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MC II Exam 3 > Transplantation > Flashcards

Transplantation Flashcards

1
Q

With transplant what 2 opposing factors are docs trying to balance?

A

Oversuppression, drug toxicity and Infection VS Undersuppression & Organ/cellular rejection.

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2
Q

What mediates the main antigenic response to the transplanted organ?

A

T lymphocytes

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3
Q

What are common psychological issues post transplant?

A

Unfulfilled expectations - patient anticipates return to pre-disease level.

  • Doesn’t understand transplant process: “chronic transplant disease”.
  • Complex medical regimen
  • Moodiness/ agitation
  • Post-operative complications
  • Unaccustomed lifestyle
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4
Q

What are common medical issues post transplant?

A 
anemia
hypertension
electrolyte abnormalities:
excessive weight gain
glucose intolerance/ DM
Myopathy***
Osteoporosis***	(avascular necrosis)
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5
Q

What are common exercise limitations post transplant?

A

VO2 max ~ 50- 60% of normal
Myopathy/ deconditioning
change in cellular respiration –> cyclosporine

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6
Q

Long term “Medical” concerns post transplant?

A

Infection/ Rejection
Malignancies
Renal failure

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7
Q

What factors have caused the # of heart transplants per year to level off?

A

donor shortages, but also mechanical hearts are being used.

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8
Q

What is survival rate after heart transplant at 10 years? at 25 years?

A

50%, and ~15%

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9
Q

What are the top 2 medical conditions which prompt heart transplant?

A

Cardiac myopathy and Coronary artery disease.

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10
Q

How many levels are there for the New York Heart Association Classification of heart failure

A

4

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11
Q

What is definition of NYHA Classification of heart failure level I?

A

Ordinary physical activity does not cause undue fatigue, dyspnea, palpitation
Can complete any activity requiring ≤ 7 mets

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12
Q

What is definition of NYHA Classification of heart failure level II?

A

Ordinary physical activity causes fatigue, dyspnea, palpitation, or angina.
Can complete any activity requiring ≤ 5 mets

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13
Q

What is definition of NYHA Classification of heart failure level III?

A

Comfortable at rest; less than ordinary physical activity causes fatigue, dyspnea, palpitation, or angina.
moderate limitations.
Can complete any activity requiring ≤ 2 - 3 mets

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14
Q

What is definition of NYHA Classification of heart failure level IV?

A

Cannot do or cannot complete any activity requiring ≥ 2 mets .
severe limitations.

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15
Q

What are some features of the denervated heart?

A

Electrical activity cannot cross suture line
Recipient atrial activity present but not conducted
Donor atrium denervated but source of electrophysiologic response

Loss of SNS, PNS innervation to donor heart
Vagal stimulation has no effect on sinus and AV nodes
No reflex tachycardia in response to hypovolemia, hypotension

ECG has 2 P waves

rely on increases in SV via Frank-Starling Mechanism and circulating catecholamine to increase CO (CO = SV x HR) with activity
“warm up” & “cool down” are critical

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16
Q

What are some sign/symptoms of acute or chronic heart transplant rejection?

A

fever , increased dyspnea, dysrhythmias, decreased exercise tolerance, reduced contractility. chronic rejection/ CAD: “Post transplant vasculopathy .

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17
Q

When vasculopathy develops from chronic heart transplant rejection, what is the treatment?

A

another transplant

18
Q

Who Are the Candidates for Lung Transplant?

A 
Advanced lung disease
50% mortality 24-36 months
Progressive dyspnea
Decreasing Function
High Lung Allocation Score
Good Match
Blood type
Body type
CMV
**Benefits of transplant versus risk of waiting**
19
Q

Contraindications to Transplant

A

Smoking – usually must prove abstinence
Extremes of weight (cachexia  obesity)
Profound debility
Symptomatic osteoporosis leading to disability
Other chronic medical conditions poorly controlled or associated with end-organ damage
E.g.: CAD/ MI; DM; renal disease; hepatic disease
Psychosocial issues (substance abuse, medical noncompliance, severe psychiatric illness)

20
Q

Which age group has the highest percentage of lung transplants?

A

50-59 years old

21
Q

What are the top two reasons to have a lung transplant?

A

COPD and IPF (idiopathic pulmonary fibrosis)

22
Q

The 50% survival rate for lung transplant is about how many years?

