Week 5 Flashcards
1
Q
What is hepatic disorder: ascites?
A
An abnormal/pathological accumulation of fluid within the peritoneal cavity as a result of some disease process. Volume of > 1.5 liters can be detected by physical exam
2
Q
What defines the progression of ascites?
A
The amount of accumulation of fluid
3
Q
What are the presentations of grade 1 ascites?
A
Small accumulation, no symptoms, diagnosed by abdominal US (req. 100 mL fluid)
4
Q
What are the presentations of grade 2 ascites?
A
At least 1000 mL fluid, ↑ abdominal girth, weight gain
5
Q
What are the presentations of grade 3 ascites?
A
- Diffuse abdominal pressure,
- Dyspnea (if diaphragm elevated by fluid)
- Pain uncommon
- Difficulty breathing
6
Q
What is the extreme progression of ascites?
A
Infectious (spontaneous bacterial peritonitis): new abdominal discomfort and fever. The fluid has now become infected by bacteria
7
Q
What are the hepatic causes of ascites?
A
• Portal hypertension (>90% of cases), usually due to
cirrhosis
• Chronic hepatitis
• Severe alcoholic hepatitis w/o cirrhosis
• Hepatic vein obstruction (Budd-Chiari syndrome)
8
Q
In what other conditions is ascites present?
A
- Heart failure
- Abdominal malignancies
- Nephrotic syndrome
- Infection
- Malnutrition
9
Q
The pathogenesis of ascites is not well known. However the hybrid theory prevails in what we know about, what does this theory entail?
A
Continuous injury to liver from combined exogenous factors (i.e., chronic alcohol or viral injury) or in the setting of an appropriate genetic disposition, which then increases the resistance to blood flow through the liver & can lead to increased pressure on the portal vein, and causes fluid to leak from the venous system, into the free abdominal cavity.
• Continued micro-processes of inflammation, necrosis, and collagen deposition/regeneration
• Above three may combine to transform liver from a low-resistance to high-resistance system & can lead to increased pressure on the portal vein (i.e., portal hypertension)
10
Q
What is the process in the setting of portal HTN?
A
In the setting of portal HTN, additional accumulation of vasodilatory substances, accumulate along with the increased fluid retention from the angiotensin aldosterone system, causing a further leak to occur
11
Q
What are some medical history and clinical exam findings a patient with ascites will present with?
A
- Signs: shifting dullness w/abdominal percussion & fluid wave across the abdomen
- Volumes < 1500 mL may not cause physical signs
- Massive: causes tautness of abdominal wall & flattening of umbilicus
- May have peripheral edema
12
Q
When diagnosing ascites, a physician may perform a diagnostic paracentesis. What does this entail?
A
Diagnostic tap analyzing cell count, total protein, albumin, cytology & cultures within the fluid in the stomach, done with a needle.
13
Q
In what type of patient is it mandatory to perform a diagnostic paracentesis?
A
This is mandatory in cases of new ascites or in cases of individual with a change in clinical status that includes fever, abdominal pain, and new onset of or worsening hepatic encepalopathy, or any sign or symptom of infection
14
Q
Depending on the presentation and physical appearance of a patient with ascites, what are the lab exams that can be ordered?
A
Laboratory exams including full liver screen
• Lactate dehydrogenase (LDH) cholesterol, amylase, total protein, and triglycerides
15
Q
What type of imaging is used in the case of ascites and why?
A
US or CT. This is used in cases of new onset ascites and to rule out portal vein thrombosis or hepatocellular carcinoma
16
Q
What will prompt the screen for an infection in the presence of ascites?
A
Pain & fever present
17
Q
Why may the peritoneal fluid found in the presence of ascites be infected?
A
The interface between the bowel, the intestinal micro-flora, and the acidic fluid is dynamic, with a constant translation of bacteria across the bowel wall
18
Q
What does the medical treatment of ascites depend on?
A
The determined etiology of the disease
19
Q
What are the medical treatments of ascites that was caused by cirrhosis?
A
- Treatment of underlying liver disease initiated ASAP
- Cessation of medications/alcohol that worsen ascites (angiotensin-converting enzyme inhibitors, NSAIDS, aminoglycosides)
20
Q
What are the medical treatments of ascites that was caused by cirrhosis, that will be done in the hospital?
