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374 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

weaning, right ventricular outflow obstruction may to irritability, insomnia, profound depression, mania or
occur. 142 These potential events confirm that careful titra- psychosis. 135
tion of fluid and inotropic therapies, guided by frequent, Although LTx surgery offers recipients relief from short-
accurate monitoring of invasive haemodynamic param- ness of breath and increased exercise tolerance, many
eters, is required in patients with preoperative pulmonary patients have to continue managing other aspects of their
hypertension.
underlying disease (e.g. cystic fibrosis). Thus, the burden
Renal and Gut Dysfunction of living with a chronic illness remains. Conversely, some
recipients experience wellness for the first time in their
Reasons for renal dysfunction in LTx recipients in the life, and this can alter family and relationship dynamics.
early postoperative phase are similar to those for heart In circumstances where lung function deteriorates after
recipients. The situation is, however, compounded in initial success, patients and families experience feelings
lung recipients due to aminoglycoside and NSAID use of devastation and hopelessness. Counselling services are
preoperatively, the high number of patients with diabetes essential in both the preoperative and the postoperative
and a requirement for ‘dry’ lungs postoperatively. Fortu- phase. 135,158-166
nately, the use of interleukin-2 receptor antibody drugs
can assist in lowering the doses of calcineurin inhibitor Long-term Sequelae
agents to offer some early protection to the kidneys Long-term sequelae for lung transplant recipients include
without inducing acute rejection. 156
renal impairment, hypertension and increased risk
Nursing practice of malignancies, similar to those with heart trans-
plantations. Further information about long-term com-
Routine management of gut function is an important plications specific to lung transplantation, such as
aspect of nursing practice, including the prevention of bronchiolitis obliterans syndrome and other non-
constipation (see Chapter 19). For patients receiving pulmonary complications, is available. 135
surgery for cystic fibrosis, pancreatic enzyme supplements
are required postoperatively. As these patients are invari-
ably debilitated preoperatively, enteral feeds that do not SUMMARY
require pancreatic enzyme supplements should be com- Respiratory alterations, whether a primary disruption or
menced as soon as possible after surgery, as these supple- a secondary complication of comorbidity, are the primary
ments cannot be administered via enteral feeding tubes. reason for ICU admission. Vigilant assessment, monitor-
Further specific information on managing patients with ing and being responsive to a deteriorating state are
cystic fibrosis is available. 157 central to critical care nursing practice. Contemporary
approaches to respiratory support focus on preserving a
Psychosocial Care patient’s respiratory function, including NIV, using less
In the early postoperative period, corticosteroids, seda- controlled ventilation when appropriate and consider-
tives, sleep deprivation and persistent pain contribute to ation of weaning from mechanical ventilation at the earli-
acute organic brain syndrome 135 (see Chapter 7). Rejec- est opportunity. The current evidence base supports
tion episodes can be emotionally demanding, and the strategies to prevent VAP, using daily checklists or care
requirement for higher doses of corticosteroids can lead bundles.

Case study

Frances is a thirty-six-year-old female. She presented to her local Investigations revealed:
general practitioner (GP) with an 11-day history of cough, fever and ● U&E: Na 132 mmol/L, K 3.2 mmol/L, BGL 8.5 mmol/L, Cr
+
+
shakes, and a 5-day history of expectorating tenacious yellow– 99 µmol/L, eGFR >90, bHCG <0.5
9
9
green sputum, decreased appetite and mild right-sided chest pain ● FBE: Hb 130 g/L, WCC 12.89 x 10 /L, Neut 174 x 10 /L
with increasing dyspnoea and a hoarse voice. Her GP organised for ● INR: 1.8
the ambulance to transport Frances directly to the Emergency ● CXR: Right middle lobe pneumonia
Department (ED) of the nearest major public hospital. A peripheral ● Pending: Legionella urinary antigen, atypical serology and
intravenous line was inserted and the patient was continuously respiratory polymerase chain reaction (PCR) testing.
monitored during transportation to the hospital.
Upon arrival at the ED, Frances was assessed as a Triage Category Frances’ past history included hirsutism, polycystic ovaries (PCOS),
2 patient and a baseline assessment was determined: pre-eclampsia and depression. She had no known allergies. At the
● CNS: GCS 15, Temperature 38.6 °C time of presentation to the ED her regular medications were ser-
● CVS: HR 135/min, sinus tachycardia, BP 150/78 mmHg, brisk traline and spironolactone (for PCOS). She reported that she lived
capillary refill with her partner and that she had been at home on annual leave
● RESP: RR 40/min, shallow rapid breathing, appears tired. SpO 2 from her employment for the past three weeks. Further, she
95% while receiving oxygen at 6 L/minute via Hudson Mask, reported that she had not been exposed to any exotic pets or
improving to 98% with increased flow to 8 L/minute. undertaken recent overseas travel.