A

5 years

23
Q

What are the factors that go into making the Lung Allocation Score (0-100 where higher # has higher priority)

A 
Forced vital capacity
Pulmonary artery systolic pressure
Supplemental O2 required at rest
Age
Body mass index
Presence/absence of insulin-dependent diabetes
Functional status  I-IV (NYHA Class)
Six-minute walk distance
Ventilator use
Pulmonary capillary wedge pressure
Serum creatinine
Diagnosis
24
Q

New transplant guidelines are based on a lung allocation score (LAS)

A

How sick is the patient?
LAS (0 - 100) prioritizes lung allocation
Lung donation not based on waiting list time
Get fully evaluated for future lung transplant
IPF & Cystic Fibrosis favored over Emphysema

25
Q

What are issues after lung transplant?

A 
Pulmonary Issues:
-pulmonary capillary changes
-loss of pulmonary lymphatics
-denervation
leads to Pulmonary Edema
leads to Secretions
26
Q

What are the issues related to loss of lung lymphatics following transplant?

A

increased extravascular fluid –>

increased pulmonary edema leads to high arterial-alveolar gradient causing hypoxemia

27
Q

What are the issues related to denervation following lung transplant?

A

impaired ciliary function/ decreased mucociliary clearance, decreased sensation in transplanted airway/ decreased cough reflex –>
impaired mucociliary clearance

28
Q

Surgical approaches to lung transplant:

A

bilateral transverse thoracosternotomy
“clam shell”
median sternotomy
thoracotomy

29
Q

Musculoskeletal Issues from lung transplant:

A

chest wall hurts like a bastard.
limited inspiratory/ expiratory volumes and flows
↑ risk of Post op Pulm Complications

30
Q

Post transplant inpatient management, extra pulmonary:

A

Hemodynamic instability:
-hypovolemia, -myocardial irritability, -depressed myocardial contractility, -supraventricular dysrhythmias
mechanical ventilation/ chest tubes/ lines/ physiologic monitors

31
Q

Pulmonary Surgical Considerations:

A
  • denervation

- pulmonary capillary & lymphatic changes’s

32
Q

Extra-pulmonary Surgical Considerations:

A 
HR/ CO/ BP changes’s
lines/ tubes/ monitors
Poor cough 
Impaired mucociliary clearance
increased retained secretions
 Pulmonary edema
 Pain
↑ infection risk/ Immobility & deconditioning
33
Q

Post Transplant - Inpatient Management

Airway Clearance:

A 
deep breathing/ incentive spirometry
CPT as needed
directed cough
“Brace” incision
Early & frequent mobilization
Pain control
34
Q

Post Transplant - Inpatient Management

mobilization:

A

upright/ OOB
assisted ambulation
progression to treadmill/ bicycle ergometer
physiologic responses
HR/ BP/ SaO2/ RR/ RPE
Pulmonary Rehabilitation OR Phase I Cardiac Rehab

35
Q

Transplantation: Outpatient Management

Exercise prescription initial:

A

symptom limitation: DOE/ pain
Cardiac (Phase II through III)
Pulmonary Rehab

36
Q

Transplantation: Outpatient Management

Exercise prescription later (maintenance):

A

Fitness/ Wellness Program

Signs/ symptoms of rejection &/ or infection

37
Q

Lung Transplantation: Infection and Rejection

Signs/ symptoms & treatments

A

fever/ malaise/ cough
decreased airflow (FEV1 & FVC)
oxygen desaturation
decreased exercise capacity

Tx:
activity/ exercise modifications
“collaborative self management”

38
Q

Acute lung rejection (First 3 months) scale:

A 
Biopsy
Histological diagnosis
0-no symptoms, no evidence; no treatment
1-mild
2-moderate
3-severe-rare 
4-severe-rare (likely fatal)
Rx:  ↑ immunosuppression (e.g.: corticosteroids)
39
Q

Chronic lung rejection (> 1 year)

A 
Bronchiolitis Obliterans Syndrome (BOS)
Diagnosis of exclusion
Worsening Pulmonary Function Testing
Rx: ↑ immunosuppression
             retransplant
40
Q

Outcomes Associated with Physical Therapy in lung Transplant

A 
Improved exercise capacity
VO2 / work capacity:  significantly , but remains sub-normal (~ 40 – 60% max. predicted)
Improves “myopathy”
Improved “bone health”  ↑ BMD
Improved heath related quality of life (HRQOL)
\+/- changes in post-op” complications
HTN
Hyperlipidemia
Hyperglycemia/ DM
Increased body weight

MC II Exam 3 (8 decks)

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