Download Heart Transplants

Chapter 47:
Organ and Hematopoietic Stem
Cell Transplantation
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Indications for Transplantation
• Primary reason is end-stage disease
• Hematopoietic stem cell transplantation (HSCT)
– Used when bone marrow is defective/destroyed
• Suitability for transplantation
– Age
– Treated or absent acute/chronic infection
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Organs That Can Be Transplanted
• Kidney
• Heart
• Liver
• Lung
• Pancreas
• HCST
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Question
The two primary determinants of successful transplantation
are infection screening and liver function.
A. True
B. False
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. False
Rationale: Although liver function and absence of infection
are determined before transplantation, the patient’s ABO
type (blood type) and the HLA compatibility are the most
important determinants of success or failure in the
grafted host.
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Patient Evaluation for All Transplants
Patient evaluation is used to obtain baseline data and also follow-up
data to monitor for rejection. ABO and HLA typing most important.
• ABO Typing
–
Primary determinant for solid organ transplantation
–
Same compatibilities as blood products
• Tissue matching (histocompatibility)
–
HLA antigen system
• Antigens present on nucleated cells
• Six antigen match has greatest chance of successful
transplantation
• Both solid and HSCT
• Postop antirejection meds will prevent self, non-self reactions
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Patient Evaluation for All Transplants
(cont.)
• Infection screening
– Absence of chronic/acute disease
• Liver function studies
• Renal function studies
• Complete blood count (to rule out infection and baseline)
• Coagulation studies (baseline bleeding studies)
• GI evaluation (to rule out bleeding)
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Patient Evaluation for All Transplants
(cont.)
• GYN evaluation
• ECG
• Chest radiograph (CXR)
• Dental exam
• Social
– Psychiatric evaluation
• Motivation
– Ability to keep up with postop regimen
– Monetary means
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Donor Selection
• Types of donors
– Living (kidney, liver, pancreas, and lung)
• Exclusively for HSCT
• Severe shortage of donors
• Cadaveric donors
– Organ Procurement Organization (OPO)
– National Organ Transport Act
– United Network for Organ Sharing (UNOS)
– Severe shortage of donors
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Role of the Critical Care Nurse in
Cadaveric Transplantation
• All organ donors die in critical care units
–
Nurse is patient and family advocate
• Supportive care of the donor
–
Maintenance of hemodynamic stability
• Prevention of hypotension (nitroprusside/esmolol;
dopamine/dobutamine)
• Crystalloid and/or colloid replacement
• MAP > 60 to 80 with systolic BP > 100 mm Hg
–
Ventilatory support
• Suctioning
• Watch for and prevention of pulmonary edema
–
Urinary output > 30 cc/hr
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Organ Preservation Times
• Kidneys
• 24 to 36 hrs cold storage; 48
hrs if pulsatile perfusion
• 12 hrs
• Pancreas
• Heart and lungs
• 4 to 6 hrs
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Assessment/Management of Solid Organ
Transplantation
• Preop phase
– Monitoring lab values and diagnostic studies
• Surgical procedure
– How the surgery is done
• Postoperative phase
– Recovery
– Complications to watch for
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Kidney Transplant
• Placed in the iliac fossa retroperitoneally
• Ureteral anastomoses
– Donor ureter is implanted into recipient’s bladder
– Donor kidney is anastomosed to ureteropelvic
junction to the recipient’s ureter
• Indwelling catheter and possible ureteral stent
• Hematuria is present for several days postop
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Liver Transplant
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Heart Transplants: Orthotopic Transplant
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Heart Transplants: Heterotopic
Transplantation
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Pancreas and Lung Transplants
• Pancreas Transplant
– Can be combined with
kidney transplant
– Right iliac area,
heterotopic position
– Exocrine glands may
drain to bowel or
bladder
• Lung Transplant
–
Single or double
–
Anastomoses
• Mainstem bronchus
• Pulmonary artery
• Cuff of atrium
(pulmonary veins)
• Omentopexy (omental
flap wrapped around
trachea)
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Postoperative Phase
• KIDNEY: Assessment of renal
graft functioning
–
BUN
–
Creatinine
–
• LIVER: Hemodynamic.
