Download Rejection - University of Michigan–Flint

Rejection
Normal response
Inflammation
25% of pt. will have acute rejection
during the first year post transplant
Causes:
Previous Rejection
 Noncompliance
 High cholesterol

3 Kinds of Rejection
Hyper-acute: happens immediately
Acute: within 1 month of transplant
Chronic: all pts have this
Likely sources of
rejection: 0-1 Month
IV line infection
 Urinary tract infection
 Wound infection
 Pneumonia
 Human herpes simplex virus

Outcomes – Heart
Transplant
Hospital LOS

Typical 15
Long Term Survival
3mo: 93%
 1yr: 88%
 5yr: 76%
 10yr: 54%, can go 20+ years

Outcomes – Lung
Transplant
Hospital LOS

1-3 weeks
Long Term Survival
3mo: 91%
 1yr: 80%
 5yr: 51%
 10yr: 21%

Morbidity and Mortality
Most common causes of death in
patient’s with transplant are infection
and rejection
Most common complications for these
patient’s are CVA, kidney failure,
development of DM, muscle atrophy
Physical Therapy Goals
Airway Clearance
Patient Function
Patient Education
Strengthening HEP
Aerobic Training HEP
Pacing, self-monitoring, targeting
exercise, progression of HEP
Discharge Plans
Mechanical Assist
Devices
Cardiac
Ventricular Assist Device
 Total Artificial Heart

Respiratory

Venous-Venous Extracorporeal membrane
oxygenation (ECMO)
Cardiac and Respiratory

Venous-Arterial Extracorporeal membrane
oxygenation (ECMO)
Ventricular
Assist
Devices
•
What is it?
•
Purpose
•
Placement: L side
•
Attachments
•
Equipment: pump
implanted in body,
runs a long cord to
keep infection away.
Ventricular Assist
Devices
LVAD:
RVAD: temporarily
BiVAD: not good success
Total Artificial Heart: bilateral heart failure
Purpose
Temporary: usually because of
complications or younger patients.
Long Term
Bridge to Transplant
 Bridge to Explant: wean off VAD
 Destination

Ventricular Assist
Devices – History
Technological
Advances
Ventricular Assist
Devices – Types
Types


Pneumatic
Axial Flow: screw that spins fastly
Heartmate 2
• Continuous Flow
• Significantly decreased
pulse pressure
• Anticoagulation
• Hemolysis
• “Vitals”
• Flow: set rate
• Speed
• Power
• Pulsatility Index
Ventricular Assist
Devices – Types
Types



Pneumatic
Axial Flow
Centrifugal Flow
HeartWare
Jarvik 2000
Total Artificial Heart
Purpose: bilateral
heart failure
Differences: remove
values
Surgical Procedure:
sternotomy
ICU vs. Home
Equipment
Total
Artificial
Heart
Ventricular Assist
Devices
Operative Procedure

Median Sternotomy
Benefits: able to be on wait list longer
Risks: infection, clotting, bleeding,
cognitive changes.
Lifestyle changes:
24 hour supervision: trained with VAD
emergency.
Stay away from water
Restriction on recreation and exercise
Restriction for static electricity
Necessary equipment: back-up power in
<5min.
Temporary / External
VADS
Purpose
Types

AbioMed
Blood Pump 5000
 Ventricles


CentriMag
Stay in ICU
Functional Limitations
AbioMed Ventricle
CentriMag
Patient Video:
CentriMag and
Heartmate II
Veno-Venous
Extracorporeal Membrane
Oxygenation (ECMO)
Arterial vs.
Venous ECMO
Purpose: used if there is
heart and lung failure.
Venous ECMO: Lines in
jugular that take deO2
blood out, oxygenate it
and then pumps it back
in.
Helps to improve
condition for surgery
Patient Video: VVECMO
Implications For PT
Physiology of LVAD
Preload and afterload dependent
 BP (with axial or centrifugal flow)
 appropriate target for exercise intensity
 Arrhythmias
 AICD
 Lab Values-HgB/Antibodies

Equipment
Emergency Procedures
Post-Operative Course
Post Transplant Or VAD
ICU Course
Multiple chest tubes, IV lines, A-line, swanganz, catheter, pulse ox, SCDs, telemetry
 Delayed sternal closure
 Intubated/Sedated
 PT POD #1
 Focus on Early Mobility: winkleman “bed rest
in hell and critical illness, a body systems
approach”

Early Post-Op Course
Day 1 common problem list
 Impaired airway clearance
 Decreased chest wall mobility
 Decreased functional mobility
 Decreased ROM and strength
 Limited knowledge of post-surgical
precautions
Other considerations
 Pressure relief / skin care
 Edema management
Early Post-Op Course
Day 1 common treatment activities
 Airway clearance
 Breathing exercises
 Chest wall mobility
 Positioning for postural drainage and
edema management
 Shoulder exercises
 Bed mobility
 Transfer to chair
 Initiate patient/family education
 Discharge planning
Early Post-Op Course
Day 2-3
Continues in ICU usually PA catheter and
A-line are taken out
 Continue with day 1 treatment activities
adjust and progress as necessary
 Progress ambulation

Early Post-Op Course
Day 4-14:

Moves out of ICU

Teach independent airway clearance

Progress mobility/activity

Begin stair climbing

Nu-Step or treadmill training

Aerobic home exercise program

Strengthening home exercise program

Functional Outcome Measures

Complete patient/family education
For patients s/p transplant
or LVAD: Issues Regarding
Discharge Home
Significant medication regime and side
effects
Frequent lab, procedure and MD
appointments
Changes in physical appearance/return to
intimacy
Depression and mood disorders
Stress on finances and social support system
Outpatient Treatment
Options
Outpatient Cardiac Rehabilitation

VADs not covered
Outpatient Pulmonary Rehabilitation
Outpatient PT (for VADs - comfort level of
therapists?)
Subacute rehab, acute rehab, etc.