels, and can cause renal dysfunction, hypertension, tremors, hirsutism, gingival hyperplasia
tip:
Hypercalcemia -> osteoporosis and bone degredation
41
Medications - Antimetabolits
Blocks the proliferative phase of acute cellular rejection by inhibiting DNA synthesis
- Azathioprine (Imuran): Prophylaxis rejection, Monitor CBC and LFT’s, can cause Leukopenia, hepatotoxicity, neoplasia.
- Mycophenolate mofetil (Cellcept): Prophylaxis rejection, Monitor CBC, can cause Diarrhea, leukopenia, sepsis
- Others include methotrexate, azathioprine, flourouracil
42
Medications - Steroids
Blocks T-cell expression (cell-mediated response)
- Prednisone & Solumedrol: Prophylaxis of rejection, monitor glucose and watch for infection, cause fluid retention, hyperglycemia (Transplant induced DM), impaired wound healing, aseptic necrosis of the femoral head (hip fracture), peptic ulcer
43
Medications - Adjunct antibodies
Muromonab-CD3 (OKT-3)-Treatment of rejection, monitor CD3 counts, side-effects are fever, chills, dyspnea, tremor, anaphylaxis
- Blocks T-cell Activation
Equine antithymocyte globulin (ATGAM)-Treatment of rejection, monitor WBC and platelet counts; side-effects include fever, chills, leukopenia, thrombocytopenia, anaphylaxis
- Depletes T-cell concentration by binding lymphocytes with specific cell antigens
Rabbit (ATG) antithymocyte globulin thymoglobulin-treatment of rejection, monitor WBC and platelet counts; side-effects fever, leukopenia, thrombocytopenia, anaphylaxis, dyspnea
- Depletes T-cell concentration by binding lymphocytes with specific cell antigens
44
Medications - Induction Abx - Antibodies-Treatment of Induction
Basiliximab (Simulect): Monitor for signs of infection; side-effects fever, chills, malaise, hypertension
Daclizumab (Zenapax): Monitor for signs of infection; side-effects fever, chills, malaise, hypertension
45
Organ Transplant: Renal
Indication in ESRD as defined creatinine clearance <20ml/minute
Patients are listed for transplant on the basis of their ABO type, wait time and compatibility with donor.
Preemptive transplantation, performed before the start of dialysis, may be possible, if there is a living donor.
46
Organ Transplant: Renal - Evaluation Criteria: Living donor
Psychosocial evaluation of donor with assessment of willingness to donate
Medical assessment of donor
- Tissue typing to determine compatibility (HLA panel)
H & P
- Chest xray, Comprehensive chemistry panel, ECG, renal studies by CT or MRA and renal arteriogram (good perfusion to kidneys)
Review of expectations of donation process
Financial considerations of the donation process
47
Organ Transplant: Renal - Evaluation Criteria: cadaver kidney donation
Meet criteria for neurological death (absence of brain function, can take anything) or irreversible brain injury with life support (some brain stem function but not enough for living, can only take kidney, liver lungs, bone marrow)
Absence of carcinomas or other malignancies
Absence of active systemic infections
Absence of significant renal disease
Absence of uncontrolled HTN
Obtain consent for organ donation from DPA.