A
- Moderate sodium restriction to 80-120 mmol/day
- Use of diuretics (Spironolactone is one of choice w/ or w/o addition of furosemide); monitor weight loss, creatinine, & sodium levels
- Therapeutic paracentesis if volume large
21
Q
What are the medical treatments of ascites in cases where the ascites keeps coming back(refractory cases), even after Na-restrictions & max dose diuretics?
A
• Assoc. w/one-year mortality of 40%
• Large volume paracentesis
• Work-up for liver transplantation along w/TIPS (transjugular intra-hepatic portosystemic shunt) as
a bridge to transplant
22
Q
Another condition that can happen in the case of severe ascites is pulmonary complications. How does this work?
A
Ascites fluid can collect in the pleural space, happening in about 10% of cirrhosis cases
23
Q
Cirrhotic patients with a significant amount of pleural cavity have what type of symptoms?
A
• SOB and cough The accumulation of the fluid can lead to: • Hypoxemia • Atelectasis • Pneumonia • Empyema
24
Q
What are the renal complications that can be seen in cases of ascites?
A
Acute to chronic renal injury.
- Very common in decompensated cirrhotic patients
Vascular tone, immune function, and related infections
25
What principle does the TIPS (transjugular intra-hepatic portosystemic shunt) procedure rely on?
The principle of establishing a direct continuity or low resistance from the large portal branch vein to the hepatic vein, by way of a shunting stent, which then bypasses the cirrhotic/high resistant fibrotic tissue(which generates the portal HTN and causes the ascites)
26
What are the benefits of the TIPS (transjugular intra-hepatic portosystemic shunt) procedure?
* Decreased requirements for diuretics
* Improved quality of life
* Improved mortality when compared to repetitive therapeutic paracentesis in patients with refractory ascites
27
What is the medical treatment of ascites in the case of infection?
Immediate use of a cephalosporin via IV
28
What are the PT considerations for treating a pt with ascites?
* Increased resting comfort in high Fowler position (HOB raised 18-20 in. above the level position w/knees elevated)
* Monitor for peripheral edema
* Patients may have more muscle wasting than evident due to the masking effect of edema
* Be aware of medical complications of medications used to decrease fluid retention
29
What is cirrhosis?
Chronic disease state characterized by hepatic parenchymal cell destruction & necrosis and the regeneration of tissue w/fibrosis or scar tissue formation. This may take years to develop
30
What are the primary complications that may develop in the presence of cirrhosis?
* Portal hypertension
* Ascites
* Jaundice
* Impaired clotting
* Hepatic encephalopathy causing mental status changes
31
What are the most common causes of cirrhosis?
- Alcoholic liver disease
| - Viral hepatitis
32
What are the other causes of cirrhosis?
```
• Autoimmune:
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Primary sclerosing cholangilitis
- IgG4 cholanglipathy
• Chronic biliary disease
- Recurrent bacterial cholangitis
- Bile duct stenosis
• Cardiovascular
- Budd Chiari syndrome
- R heart failure
- Osler disease
• Storage diseases
- Hemochromatosis
- Wilson disease
- Alpha-1 - antitrypsin deficiency
• Fatty liver disease
- Alcoholic liver disease
- Non alcoholic fatty liver disease
• Rare causes
- Medications and porphyria
```
33
Cirrhosis may be asymptomatic for years. When may symptoms commence, and when they do, what are they?
* Symptoms may commence when decompensation starts occurring
| * 1st symptoms may be nonspecific (generalized fatigue, anorexia, malaise, weight loss)
34
What are other existing risk that may be present and help confirm the case of cirrhosis?
* Metabolic syndrome
* Heavy alcohol consumption
* Exposure to hepatotoxic substances
* Use of hepatotoxic medications
35
What are the common signs and symptoms of cirrhosis?
