vents & transplant Flashcards
initial vent settings
AC or SIMV
RR 12-16
TV 6-8ml/kg IBW
PEEP 5
FiO2 100%
RSBI
rapid shallow breathing index
respiratory rate/TV
=breaths/min/L
<105 is positive = extubation
> 105 likely to fail extubation
warm vs cold ischemic time
warm - amount of time the organ remains at body temp after blood supply has been stopped or reduced
cold - amount of time organ is preserved in hypothermic state prior to transplantation (4-6h for heart, <12 for liver/pancreas, <24 for kidney)
initial blood testing prior to transplant
blood type testing, HLA, crossmatch
major AE of calcineurin inhibitors (cyclosporine, tacrolimus)
renal insufficiency
immunosuppression options
glucocorticoids
calcineurin inhibtitors
antimetabolites
proliferation signal inhibitors
primary indication for cardiac transplant
stage IV heart failure-refractory to maximum medical therapy
NYHA heart functional classification HF
stage I - no physical activity limitations
stage II - slight limitation of physical activity resulting in fatigue, palpitation, dyspnea, or angina
stage III - marked limitation of physical activity, less than ordinary physical activity results in symptoms
stage IV - inability to carry out any physical activity without discomfort, may have angina at rest
what is denervation?
after heart transplant, the heart is denervated and has altered response to cardiac meds (digoxin, atropine)
common findings after heart transplant
HTN, HLD, DM, renal dysfunction
diagnostic for transplant rejection
biopsy!!!
heart - end-myocardial biopsy
lungs - transbronchial biopsy
kidney - renal biopsy
pancreas - ultrasound guided pancreatic biopsy
liver - liver biopsy
intestine - endoscopic biopsy
heart transplant follow up
immunosuppression
heart Cath yearly
biopsy/ECHO periodically in first year
stresst test at 6-8 weeks
LHC at one year
CT C/A/P every 3 years
s/s of heart transplant rejection
arrhythmias and HF symptoms (edema, SOB)
main indications for lung transplant
advanced COPD
idiopathic pulmonary fibrosis
cystic fibrosis
lung transplant follow up
CXR weekly x6 weeks, then PRN
PFTs annually
chest CT at 6 mo, annually
bronch bimonthly then PRN
s/s of lung transplant rejection
dyspnea, cough, sputum production, low-grade fever
pulmonary primary graft dysfunction
diffuse pulm infiltrates and hypoxemia within 72 hours of transplant
bronchiolitis obliterans
chronic lung rejection syndrome characterized by decreased FEV1, dense fibrosis, cough, and DOE
treat with high dose steroids
main renal transplant indication
stage IV - V ESRD
secondary to DM most common
renal transplant monitoring
creatinine weekly, then monthly
doppler or MRA
renal biopsy if suspicious for rejection
manage HTN - thiazide, CCB, ACE/ARB
monitor proteinurea
leading cause of death after kidney transplant
cardiovascular disease
pancreas transplant rejection monitoring
hyperglycemia
monitor serum crt, urinary amylase, C peptide, serum lipase
ultrasound-guided pancreatic biopsy
MELD components
serum bili, creatinine, INR
10+ should be considered for transplant
liver transplant monitoring
liver biopsy if s/s of rejection
LFT biweekly for 2 weeks, then weekly, then monthly
s/s of liver rejection
fever, elevated LFTs, jaundice, fatigue
hyper acute rejection
occurs within minutes, humoral mediated
rapid tissue necrosis - transplanted organ must be removed immediately
accelerated acute rejection
1-5 d postop
acute rejection
within first months after transplant
cellular mediated
treated with high dose steroids, optimization of immunosuppression
chronic rejection
occurs slowly, no difinitive treatment
common complications after transplant
hypertension
post-transplant DM
renal insufficiency
hyperlipidemia
bone disease
malignancy
antimicrobial prophylaxis
fist year after transplant
against oral candidiasis, toxoplasmosis, pneumocystitis, CMV
common infections in immunosuppressed
viral - CMV
fungal - candida, aspergillus
bacterial - staph, psudomonas, E. coli, klebsiella
live vaccines contraindicated!!!
pancreas transplant indications
DM1
hypoglycemia unawareness
liver transplant indication
cirrhosis of all types
acute liver failure
CHRONIC HEPATITIS
ALCOHOLIC LIVER DISEASE
genetic disorders
Wilson’s disease
hepatocellular carcinoma
intestinal transplant indications
intractable TPN-related issues
necrotizing enterocolitis
Crohn’s disease
short bowel syndrome
radiation enteritis
stenosis of the small bowel
intestinal transplant s/s concerning for rejection
abdominal pain, distention, increased fecal volume/stomal output, bloody output, fever
contraindicated vaccines in transplant
MMR
intranasal flu
varicella
yellow fever
live zoster
oral typhoid
absence of safety data and concern for vaccine-associated infection