tip:
Absence of carcinoma through HTN is like 90percent of your population
48
Organ Transplant: Renal - Patient evaluation eligibility for receiving organ (full h&p)
Cardiovascular non-cardiac surgery risk assessment
Dental and oral health
Endocrine system
GI
GYN for females
Immune system - (Infection free: screen for viral, fungal and bacterial infections, Free of Neoplastic disease)
Physiologic age
Psychosocial exam
Pulmonary system health
Primary renal disease cause and current state of control
Urinary tract capabilities
49
Organ Transplant: Renal - Postoperative complications (surgical)
Graft Thrombosis-2-3 days post op
Arterial & venous thrombosis present with sudden cessation of UO + azotemia
Venous thrombosis present with graft swelling * gross hematuria
Dx confirmed by doppler ultrasound
Prognosis is poor, and the results in graft loss
50
Postoperative complications: Urine leak
Occurs 2-3 days after surgery. Caused by surgical technique or by necrosis of the ureteral anastomosis to the bladder (leak around graft ureter and native ureter)
Present with abdominal fullness or pain with elevated serum creatine
Dx by needle aspiration and analysis of fluid, which reveals creatinine
Tx is foley catheter, nephrostomy tube or surgical repair via stent
51
Organ Transplant: Renal - Lymphocele
Collection of lymph fluid that surrounds the allograft as a result of severed lymphatics around the iliac vessels
May cause ureteral obstruction, compression of the iliac vein, scrotal edema, and abdominal pain
Ultrasound-guided needle aspiration of clear, protein-containing fluid is diagnostic
Tx percutaneous aspiration, redirect fluid into internal cavity, or sclerosis
52
Organ Transplant: Renal - bleeding
bleeding can occur
53
Organ Transplant: Renal - Ureteral obstruction
Presents as a decline in allograft fx
Obstruction may be due to blood clot, surgical technique, stricture, rejection or infection
Ultrasonography may reveal hydronephrosis
Tx nephrostomy tube placement, dilatation of the stricture, removal of the clot, or surgical correction (relieve obstruction)
tip:
Ureteral obstruction -> post renal obstruction
54
Organ Transplant: Renal - non surgical
Delayed graft function or inability of the newly transplanted kidney to function: occur in 10-50% of transplanted kidneys
Its source is ATN, accelerated acute rejection, and ischemic-reperfusion injury
Tx dialysis and modification of the immunosuppressive regimen
Rejection
Infection
- UTI
- Antibiotic tx guided by C & S of urine
- BK-type polyoma virus: found in recipients; see increase serum creatinine, possible hematuria, maybe confused with acute rejection. Tx with IV cidofovir (Vistide) and reduction immunosuppression, lies dormant
55
Organ Transplant: Renal - pre-op nursing care
Collaboration with transplant team to ensure a timely and successful graft placement
Assisting in dialysis: maybe performed before surgery dependent on fluid and electrolyte status
Maintain patient NPO
Nursing assessment: VS, accurate weight pre op, and distal pulses
Review medical H & P, implement orders:
- Immunosuppressive and antibiotics
- ECG, Chest x-ray and blood work to determine infectious state, tissue typing
- Place IV
- Skin prep
56
Organ Transplant: Renal - Post transplant nursing intervention
Ambulate as soon as possible, with assistance
Frequent assessment for signs and symptoms of complications
Assessment of circulatory function and comparison with preoperative baselines
Bowel elimination
Daily weights and assessment of fluid volume status
Diuretics as ordered
Immunosuppressive coverage as ordered
Laboratory testing daily
Pain and comfort management Prevention of infection
Pulmonary toilet and maintenance of adequate respiratory function
Strict I & O’s with details on color and clarity of urine
Wound care
57
Organ Transplant: Renal - discharge teaching
Extraperitoneal space is where new kidney is placed for ease of biopsy
Emotional support and referral to social worker, psychotherapist or psychiatrist. Hopefully a relationship was established prior to transplant
ADL: daily exercise
Alcohol moderate at most
Dietitian: food-drug interactions
Financial: social services consult to obtain immunosuppressive medications
Follow-up care
Infection: signs an symptoms, how to prevent infection including STD’s
Medications: how to take and when, interactions with OTC and herbal preps
Rejection: s/s of rejection teaching
Smoking cessation
1Regular cancer screening.
