Page 396 - ACCCN's Critical Care Nursing

Respiratory Alterations and Management 373

Independent lung ventilation is then established to reduce the postoperative pain experienced by recipients.
ensure that the native lung receives no PEEP and a Ideally, all lung transplant recipients should receive epi-
minimal tidal volume and rate (e.g. four breaths of dural analgesia; however, the insertion of an epidural
100 mL/min). 148 The allograft may require high levels of catheter at the time of surgery may be contraindicated
PEEP to provide adequate ABGs. Ongoing assessment of due to preoperative anticoagulation therapy. In these cir-
respiratory function determines the timing of weaning cumstances, epidural analgesia should be instituted as
from the dual-lumen ETT and independent lung ventila- soon as appropriate after surgery. Higher failure rates of
tion to a single-lumen ETT and standard ventilatory prac- transition from epidural to oral analgesia have been
tice. If PDH is not recognised until the patient has a reported in lung transplant recipients than in other tho-
150
cardiac arrest, the single-lumen ETT should be pushed racotomy patients, and in our experience it is not
into the bronchus of the transplanted lung in order to uncommon for BSLTx recipients to require opiate analge-
selectively ventilate the allograft until the patient’s condi- sia for a month after surgery in order to perform activities
tion is stable, when a dual-lumen ETT can be safely of daily living and physiotherapy.
inserted.
Patients with allograft dysfunction are always assessed Nursing practice
by doctors for the emergence of rejection and pulmonary Consultation with pain services to ensure that patients
infection via bronchoscopy (using transbronchial biopsy receive optimal analgesic regimens should be an integral
and bronchoalveolar lavage) in critical care. Evidence component of patients’ postoperative management (see
of rejection will be treated with changes in the Chapter 19). Paracetamol is beneficial in relieving mild
im munosuppression regimen and appropriate ventil- to moderate pain, and may be used as an adjunct to
151
atory and haemodynamic support. Many patients with centrally-acting analgesics for moderate to severe pain.
rejection in the immediate postoperative period may The use of non-steroidal antiinflammatory drugs should
not exhibit classic signs of rejection such as abrupt onset be avoided, due to their detrimental effects on renal and
of dyspnoea, cough and chest tightness while mechani- gastrointestinal function. 151
cally ventilated. Subtle changes in respiratory effort, The nursing management of intercostal chest tubes is
gas exchange and minute ventilation may be the only similar to that for cardiac surgical patients 152 (see Chapter
signs to alert the nurse to respiratory dysfunction sec- 12), with a few additional considerations. Recipients of
ondary to rejection or infection during mechanical SLTx have one apical and one basal chest tube, whereas
ventilation.
BSLTx recipients have four chest tubes: two apical and two
Classic clinical signs of pulmonary infections include a basal. Both BSLTx and HLTx recipients have one pleural
low-grade fever, increasing dyspnoea and sputum produc- space, so the amount and consistency of drainage from
tion, cough and infiltrates on a chest X-ray. Hypotension, basal tubes will vary depending on patient positioning.
a reduced cardiac index and subtle changes in respiratory Apical chest tubes are removed prior to basal tubes. Once
parameters during mechanical ventilation noted above lung expansion is optimal and any pneumothoraces have
may also be present. Pulmonary infections may be resolved, the apical tubes are removed. Basal chest tubes
acquired through nosocomial, community or donor are removed once drainage is considered minimal in
means, with recipient-colonised and opportunistic volume (approximately 250 mL/day) and serous in
in fections prevalent. Regardless of the means of acquisi- nature.
tion, all infections are treated promptly with specific anti-
biotic, antifungal or antiviral therapies. The risk of Haemodynamic Instability
developing CMV and Pneumocystis carinii in lung trans- As noted earlier, all lung transplant patients can experi-
plant recipients is somewhat higher than in heart trans- ence haemodynamic compromise and renal impairment
plant recipients, so prophylactic therapies for both postoperatively as a result of managing respiratory func-
infections are provided. Clinicians play an important role tion. Potential causes of a low cardiac output are outlined
in preventing the transmission of infection between in Table 14.14. Patients with pulmonary hypertension
patients and cross-contamination within patients. Metic- must be carefully managed in the early postoperative
ulous hand-washing between patients and between pro- period because of impaired cardiac output and changes
cedures, as well as minimising traffic into and out of in right ventricular dynamics. Prior to surgery, prolonged
patient care areas, are important measures in reducing periods of a high right ventricular afterload lead to right
infection rates. 149
ventricular thickening and stiffness, accompanied by
limited wall motion of the left ventricle. 153
Pain

All recipients of lung transplantation can experience Nursing practice
severe pain afterwards due to the incisions and chest During arousal from anaesthesia and patient activity, fluc-
drains. However, recipients of BSLTx in particular experi- tuations in oxygenation and systemic and pulmonary
ence extremely severe postoperative pain secondary to the pressures exacerbate haemodynamic instability. 154,155
transverse sternotomy (clam-shell incision) and presence When weaning from mechanical ventilation, as ventila-
of four chest tubes. The recent use of a minimally invasive tion pressures fall, increases in preload may precipitate
thoracotomy rather than transverse sternotomy for acute pulmonary oedema, even days after surgery. 154 Con-
patients with obstructive respiratory illnesses may also versely, if the patient is hypovolaemic at the time of