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Respiratory Alterations and Management 369

To prevent VTE, prophylactic interventions include hydra- cardiac death has the potential to significantly increase
tion and early mobilisation that, depending on the need the number of organs available for lung transplanta-
for patient admission are not always possible in the tion. 132 In 1985, 13 lung transplant procedures were
critical care setting. Mechanical measures of prophylaxis reported worldwide. 133 In subsequent years, the number
aim to reduce venous stasis via external compression. of recipients worldwide has steadily increased to be in
134
Commonly employed measures include knee- or thigh- excess of 2700 annually. Patients have received lung
length graduated compression stockings and/or inter- transplants in Australasia since the early 1990s. Lung
mittent pneumatic compression and/or venous foot transplantation can be either single or double, depend-
pumps. Clinical practice guidelines are published to ing on a patient’s underlying disease state. In the post-
support evidence-based care. 124 Two Cochrane systematic operative period, clinicians need to carefully balance
reviews have established that combined modalities fluid management to optimise respiratory function
reduce the incidence of DVT but the effect on PE remains without causing haemodynamic compromise or renal
unknown. 127,128 dysfunction. As severe pain, particularly for transverse
thoracotomy incisions, can compromise recovery signifi-
Medications cantly, effective analgesic regimens to facilitate physio-
therapy are critical.
Table 14.12 outlines the key medications recommended
and prescribed for patients with PE. Risk reductions for
DVT postsurgery have been reported following the use of INDICATIONS
prophylactic medications. 129 Studies continue to postu- The two generally-accepted criteria for lung transplanta-
late the efficacy of novel versus standard medication tion in patients with end-stage pulmonary or pulmonary
administration for VTE with only preliminary conclu- vascular disease are a poor prognosis (less than 50%
135
sions available. 130,131 chance of surviving 2 years) and poor quality of life. In
terms of quality of life, prospective lung transplant recipi-
LUNG TRANSPLANTATION ents usually struggle to perform activities of daily living,
may be oxygen-dependent and have New York Health
Transplantation is a life-saving and cost-effective form of Authority functional class III or IV symptoms. As a result,
treatment that enhances the quality of life for people most patients presenting for surgery are at risk of being
with chronic respiratory disease. Lung transplantation is debilitated and may be malnourished or overnourished,
facilitated by organ donation from patients with brain and therefore require specific interventions by health
death or donation after cardiac death. 132 Donation after team members.

TABLE 14.12 Medications for pulmonary embolism
Type of drug Generic medication Action Nursing Considerations
Opioid morphine Pain relief See Table 14.10
Anticoagulant unfractionated heparin A strongly acidic muco-polysaccharide with Prophylaxis and treatment of venous
rapid anticoagulant effects. thromboembolism, PE and disseminated
Inhibits thrombin and potentiates naturally intravascular coagulopathy.
occurring inhibitors of coagulation, To prevent clotting in extracorporeal blood
antifactor X (Xa) and antithrombin III. circuits (e.g. renal dialysis or intravascular
No effect on existing thrombi. catheters).
Standard heparin has a molecular weight of Prophylaxis of arterial thrombosis (e.g. after
5000–30,000 daltons. vascular surgery, interventional radiology
or after thrombolysis for an AMI).
Low-molecular-weight LMW heparin ranges from 1000 to 10,000 Administered subcutaneously.
(LMW) heparin daltons, resulting in distinct properties.
LMW-heparin binds less strongly to protein,
has enhanced bioavailability, interacts
less with platelets and yields a very
predictable dose response, eliminating
the need to monitor aPPT.
Acetyl salicylic acid aspirin Preventive: inhibits thromboxane A 2 The aspirin antiplatelet effect lasts 8–10
(platelet agonist), prevents formation of days (the life of a platelet in general);
thrombi and arterial vasoconstriction. aspirin should be stopped 1 week
before surgery.
Thrombolysis recombinant tissue- massive pulmonary embolism, where The risks of therapy include haemorrhage.
type plasminogen restoration of pulmonary arterial flow Safety and monitoring of the patient’s
activator (rt-PA) is urgently required due to right clinical state are paramount
alteplase, urokinase, ventricular failure
and streptokinase