58
what metabolizes a lot of OTC supplements and herbals
cytochrome p450 system
59
Organ Transplant: Renal - complications
Cardiovascular disease
Rejection
Delayed graft function
Anemia
60
heart transplant contraindications
advanced age
significant systemic or multi-system disease
fixed severe pulmonary HTN
active infection
recent pulmonary infarction
cachexia or obesity
psychiatric illness
drug or alcohol abuse
61
Most common cause for heart transplant:
Cardiomyopathy (teens, young adults)
Cardiac tumor
Congenital defect (kids)
Valvular heart disease (not as common cause)
- Can do allograft (xenograft)
Endstage Heart failure that is refractory to medications without multi organ failure
May have had LVAD prior or IV inotropic medications (digoxin/isoproterenal, LVAD s/d cardiomyopathy)
62
what kind of ECG would be present in a heart transplant?
2 p waves d/t part of RA maintained to keep 2 SA nodes to stimulate graft of SA node to increase or decrease HR in response to sympathetic stimuli
63
Organ Transplant: Heart - complications
Bleeding
Rejection
Denervation: altered response to CV drugs. Will not respond to atropine and digoxin
- WILL respond to isoproternal (Inotrope)
- Beta blockers, ACE-I, ARBS, Ca Channel blockers all OK
- Delayed sympathetic response (at level of T6)
Hepatitis C
Infection
Hypertension
Diabetes
Dyslipidemia
Osteoporosis
- All s/d to immunosuppressive regimen
Graft coronary disease
Renal Insufficiency
Malignancy
Medical noncompliance
Mental health limitations
Quality of life limitations
- Hyperglyemica
- Fluid retention
- Steroids can change lives
tip:
- Delayed SNS (d/t vagus nerve being denervated in the heart (loss of nerve innervation))
- Brain tells heart fastest, so it relies on circulating catecholamine’s -> take longer to affect the heart.
- Wont have the same type of pain associated with MI’s or angina.
- lower heart rate associated with exercise
64
Organ Transplant: Heart - Recipient contraindications
Advance age (usually over age 65 years, but absolute over 70 years)
Severe liver or kidney dysfunction (co-conmitant injuries)
Active infection
Recent pulmonary infarction
Severe pulmonary hypertension
History of drug or alcohol abuse including tobacco
65
Organ Transplant: Heart - Donors
No severe chest trauma (include hitting steering wheel)
No prolonged cardiac arrest
No heart disease or infection
ABO blood group compatibility
Sufficient heart size
Negative cytotoxic antibody screen
Negative lymphocyte cross match
Acceptable age is 55 years or younger
Transplant team goes to where the donor is to perform cardiectomy and evaluate the heart, remove it, pack in ice and transport to the hospital where the recipient will be waiting
tip:
Cytotoxic antibodies- antibodies that directly attack cells.
66
the recipient needs to be at transplant hospital within?
2 hours after receiving phone call to receive organ
67
Organ Transplant: Heart - postoperative medical and nursing mgmt
Rejection surveillance
- Determined by endomyocardial biopsy
Infection surveillance
- High priority because of immunosuppression
- Heart is very vascular and can end life if failed
68
Organ Transplant: Heart - patient education
Immunosuppressive medication regimen
Risks and signs and symptoms of infection
Myocardial biopsy
Symptoms of heart failure
May need to perform self-monitoring of blood glucose, blood pressure, and daily weight
Follow-up visits and laboratory work
69
Organ Transplant: Heart - LT considerations
Chronic immunosuppression
- Other side effects and adverse effects of steroids and other medications
Graft vasculopathy or coronary artery disease in grafted heart
- vasculopathy
70
Heart-Lung Transplantation
Phrenic nerve – responsible for diaphragmatic expansion, injury can lead to impaired diaphragmatic ventilation leading to VAP or HAP -> further infections
71
Single- and Double-Lung Transplantation
Lung volume reduction surgery (diseased lobe, scarring and sclerosis)