* Cutaneous signs– jaundice, dry skin
* Firm liver on palpation
* Abdominal wall vascular collaterals (caput medusa)
* Ascites
* Asterixis
* Clubbing and hypertrophic osteoarthropathy
* Constitutional symptoms including anorexia, fatigue, weakness, and weight loss
* Splenomegaly
* Testicular atrophy
* Hepatomegaly
* Gynecomastia
36
What are the diagnostics available to diagnose cirrhosis in conjunction with the signs and symptoms?
- No specific lab test can diagnose it accurately
- Biopsy, which is the gold standard in diagnosing cirrhosis, but is only considered after a thorough and non invasive serologic and radiographic exam has failed to confirm the diagnosis
- Liver function test, but dont always correlate with hepatic function. Will include a liver panel with: AST, ALT, and alkalinphosphotase
- CBC with platelet prothrombin time
- Radiographic studies, even though there is no gold standard. CT and MRI can demonstrate the nodularity and low bar atrophic and hypertrophic changes and ascites
37
___ is the most cost effective screening test for identifying metabolic or drug induced hepatic injury
*ALT* is the most cost effective screening test for identifying metabolic or drug induced hepatic injury
38
How is the biopsy for the diagnosis of cirrhosis conducted?
It will be performed through a percutaneous transjugular laproscopic open operative or an ultrasound, or . CT guided fine needle approach
39
What is the 1st medical intervention for cirrhosis?
Prevention of cirrhosis by early dx of chronic liver disease via screening
40
What are the medical interventions for cirrhosis after the patient has been diagnosed?
• Prevention of cirrhosis by treating chronic liver disease
• Antiviral therapy in cirrhosis due to Hep B or C
• Immune suppression in autoimmune hepatitis
• Treatment of iron overload in hemochromatosis and copper overload in
Wilson disease
• Abstinence from alcohol in alcoholic cirrhosis
41
What do we want to screen patients for regularly when they have cirrhosis?
Regular screening for hepatocellular carcinoma
| • Abdominal US every 6 months
42
What are the general supportive care for patients with cirrhosis that may have developed into cancer?
* Stopping injurious drugs
* Providing nutrition (including supplemental vitamins)
* Treating the underlying disorder
* Reduction of drugs metabolized in the liver
* Avoidance of hepatotoxic substances and drugs
* Vaccination against viral hepatitis A & B
43
What is the more invasive method of treating cirrhosis?
TIPS (transjugular intra-hepatic portosystemic shunt)
44
How do we treat severe cases of cirrhosis?
Liver transplantation
45
What is the progression of chronic liver disease?
- Chronic disease will lead to hepatic fibrosis (may be reversible with treatment)
- Hepatic fibrosis will lead to compensated cirrhosis (may be reversible with treatment) or it can lead to decompensated cirrhosis
- Compensated cirrhosis will lead to hepatocellular carcinoma (this is irreversible)
46
What are the PT implications of cirrhosis as seen with advanced liver disease?
Advanced liver disease is catabolic leading to sarcopenia, causing:
• Physical activity to be lower than in control groups
• Poor caloric intake typical in group and contributes to sarcopenia
47
True or False
There is a significant decrease in exercise capacity & muscle strength regardless of cirrhosis
etiology
True, There is a significant decrease in exercise capacity & muscle strength regardless of cirrhosis etiology
48
What are the predictors of mortality in cirrhosis?
High 6MWT, low maximal inspiratory pressure, & low VO2max
49
What were the effects of exercise training in patients with cirrhosis?
Exercise training well tolerated in cirrhosis pts. & results in improvements in exercise capacity & muscle mass. Although adherence is an issue, studies have shown 8 weeks of home exercise training effective
in improving peak aerobic power, submax aerobic endurance, & thigh muscle mass
50
Why is there a significant risk of falls in cirrhosis patients?
Due to minimal hepatic encephalopathy, loss of muscle strength, psychoactive drugs,
autonomic dysfunction, hyponatremia, sleep difficulties
51
___ is a common complication of cirrhosis
*Frailty* is a common complication of cirrhosis
52
What are the effects of transplants in cases of cirrhosis?
• Significant & independent assoc. between pre-transplant exercise capacity &
post-transplant survival
• Measuring & improving exercise capacity & muscle strength of patients w/cirrhosis awaiting liver transplant could improve outcomes
53
____ management is KEY component in cirrhosis due to increases shown in
skeletal muscle volume & strength and exercise capacity!
