Page 342 - ACCCN's Critical Care Nursing

Cardiac Surgery and Transplantation 319

monitoring of cyclosporin levels, and avoidance of hypo- ● Haemodynamic stability constitutes the most
volaemia and other nephrotoxic drugs are important common challenge in the postoperative period and
measures in reducing progression to renal failure. Impor- may be managed with fluids, cardiovascular medica-
tantly, findings from recent research indicate that chronic tions, cardiac pacing and intra-aortic balloon
cyclosporin nephrotoxicity can be reversed by eliminat- pumping.
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ing cyclosporin from immunosuppression regimens. ● Bleeding in the postoperative period may be due
End-stage renal failure requiring dialysis or renal trans- to inadequate reversal or heparin, coagulopathy or
plantation has been reported in 3–10% of patients. 151 surgical bleeding; therefore, appropriate diagnosis
must occur before relevant treatment is instigated.
Systemic hypertension following transplantation has
been linked with cyclosporin-induced tubular nephrotox-
icity, peripheral vasoconstriction and fluid retention. 152
Lifestyle modifications such as weight loss, low sodium INTRA-AORTIC BALLOON PUMPING
diet and exercise are recommended along with optimal ● Major benefits include increasing cardiac output,
therapeutic doses of cyclosporin, and combinations of increasing myocardial oxygen supply and decreasing
calcium channel blockers and angiotensin-converting myocardial oxygen demand.
enzyme inhibitors and blockers. Such approaches have ● Appropriate timing is essential to obtain maximum
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been reported to achieve blood pressure control in up to benefits, so correction of timing errors forms a central
65% of patients. 153 component of care.
● Assessment of limb perfusion, with timely interven-
tion when perfusion is inadequate, is essential to
LIFESTYLE ISSUES prevent limb ischaemia.
Following such momentous surgery, patients require
sound advice regarding returning to driving, work,
exercise and sexual activity. Cardiac rehabilitation with HEART TRANSPLANT
aerobic and resistance exercise is recommended to prevent ● A triple-therapy regimen consisting of corticosteroids,
short-term weight gain and glucose intolerance, as well a calcineurin antagonist and an antiproliferative
as adverse effects of immunosuppressive therapy on skel- cytotoxic agent is used to suppress the immune
etal muscle. Return to work or education is expected system after organ transplantation. All cytotoxic
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and encouraged after surgery. Driving a vehicle can be agents necessitate specific administration and dis-
considered once the patient’s gait, tremor and other posal procedures.
neurological issues are normalised, and any bradycardia ● Indications for heart transplantation include end-
managed by pacemaker implantation. Pregnancy is stage heart failure secondary to ischaemic heart disease
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possible after one year following transplantation; but and cardiomyopathy. Possible complications in the
only under the management of the multidisciplinary early postoperative period include acute rejection,
team who will explain the considerable risks involved. 113 infection, haemorrhage, renal failure, right ventricular
failure and allograft dysfunction (left ventricular
dysfunction/failure).
SUMMARY ● Although early signs of low-grade rejection can be
Primary compromise of the cardiovascular system causes non-specific, signs of moderate rejection usually
patients to require admission to a critical care area and present as organ dysfunction/failure.
the need for specialised care including intra-aortic balloon ● The CMV status of the donor and recipient must be
pumping, and post cardiac surgery management. Appro- known so that blood products with an appropriate
priate assessment and management is essential to prevent CMV status are administered.
secondary complications arising. Important principles of ● Denervation of the heart renders vagal manoeuvres
care are summarised below. (e.g. carotid sinus massage), and drugs that act directly
on the autonomic system (e.g. atropine, digoxin) to
CARDIAC SURGERY modify heart rate, ineffective.

● Surgical procedures may be performed as treatment ● Nursing practices for managing patients with heart
for structural abnormalities, ischaemic lesions within transplantation focus on prevention and management
coronary arteries, and repair or replacement of cardiac of complications, maintenance of comfort and pro-
valves. motion of long term recovery.