Single-lung surgical procedure (SLT)
Double-lung or bilateral-lung transplant
Living donor lung transplantation (one lung, not common)
tip: need to fill negative space
- Isolated pul HTN, cystic fibrosis - prolific mucus production in pancreas and lungs affecting ability to breathe
- Even if lung transplant, patient still has CF so on a bunch of CF meds and immunosuppressive agents as well
- Still have pneumonia
- Survival is 44 years
72
Liver Transplantation Indications and selection - Not offered to persons who
Would not likely survive major surgery
Would not survive the effects of long-term immunosuppression
Have a disease that is likely to recur quickly and fatally after transplantation
Are not willing to comply with long-term, sometimes difficult and demanding medical regimen (i.g. alcoholic cirrhosis)
73
what is cholestatic liver diseases
bile duct is backing up into liver causing biliary cirrhosis
74
hepatocellular disease is related to
acetaminophen (suicide through narcotics binded with acetaminophen)
75
contraindications for liver transplant
issues with ammonia clearance
76
Liver Transplantation Indications and selection
Recipient evaluation – MELD criteria
Pretransplant phase (finance, sober for 6mo-1yr)
Determining donor suitability
Live donor liver transplantation
77
Liver transplant surgical procedure
Technically difficult, long surgery
Three stages
- Recipient hepatectomy
- Vascular anastomoses with donor liver (connect arteries and veins with donor)
- Biliary anastomosis
78
pre-patient history for a patient with ESLD
viral hepatitis
79
what kind of drain is used for liver so that bile doesn't accumulate in cavity
t-tube
80
Liver Transplantation Postoperative medical and nursing management
Fluid status
Electrolytes
Post-operative complications
Immunosuppression
Infection risk
Posttransplant assessment of hepatic function (PTT, INR, coags, BUN production, albumin, bilirubin clearance, etc.)
- Liver graft non-function
Patient education (stay away from hepatotoxic substances, no alcohol or Tylenol)
81
what is a common complication after liver transplantation that we are concerned about
graft thrombosis within 1 week s/d immunosuppressive regimen
82
liver transplant long term follow up
Hypertension
Kidney failure
Obesity
Dyslipidemias
Biliary and infectious complications
Malignancies
83
Pancreas Transplantation Selection for transplantation
Special care needed for diabetics because of possible systemic effects of diabetes
Will develop insulin resistance
84
Pancreas Transplantation: Pancreas transplant surgical procedure
Variety of methods
- Provide adequate arterial blood flow to pancreas and duodenal segment
- Provide adequate venous outflow from pancreas via portal vein
- Provide management of pancreatic exocrine secretions (manage amylase and lipase)
Native pancreas is not removed (small, enough space for both)
85
Pancreas Transplantation Post transplant medical and nursing care
Patient education
- Blood glucose testing
- Recurrent diabetes
Long-term considerations
- Rejection difficult to detect
- I-slet cell transplantation
tip: develop way to make islet cells look like non-foreign antigen
86
Tissue Donation
Nurse must consider if deceased may be tissue donor
One tissue donor may benefit up to 50 people
Transplants of
- Skin grafts
- Corneas
- Cardiovascular tissue (heart valves and pericardium)
- Bone, cartilage, tendon grafts
87
Hematopoietic Stem Cell Transplantation-Contraindications
Poor or no response to conventional-dose chemotherapy (destroys cancer and bone marrow tx saves life)
Poor performance status
Advanced cardiopulmonary or renal disease
Brain Metastasis
Age >70 years
tip:
Pleuripotent stem cells-
Lymphomas or leukemias
Chemo to wipe out all bone marrow and then receive transplant
88
Candidates for HSCT
Leukemia's, myelodysplastic syndrome, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, multiple myeloma, and selected solid tumors (don’t need to know).