**Exercise** management is KEY component in cirrhosis due to increases shown in
skeletal muscle volume & strength and exercise capacity!
54
What are the general criterias for an organ transplant?
* Presence of end-stage disease in a transplantable organ
* Failure of conventional therapy to treat the condition successfully
* Absence of untreatable malignancy or irreversible infection
* Absence of disease that would attack the transplanted organ or tissue
55
What are the additional criterias for a liver transplant?
* Demonstrate emotional and psychological stability
* Have an adequate support system
* Be willing to comply w/life-long immunosuppressive drug therapy
* Undergo extensive laboratory and diagnostic studies during evaluation process
Specific other criteria may include age limits, absence of drug/alcohol abuse
56
What are the indications for a liver transplant?
```
• End-stage hepatic disease
• Primary biliary cirrhosis
• Chronic hepatitis B or C
• Fulminant hepatic failure (FHF)
resulting from an acute viral, toxic, anesthetic-induced, or medication induced liver injury
• Congenital biliary abnormalities
• Sclerosing cholangitis
• Confined hepatic malignancy
(hepatocellular carcinoma)
• Hereditary metabolic diseases (such as familial amyloid polyneuropathy)
• Wilson’s disease
• Budd-Chiari syndrome
```
57
What are the contraindications for a liver transplant?
Diseases that will impair the ability of the patient to withstand an excessive surgery, will contribute to a significantly lower functional level, or will impair the patient's ability to recover well from the transplant such as:
• Advanced cardiac disease
• Myocardial infarction within the previous 6 months
• Severe COPD
• Active alcohol use/other substance abuse (required time to be substancefree determined by transplant center, but is usually > 6 months)
58
What are the different types of liver transplant?
* Orthotopic cadaveric
* Cadaveric split liver
* Living adult donor
59
What happens with the orthotopic cadaveric liver transplant?
They remove the diseased liver, and replace it with a full cadaveric liver in the normal anatomic placement
60
What happens with the cadaveric split liver transplant?
A cadaveric liver is split into 2 functional alographs, the smaller left lobe will be donated to a child, and the larger R lobe will be donated to an adult
61
What happens with the living adult donor transplant?
A single lobe of a living donor is given to a recipient, so they can both be regenerated
62
There is a scarcity for livers, so there is a liver allocation for managing this. What are the characteristics of the liver allocation?
* Criteria set by United Network for Organ Sharing
* Model for End Stage Liver Disease (MELD) scoring system ranks candidates based on 90 day predicted mortality
* Donor must be of right blood type and similar body weight
* Often long waiting periods
* A willing living donor helps avoid this wait
63
What are some pre-liver transplantation issues that our patients may present with?
* Often deconditioned & malnourished
* Weakness & sarcopenia
* Anasarca and/or ascites add weight gain and may produce balance impairments
* Physical therapy very beneficial and necessary during this time
64
What is the typical LOS of a patient in the hospital post liver transplant?
Typical LOS ranges 1-3 weeks, part of stay in ICU
65
Post liver transplant, a patient will be placed on rejection pills. What does this include?
* Cyclosporine A
* Tacrolimis
* Prednisone to decrease the inflammatory response, give in IV initially, then moved to a pill form
Followed with any liquid except grape fruit juice
66
When does acute rejection of the liver occur?
W/in the first 1-2 months post-transplant (approx. 25% have
| at least one episode)
67
When does delayed/chronic rejection of the liver occur?
Years post surgery (approx. 2-5% of patients)
68
What is the survival rate of patients post liver transplant?
One-year survival 88%; 5-year survival 75%
69
What are the side effects of prednisone?
- Increased susceptibility to infections
- Osteoporosis
- Muscle weakness
- Salt and water retention
- Potassium loss
- Stretch marks
- Nausea
- Vomitting
- Gastric ulcers
- Increased cholesterol and triglyceride levels
- More hunger
- Blurred vision
- Rounded face
- Inability to sleep
- Mood swings
- Enlarged abdomen
- Hand tremors
70
What is chronic kidney
| disease (CKD)?