Oxygenation and electrolyte
functioning.
–
Monitoring of adequate
oxygenation
Potassium (high K+)
–
Coagulation studies
–
Renal scans
–
Hyperglycemia
–
Assessment and treatment
of urinary drainage
–
Hyperkalemia
–
Urinary leakage
–
Metabolic acidosis
–
Calcium, phosphorus, and
magnesium are usually due
to fluids/blood
administration
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Question
After teaching a patient who has just received an
orthotopic heart transplant, the nurse knows that the
teaching was effective when the patient states:
A. “I will have to take my digoxin religiously.”
B. “I will have to get out of bed slowly.”
C. “I will have to take a stool softener every day.”
D. “My resting heart rate will be just above 60.”
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. “I will have to get out of bed slowly.”
Rationale: Orthostatic hypotension commonly occurs in
this setting, so the patient needs to be taught to get
out of bed slowly to adjust for changes in BP. The
patient won’t respond to digoxin as readily as
before. The transplanted heart doesn’t respond to
vagal stimulation, so a stool softener isn’t necessary
unless the patient is constipated. The resting heart
rate will be around 90 to 110, faster than normal.
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Postoperative Phase: Heart Transplant
Nursing Care
• Similar to other cardiac surgeries
• Most common is orthotopic transplant
• Changes in cardiac rhythm and function due to denervation of donor
heart
–
Remnant P waves (two P waves; donor and recipient)
–
Donor P wave stimulates the QRS
–
Resting sinus rate is higher than normal (90 to 110 bpm)
–
Increases in HR and CO occur much more slowly than normal
–
Prolonged warm-up and cool-down for exercise needed
–
Observe for and teach about orthostatic hypotension
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Postoperative Phase: Heart Transplant
Nursing Care (cont.)
• Potential for ventricular failure
– Right ventricular failure is the most common cause of graft
failure
– Not totally understood, but it has to do with pulmonary
hypertension
– The new heart must work against high pulmonic pressures
and may not be able to adjust to this.
– Resultant left ventricular output fails as the right side is
unable to pump effectively to the left side.
– Drugs may help with this (dobutamine, milrinone, inhaled
nitric oxide).
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Postoperative Phase: Pancreas and Lung
Transplant Nursing Care
• PANCREAS
–
–
–
–
• LUNG
Similar to abdominal
surgery
Insulin drips required to
regulate blood sugar levels
Prevention of infection,
especially if exocrine
drainage is diverted to
duodenum
–
Intubation for 24 to 36 hrs
–
No cough reflex due to
denervation of new lung
–
Frequent bronchoscopy
–
Observation for pulmonary
edema
–
Usually kept a bit
dehydrated
–
Antibiotics
Nasogastric tube
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Assessment/Management in HSCT
• Stem cells are most prevalent in the bone marrow
– Once collected, stem cells are capable of reverting to
white cells, red cells, or platelets.
• Some in the circulating blood
• Harvested by either bone marrow harvest or apheresis
– Apheresis is less costly and easier.
– More rapid recovery of neutrophil and platelet counts
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Stem Cell Collection
• BONE MARROW HARVESTING
–
Operating room
–
1 to 2 L from posterior iliac
crest aspiration
–
Takes 1 to 2 hours
–
Taken directly to recipient‘s
room
–
Pressure dressing on site and
24-hour observation of donor
• PERIPHERAL BLOOD
–
Granulocyte colony-stimulating
factor (G-CSF) or granulocytemacrophage colony
stimulating factor (GM-CSF)
given SC (priming)
–
Collection begins 4 to 5 days
later
–
Leukapheresis for 3 to 4 h
–
Immediately cryopreserved
–
Donor observed for
hypocalcemia (citrate infusion)
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Question
A patient has had a hematopoietic stem cell transplant
from his twin. This type of transplant is know as:
A. Autologous transplant
B. Allogeneic transplant
C. Cord blood transplant
D. Syngeneic transplant
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Answer
D. Syngeneic transplant
Rationale: An autologous transplant is one from self tissue.
