Page 341 - ACCCN's Critical Care Nursing

318 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

TABLE 12.6 Summary of nursing practice for patients after heart transplantation

Clinical manifestation Nursing practice considerations
Acute rejection ● Detect acute rejection by clinical signs and endomyocardial biopsy.
● Suspect low-grade rejection when malaise, lethargy, low-grade fever and mood changes are present.
● Acute rejection is manifested by a sinus tachycardia >120 beats/min, a pericardial friction rub, or
new-onset atrial dysrhythmias.
● Suspect severe acute rejection with manifestations of left and right heart failure; awake patients may
complain of severe fatigue, sudden onset of dyspnoea during minimal physical effort, syncope or
orthopnoea.
Infection ● Standard infection control precautions and meticulous hand-washing is required.
● Observe for signs of infection: low-grade fever, hypotension, tachycardia, a high cardiac output/index,
a decrease in systemic vascular resistance, changes in mentation, a new cough, dyspnoea, dysuria,
sputum production, or pain.
● Monitor blood, sputum, urine, wound and catheter-tip cultures, infiltrates on chest X-ray, and institute
aggressive and prompt treatment for specific infective organisms.
● Check CMV status before administering blood products.
Haemorrhage/cardiac ● Monitor haematological status; chest tube patency, drainage volume and drainage consistency; and
tamponade trends in haemodynamic data that suggest cardiac tamponade.
● Patients who are hypotensive sporadically should be assessed to eliminate cardiac tamponade as a
cause.
Acute renal failure ● Support renal function, including titration of immunosuppressive agents to individual risk factors and
clinical status, and early haemofiltration.
Early allograft dysfunction ● Augment the immunosuppression regimen to manage the acute rejection.
Left heart failure ● Observe for depressed left ventricular compliance and contractility: reduced cardiac index, possible
bradycardia (may not be evident due to atrial pacing and/or isoprenaline), decreased mental status,
oliguria, poor peripheral perfusion, slow capillary refill and raised serum lactate, low systemic venous
oxygenation, and dyspnoea.
● Fluid resuscitate to a PAWP of 14–18 mmHg, high-dose inotropes, vasodilator agents, IABP to achieve
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a cardiac index >2.2 L/min/m with adequate end-organ perfusion.
● Insertion of full mechanical circulatory support (ECMO or LVAD) is indicated when other interventions
do not provide adequate end-organ perfusion.
Right heart failure ● Observe for right heart dysfunction/failure: rising CVP, low to normal PAWP, high calculated
pulmonary vascular resistance, raised pulmonary artery pressures, systemic hypotension, and oliguria.
● Optimise right ventricular preload and afterload: titrate fluid and medications to achieve adequate
end-organ perfusion; fluid resuscitate to a CVP of 14–20 mmHg; consider inhaled NO (selective
pulmonary vasodilation and improved oxygenation from reduced ventilation/perfusion mismatch),
prostaglandin E1 or prostacyclin, milrinone, or drug combinations with afterload reduction and
inotropic support (e.g. sodium nitroprusside and adrenaline).
● Institute appropriate respiratory management to minimise hypoxaemia and metabolic or respiratory
acidosis.
● If no sustained improvement in right ventricular performance, a right VAD is indicated for temporary
support.
Denervation ● Drugs with direct autonomic nervous system actions on heart rate (e.g. atropine, digoxin) and vagal
manoeuvres (carotid sinus massage) are ineffective.
● Use overdrive atrial pacing to treat tachyarrhythmias.
● Sinus or junctional bradycardias may occur, and atrial/ventricular epicardial pacing is used to ‘train’
the sinus node.
● Orthostatic hypotension is common: patients should sit up slowly from a lying position.
● Patients rarely feel anginal pain after surgery: they need to identify other clinical signs of angina, such
as shortness of breath and sweating.

disease and is insensitive to early lesions. Currently, disorders 147,148 as a consequence of long-term immuno-
142
intravascular ultrasound (IVUS) provides the most reli- suppression therapy. 149,150 Nurses play an important role
112
able quantitative information about the degree of CAV. in educating patients about how to avoid and reduce the
As the definitive treatment for CAV is retransplantation, risks of sun exposure. Treatment options in transplant
143
ongoing research into the prevention of CAV will be recipients are the same as for the general population (e.g.
the most important factor in reducing the incidence and chemotherapy, radiation therapy and surgical excision),
associated mortality. in addition to a reduction in immunosuppression therapy;
however, outcomes remain poor. 146
All heart transplant recipients are at a greater risk of devel-
oping malignancies than the general population, particu- Long-term renal dysfunction occurs primarily post-
larly carcinoma of the skin 144-146 and lympho-proliferative transplantation due to cyclosporin nephrotoxicity. Careful