Altered renal function or structure for 3 or more
| months
71
What are the primary causes of chronic kidney disease (CKD)?
• Diabetes
• Hypertension
• Glomerulonephritis
• Risk also increases with excessive OTC drug use such as
acetaminophen , aspirin, combo analgesics
72
What is stage 5 of chronic kidney disease (CKD)?
End stage renal
| disease/failure (ESRD/F). This has a high mortality rate
73
___ is the functional unit of the kidney
The **nephron** is the functional unit of the kidney
74
What does the nephron consist of?
- Glomeruli
- Renal tubules
- Collecting duct
75
What is the pathophysiology of chronic kidney disease (CKD)?
• Secondary to disease processes such as DM, HTN, and glomerulonephritis, angiotensin II is released and causes vasoconstriction of arterioles and arteries to the glomerulus to keep pressure for filtration intact
• Thus attracting inflammatory cells which release cytokines
and growth factors that change the structure of the
glomerulus and eventually results in fibrosis and sclerosis
• The glomerular filtration rate (GFR) is reduced
76
What are the characteristics of stage 1 CKD?
Kidney damage normal GFR of >/ 90 mL/min
| • Asymptomatic typically, causes a problem of catching it
77
What are the characteristics of stage 2 CKD?
Mild decrease in GFR to 60-89 mL/min
• May see small amounts of albumin in urine
• HTN and anemia
78
What are the characteristics of stage 3 CKD?
Moderately decreased GFR 30-59 mL/min
| • Increased albumin in urine, decreased in blood (noticeable edema); increase in BUN and creatinine (azotemia)
79
What are the characteristics of stage 4 CKD?
Severely decreased GFR 15-29 mL/min
| • Proteinuria
80
What are the characteristics of stage 5 CKD?
ESRD, GFR < 15 mL/min
81
What are the clinical manifestations of CKD?
* Anemia due to reduced erythropoietin by the kidney, hence less RBCs, which leads to fatigue.
* CVD disease such as: left ventricular hypertrophy to CHF, CAD. symptoms include chest pain, nausea, SOB, sweating
82
___ is the #1 cause of mortality in ERSD
*CVD disease* is the #1 cause of mortality in ERSD
83
What are the GI issues seen with CKD?
* Nausea, vomiting, anorexia
| * Malnutrition, fatigue, weakness, and malaise
84
What are the MSK issues seen with CKD?
Abnormal calcium, phosphate, Vit D metabolism
• Renal osteodystrophy(a drop in the serum calcium levels) leading to bone pain, fractures
• Calcification of soft tissues and vessels, which results in tendon rupture, CAD
85
What are the neurologic issues seen with CKD?
```
Sleep disturbances(going to sleep and staying asleep), uremic encephalopathy (GFR < 10 mL/min)
• Memory loss, confusion, perceptual errors, decreased alertness
```
86
What are the medicines that are part of the medical management for CKD?
* HTN meds
| * Erythropoietin (EPO)
87
What are the characteristics of the renal replacement therapy that is used to treat stage 4 CKD or ESRD?
* Hemodialysis (HD) - most common
* Peritoneal Dialysis (PD), including: Continuous Ambulatory Peritoneal Dialysis (CPAD) and Continuous Cycling Peritoneal Dialysis (CCPD) **can be done w/out a machine**
88
What are the PT implications for treating patient with CKD?
Fatigue, fatigue, fatigue!
• Schedule flexibility
• Trial and error
• Variable exercise tolerance
• Monitor vitals and labs(albumin levels, BUN and creatinine level and blood cells count)
• Possible fluid restrictions
• Maintain integrity of arterio-venous fistula or graft (aka shunt), usually located in UE or LE. No BP over shunt
• Slower progression
• Don’t forget what led to this (HTN, DM,) and where it is typically headed (cardiovascular disease)
89
What are the exercise parameters for patients with CKD?
* During first 2 hours of HD, no mobility, but we can still perform exercise
* Cycle ergometer, LE weight exercises (use RPE)
* Blood chemistries at optimal levels after dialysis…but fatigue
90
What are the common causes of heart transplants?