An allogeneic transplant is from another unrelated
person. A cord blood transplant is from either related or
unrelated umbilical cord stem cells. A syngeneic
transplant, one from an identical twin, has the least
chance of rejection.
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Types of HSCT
• Autologous – self
• Syngeneic – from an identical twin
• Cord blood
– Related
– Unrelated
• Allogeneic – non-self
– Related
– Unrelated
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Recipient Conditioning Regimen
• Autologous transplantation – conditioning is not required
• Allogeneic transplantation conditioning is done to:
– Eradicate any existing malignancy
– Create a new space for donor stem cells
– Allow engraftment and decrease rejection
• High-dose chemotherapy – purpose is to kill more tumor cells,
resulting in better response to transplantation
– Done over 2 to 8 days, with a 1- to 2-day rest before
transplantation
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Transplantation
• AUTOLOGOUS/ALLOGENIC
–
–
Preservative is
dimethylsulfoxide (DMSO)
Premedicated with
acetaminophen,
hydrocortisone, and
diphenhydramine
• COMPLICATIONS
–
Pulmonary edema
–
Hemolysis
–
Infection
–
Anaphylaxis
–
Prehydrated
–
–
Thawed at bedside in warm
NSS
Garlicky odor/taste from
DMSO
–
Monitor for embolism
–
Cells infused into central
line (not unlike
transfusion)
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Engraftment
• Stem cells travel to the bone marrow
• New hematopoietic cells are produced
–
Peripherally obtained cells are produced within 11 to 16 days
–
Bone marrow cells are produce within 2 to 3 weeks
–
Cord blood as long as 26 to 42 days
• Hospitalized during the phase of severe pancytopenia and
immunosuppression
–
Observation for infection and bleeding
• Patients discharged earlier
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Question
To prevent graft-versus-host disease (GVHD), all blood
products given to a patient after a stem cell transplant
must be filtered to remove white blood cells.
A. True
B. False
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Answer
A. True
Rationale: Patients need to be protected against disease
and GVHD after a stem cell transplant. All blood products
need to be either irradiated or filtered to remove WBCs.
Most institutions suggest this method of transfusion
should continue for the rest of the patient’s life.
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Immunosuppressive Therapy
• Needed to prevent the self versus non-self recognition and
therefore rejection
• Several drugs needed with solid organ transplants or
triple/three drug therapy
– Prednisone, azathioprine or mycophenolate mofetil, and
cyclosporine A or tacrolimus
– Quadruple therapy includes the above plus antithymocyte
antibody preparations or monoclonal antibody,
monomurab CD3
• The dose of each drug is lower in combination, therefore
creating fewer side effects.
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Complications of Transplantation
• Risk is highest in the first 3 months.
• The earlier and more severe the complication, the worse the
prognosis of the graft.
• Organ rejection (types)
– Hyperacute rejection – in the OR during transplantation
– Accelerated rejection – within 1 week after procedure
– Acute rejection – first 3 months
– Chronic rejection – 3 months to years
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Nursing Assessments to Monitor for
Rejection
• SIGNS/SYMPTOMS
– Temperature >100F
– Tenderness over graft
site
– Decreased urinary
output
– Edema
• LAB VALUES
– Increased BUN,
creatinine
– Decreased creatinine
clearance, urine sodium,
and urine creatinine
– Decreased blood flow on
renal scan
– Weight gain
– Increased BP
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Nursing Care to Prevent Infection
• Most common transplant
complication
• Observe for small increases
in temperature
• Opportunistic organisms
common
• Proper handwashing
• Multiple invasive lines
• Good oral and skin hygiene
practices
• Broad-spectrum antibiotics
• Isolation
• Filter blood products for CMV
after the first month
• Nutrition with low-microbial
diets
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Other Complications
• Bleeding
– Pericarditis/cardiac tamponade
• GI complications
– Peptic ulcers/erosive gastritis from stress/steroids
– Histamine blockers or proton pump inhibitors
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HSCT Complications
• Graft failure
• Veno-occlusive disease of the liver
• Pulmonary complications
• GVHD (acute or chronic)
– Immunosuppressive medications
– Steroids
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