Donor sources
- Autologous (self)
- Syngeneic (identical twin)
- Allogeneic (Nonself): Related/Unrelated
- Cord blood (related and unrelated) -> new baby bone marrow, stem cells harbored from cord blood
89
Hematopoietic Stem Cell Transplant Method of Collecting stem cell
1) Bone marrow harvest – best option for highest concentration
2) Peripheral blood stem cell collection by apheresis (not as high concentration)
3) Treatment Intensity for recipient-
*Myeloablative: High dose of chemotherapy, to destroy the recipient hematopoietic and immune system. Associated with high mortality, lower relapse (will do if cancer refractory with reduced intensity)
*Reduced intensity (start): Lower chemotherapy doses with Immunosuppression to facilitate engraftment of donor hematopoietic cells.
tip:
Needle into ischial crest to pull bone marrow out
DNP to develop bone marrow transplant
Expensive
90
Organ Transplant: Signs of rejection
Heart: Fatigue, exercise intolerance, dyspnea. Atrial arrhythmias, new S3, friction rub, JVD, edema, pulmonary edema
Kidney: Decreased UO, chills, arthralgias/myalgias, graft tenderness; may be asymptomatic. Elevated BUN and creatinine, increased resistive indices on Ultrasonography.
Liver: Fatigue, pruritus, graft tenderness. Elevated Liver enzymes, elevated bilirubin, dark-colored urine, jaundice, ascities
Lung: cough, dyspnea, fatigue, fever pulmonary effusions and infiltrates, decreased in spirometry, hypoxemia
Pancreas: Graft tenderness, elevated serum amylase/lipase, hyperglycemia (late)
Intestine: malaise, abdominal pain, change in stools, nausea, vomiting. Endoscopic evaluation may show edema, erythema, and reduced peristalsis, serum citrulline may be marker for rejection (rare, need severe ulcerative colitis, other measures can be taken)
91
Organ Transplant
Patient can live 10-20 years after transplant
They will develop other medical problems and you may see them on your units
The transplant team needs to be involved at all times in the acute care setting
Do NOT hold any of the immunosuppressive medications unless the Transplant team is aware.
If immunosuppressive medication is not available by your institution, then the patient needs to take their own. The medication effectiveness is dependent on serum levels.
92
Goals of Nursing Care in Transplant Patient
Prevention infection:
- These patients are immune compromised and should be admitted to a private room if possible
- If no private room available, then should not be with a patient who is actively infected
- Stethoscope assigned to the patient
Prevention rejection:
- Medications given in a timely manner, no skipped doses
- Anti-rejection medication from home should be used if in facility that does not have on formulary
- Patient and families should know when to call provider
Patient and family teaching:
- Medication
- Preventing infection
- Immunizations
- Cancer screening
- Knowledge of drug-to-drug , food to drug interactions
Coordination of care with transplant team
- Home medication reconciliation
- Making sure complete medical and surgical history is placed in chart or EMR
- Know policy and procedure of institution regarding transplant patients (All admitted to one unit?
Is the patient to be transferred back to transplant center)
- Notification of transplant team that patient is admitted
- Notify the admitting team the patient had a organ transplant (Where, when and what organ(s))
93
Organ Donor Most common exclusion criteria in the ICU
Sepsis/active infection
Old age
Metastasis
Medical Hx
- Ie. COPD, CHF, CRF
94
Brain Death
Nuclear flow study/cerebral angiogram
EEG
clinical exam x2 (usually >6hr apart)
- Apnea test
- Absence of brainstem reflexes
- All hospitals will have protocol
95
Brain death criteria
Individual devoid of cerebral and brainstem function
Uniform determination of death act 1982
Organ procurement organizations (i.e gift of life) are responsible for recovery of organs from deceased and deceased donation after cardiac death (DCD) donors
No withdrawal of life support necessary
All organs available unless ruled out for medical history or lack of interest
We can stop the heart when ready at the end of the case prior to organs coming out.