* Cardiomyopathy (Dilated, Hypertrophic, Restrictive)
* Coronary Artery Disease
* Congenital Heart Disease
* Valvular Heart Disease
* Cancer
91
What are the common causes of lung transplants?
* Congenital (Eisenmenger’s Syndrome)
* Emphysema/COPD
* Cystic Fibrosis
* Pulmonary Fibrosis
* Pulmonary Hypertension
* Other (Sarcoidosis, Burns/Trauma, Rheumatoid Arthritis)
92
What are the common causes of liver transplants?
* Non-cholestatic Cirrhosis (alcoholic and non-alcoholic)
* Cholestatic liver disease/Cirrhosis (Crohn’s)
* Acute hepatic necrosis (Hepatitis C and B)
* Metabolic Disease (Wilson’s dx, A-1-A deficiency)
* Malignant Neoplasms
* Other (Cystic Fibrosis)
93
What are the common causes of kidney transplants?
* Glomerular disease (Sickle Cell, Lupus)
* Diabetes
* Hypertensive
* Renovascular and other vascular
* Congenital
* Tubular and Interstitial disease (Sarcoidosis)
* Neoplasms
* Transplant Drugs (cyclosporin)
94
What are the general concerns that we may have for a patient prior to an organ transplant?
* Muscle Weakness
* Fatigue
* Prolonged hospitalization
* Poor ambulatory skills
* Poor breathing mechanics
* Inability to adequately clear pulmonary secretions
* Extended confinement to bed, room, or house
95
What are the general concerns that we may have for a patient post an organ transplant?
* Weakness
* Fatigue
* Poor ambulatory skills
* Poor breathing mechanics
* Inability to adequately clear pulmonary secretions
* Extended confinement to bed, room, or house
96
HF is one of the causes of hospitalization prior to an organ transplant. What are the types of HF that is included in this?
* Ischemic Heart Failure
| * Non-Ischemic Failure
97
What are the presentations of HF that will warrant hospitalization prior to an organ transplant?
* Shortness of Breath (SOB)
* Fluid Overload
* Weight Gain
* Fatigue
98
What are the conditions that can cause lung failure and requires hospitalization prior to an organ transplant?
* Pneumonia
* Infection
* COPD Exacerbation
* Cystic Fibrosis Exacerbation
* Idiopathic Fibrosis
99
What are the presentations of lung failure that will warrant hospitalization prior to an organ transplant?
Severe SOB
100
What are the conditions that can cause liver failure and requires hospitalization prior to an organ transplant?
* Hepatic Encephalopathy
* Ascites
* Spontaneous Bacterial Peritonitis
* BI Bleeding
* Renal decompensation
* Obstructive Jaundice
* Falls due to progressive weakness/ muscle atrophy
101
What are the presentations of liver failure that will warrant hospitalization prior to an organ transplant?
* Jaundice
* Confusion
* Coma
* Nausea/Vomiting
* Edema
* Abdominal Pain or Distention
* Muscle Wasting
* Fatigue
* Insomnia
* Anemia
* Peripheral Neuropathy
102
What are the conditions that can cause kidney failure and requires hospitalization prior to an organ transplant?
* Dehydration
* Elevated Creatinine
* Malfunction of HD Venous Access
* Cardiovascular Complications
* Electrolyte Imbalances
* Diabetic Complications
103
What are the presentations of kidney failure that will warrant hospitalization prior to an organ transplant?
```
Nausea/Vomiting
• Fatigue
• Confusion
• Progressive Weakness
• Falls
• Malnutrition
• Neuropathy/Retinopathy
```
104
What are the PT implications in patients pre-transplant?
* SOB
* Weakness
* Fatigue
* Pain
* Edema
* Fall Risk (Balance/ Strength)
* Decreased Mobility
105
What are the components of the acute evaluation of a patient pre- transplant?
* Social Situations
* Vital Signs
* Strength
* ROM
* Aerobic Capacity
* Functional Mobility (FMS)
* Balance
* HEP Compliance
* Discharge Recommendations
106
What are the goals of the acute evaluation of a patient pre- transplant?
* Optimize aerobic capacity
* Maximize musculoskeletal strength
* Maximize functional endurance
* Exercise education for carryover in post-op stage
* Education on post-op activity expectations
* Setting recommendations for how patients may meet goals
107
What are the treatment interventions of patients in the pre- transplant stage?
* Musculoskeletal Strengthening
* Bed Mobility and Transfer Training
* Balance Skills and Core Strengthening
* Gait Training
* Endurance Training and Energy Conservation
* Edema Control
* Postural Training
* Pulmonary Enhancement/ Breath Control
* Education
108
What are the barriers to the acute PT progression of a patient prior to an organ transplant?
* Acuity of illness, including medical status or cognitive status
* ICU ventilation and sedation
* Line placement
* Lab values and vital signs outside of treatable ranges, including instability of vital signs or abnormal responses to exercise
* Inpatient testing and procedures
* Patient compliance
109
What are the changes in the cardiovascular status of a patient that just underwent a heart transplant that we need to keep in mind?
* Changes in resting HR, Blood Pressure
* HR and Peak HR with exercise/activity
* Cardiovascular Response
* Stroke volume (could be lower)
* Left Ventricular Ejection Fraction
110
What are the changes in the pulmonary status of a patient that just underwent a heart transplant that we need to keep in mind?
* VO2 Max
* Ventilatory Threshold
* Anaerobic Threshold
111
What are the changes in the pulmonary status of a patient that just underwent a lung transplant that we need to keep in mind?
* VO2 Max
* Ventilatory threshold
* Anaerobic threshold
* Respiratory Rate
* Minute Ventilation
112
What are the changes to look out for in a patient that just underwent a liver transplant that we need to keep in mind?
* Delayed Cognitive Recovery
* Malnutrition
* Delayed liver function
113
What are the changes to look out for in a patient that just underwent a kidney transplant that we need to keep in mind?
* Diabetes mellitus
* Infections: upper respiratory infection, UTI
* Anemia
* Cardiovascular Disease
114
What are the signs of a heart transplant rejection?
* Low Grade Fever
* Fatigue
* Decreased exercise tolerance • Ventricular dysrhythmias
* Increased resting BP
* Hypotension with exercise
115
What are the signs of a lung transplant rejection?
* GERD
* Low grade fever
* Leukocytosis
* Decreased arterial oxygen saturation
* Decreased exercise tolerance
116
What are the signs of a liver transplant rejection?
* Fatigue
* Fever
* Abdominal pain or tenderness
* Dark yellow/orange urine
* Claycolored stools
* Decreased exercise tolerance
117
What are the signs of a kidney transplant rejection?
* Fever
* Flu-like symptoms
* Tenderness around the kidney
* Fluid retention
* Weight gain (>2-4 pounds in 24 hours)
* Decreased urine output
118
What are the components of the post transplant acute evaluation?
* Vitals
* Strength
* ROM
* Skin/wound assessment
* Posture assessment
* Pulmonary assessment
* Endurance/ activity tolerance
* Functional Mobility (FMS)
119
What are the goals of the acute evaluation of a patient post- transplant?
* Pulmonary Hygiene and Chest wall mobility
* Improve Strength and ROM
* Increase exercise tolerance
120
What are the PT considerations for a patient post heart transplant?
• Sternal Precautions
- No pushing/pulling >10 pounds
- No reaching over 90 degrees
• Denervation of the Heart
- Educate on importance of warm-up/ cool-down
- Use RPE scale to monitor intensity
• Closely monitor vitals before, during, and after exercise
121
What are the PT considerations for a patient post lung transplant?
* CO2 Retention
* Pulmonary hypertension precautions
* Incisional precautions
* Breathing retraining
* Airway Clearance
* Postural Considerations
122
What are the PT considerations for a patient post liver transplant?
* Pulmonary Involvement
* Central nervous system complications
* Abdominal scar can contribute to poor posture
* Poor balance, coordination, endurance
* Energy conservation education
123
What are the PT considerations for a patient post kidney transplant?
* Effects of exercise on blood glucose control
* Increased incidence of cardiovascular disorders, HTN, cancer, osteoporosis
* Close monitoring of vital signs, particularly BP
* Prior to and during exercise
* Resistive exercises and osteoporosis precautions
* Increased incidence of tendon injuries (Achilles, Patellar)
124
What are the things to be addressed in patients post a transplant?