96
Donation after circulatory death (DCD)
Donor may still have reflexes
EEG wasn’t isoelectric
Cerebral angiogram showed some blood flow to brain
Can only allocate liver, lungs, kidneys from DCD
Palliative extubation usually in PACU or the OR
Donor has certain amount of time to expire (90-120 min)
Once heart stops, surgery begins
- Race against time
- Must be declared by physician
97
Determining Brain Death
Complete, irreversible cessation of function of the entire brain and brainstem
Spinal reflexes may continue to be present
Heartbeat present and maintenance of respirations with ventilator
Other organs may be functioning
98
Determining Brain Death: Application of clinical criteria
Cerebral motor response
Pupillary signs
Ocular movements (fixed movements, no tracking)
Facial sensory and motor response
Pharyngeal and tracheal reflexes (no cough or gag reflexes)
Apnea testing (slow rise of CO2 after turning off vent))
Communication with families
tip:
Ice water into ear and will show pupillary constriction (brain dead with no constriction)
99
Donor Management Goals
Maintain normovolemia
Systolic blood pressure greater than 100 mmhg
Urinary output > 1mL/kg/hr
100
Donor Management: what occurs if failure to achieve goals or instability in previous stable donor
1) consideration for right heart catheterization with PA catheter
- CVP, CO/CI, PA, SVR.
- Incorporation into management increase organ procurement rates
- Use of inotropic agents, IABP to maintain organ perfusion
- Infusion fluids PA 8-12mm HG, LR to prevent hypernatremia, Sodium Bicarbonate when acidemia PRBC’s target Hgb 10 Gm/dl.
Fluids should be warmed to 37
2) CI-Goal 2.4 L/min/m2 ; MAP >60 mmHg; SVR 800-1200dynes/sec/cm-5
3) CI-Goal 2.4 L/min/m2 ; MAP >60 mmHg; SVR 800-1200dynes/sec/cm-5
101
Donor Testing diagnostics
2D echo
Bronch
ABGs
LFTs
CXT/CT
CBC
Blood Cultures/Sputum
Biopsy for liver/kidney
102
Donor Management
Anti-arrhythmic medications
Bradycardia
- Isoproterenol or epinephrine for bradyarrhythmias
Ventricular (will r/o heart for transplant)
- Lidocaine
- Amiodarone
103
Donor Management Hormone Replacement Therapy in hemodynamic unstable donors
Thyroid replacement IV
Glucocorticoid with methylprednisolone IV
Vasopressin (ADH)
Insulin infusion with 50% Dextrose
104
Donor Management Optimization of donors respiratory status
FiO2 40%, PaO2>100mmHg, PaCO2 35-40 mmHg, pH 7.35-7.45 (lowest O2 necessary, usually isolated brain death)
Antibiotics (periodically)
Bronchoscopy to assess anatomy, remove foreign body, suctioning secretions, and infection. (if donating)
105
Donor Management Diabetes Insipidus from ischemia or infarction of posterior pituitary
UO < 200cc/hr (SIADH) Match with D5W/0.45 to treat hypernautermia, hyperosmolarity and hemodynamic instability
UO> 200cc/hr (DI) administer Vasopressin
Monitor Electrolytes and supplement every 2-4 hours
BS goal 80-150 mg/dL.
Maintain Hgb >10 by administering PRBC’s that is CMV negative and leukocyte-filtered. Notify blood bank that organ donor – additionally CMB screening and filtration to improve HLA panel
Avoid Hypothermia: Maintain temp >35 C with warming blankets, warm IV solutions
106
ISCHEMIC TIMES
Hearts: implanted within 4 hrs of x-clamp (can go up to 6hr)
Liver: implanted within 6 hrs (can go up to 12-14 hrs)
Lungs: implanted within 6 hrs x-clamp
Kidneys: implanted within 24 hrs x-clamp (can go up to 24-36hrs)
Pancreas: implanted within 6-8 hrs x-clamp
*Technology advancement with perfusion machines is growing and allows for longer times. Liver machine in clinical trials, lung machine FDA approved, heart machine FDA approved.