* Functional Impairments
* Postural Changes
* Skeletal Muscle Impairment
* Decreased Endurance
* Decreased ADL Ability
* Decreased Balance
* Anxiety/ Depression
125
What are the OMs used to measure strength in a patient post transplant?
Strength
| • Hand Dynamometry
126
What are OMs used to measure endurance in a patient post transplant?
Endurance Tests
| • Six Minute Walk Test, Gait Speed, 2 Minute Walk Test
127
What are OMs used for functional tests in a patient post transplant?
Functional Tests
| • Grocery Shelving Test, Chair Rise Test
128
What are OMs used to measure balance in a patient post transplant?
Balance Assessments
| • Forward Reach, BERG Balance, Tinetti, Rhomberg, TUG
129
What are OMs used to measure depression/anxiety in a patient post transplant?
Depression/Anxiety Assessments
| • Beck Depression Inventory, Mood/Depression Questionnaire, CESD Scale, HADS
130
What happens to the endocrine system after an injury or major stress?
Hypothalamic corticotropin-releasing hormone at the hypothalamus (CRH) ->
Releases adrenocorticotropic hormone (ACTH) @ the anterior pituitary -> stimulates adrenal glands for cortisol secretion ->
a rise in serum cortisol ->
inhibits ACTH ->
decreasing CRH secretion
131
What are the effects of chronic stress on the body?
* Stress is linked with elevated cortisol levels
* Cortisol is a key factor in glucose metabolism
* High stress can interfere with the body’s ability to make insulin and process glucose
* Stress can also interrupt sleep, and sleep disturbances may be linked with an increased risk of developing insulin resistance.
132
What are the response of the body to chronic stress?
```
• Prolonged stimulation of the sympathetic nervous
system
• Hypothalamic arousal
• Poorly regulated cortisol secretion,
• Insulin resistance,
• Elevated blood pressure,
• Visceral accumulation of body fat (central obesity)
• Proinflammatory
```
133
What are the effects of chronic stress on the brain?
* Short term memory loss
* Sleep disturbance
* Decreased focus & concentration
* Low libido
* Altered plasticity
* Appetite Changes Etc.
134
What are the effects of chronic stress on the tissues?
* Increased sensitivity
* Decreased inflammation
* Decreased blood flow
* Immune deficiency
* Potential failure
* Fatigue Etc.
135
When secreted by the adrenal gland, what parts of the body does cortisol have an effects on?
* Brain
* Tissues
* Immune system(fibromyalgia).
Once affected, they do not go back to their regular function. The system that is affected the most affected
136
An implication of chronic stress response is the development of the metabolic syndrome. What are the characteristics of this syndrome?
* Abdominal obesity
* Atherogenic dyslipidemia
* Elevated blood pressure
* Insulin resistance
* Prothrombotic and proinflammatory state of the blood
137
How do we screen for a metabolic syndrome?
* Blood Pressure
* Glucose testing
* Height and weight
* Waist circumference (most imp)
* Waist to height ratio is a good predictor for the development of DM and cardiovascular disease
138
What are the screen that are a stronger than BMI as a predictor of the development of CVD in
Waist height circumference and waist to height ratio
139
An implication for managing patients with chronic stress comes from understanding what?
The sleep- wake cycle. Cortisol levels quickly rise upon wakening, with the peak at about 30mins after. It then reduces throughout the day, until bedtime. Unless they have a problem with these levels, in which case it either never rises enough(tired all day) or it builds throughout the day and drops at night (increasing stress and anxiety throughout the day)
140
What are the implications for exercise prescription for low cortisol awakening response?
- Encouraging a high energy, and nutritious snack, followed by physical activity early in the day to boost cortisol and other hormones to improve function
141
What are the implications for exercise prescription for high cortisol awakening response?
Encourage frequent use of stress management strategies throughout the day
142
What are the treatment concepts for patients with chronic stress?
* Address broader system wide functions, not fixing mechanical deficits
* Address underlying threats to the system
* Pain neuroscience education (PNE)
* Movement
* Sleep hygiene
* Relaxation, breathing
* Diet recommendations
