organ and hematopoietic stem cell transportation!

preoperative phase

• comprehensive laboratory studies, chest radiograph, ecg, and, for kidney transplant recipients, dialysis within 24 hours of transplantation

• laboratory studies include cbc, prothrombin time (pt), partial thromboplastin time (ptt), electrolyte, blood glucose, and blood urea nitrogen (bun), creatinine, liver function tests, type and crossmatch, and urinalysis

surgical procedure - kidney

• kidney is placed retroperitoneally in the iliac fossa

• hematuria is present for several days

• failing or damaged kidney is not removed

  • removing poses a major risk for bleeding, infection, or injury

surgical procedure - liver

• transported orthotopically, that is in its normal position after the native liver is removed

surgical procedure - heart

• orthotopic transplantation

  • most commonly used

  • the patient is placed on bypass

  • the surgeon excises recipient’s heart and implants donor’s heart in its place

• heterotopic transplantation

  • infrequently done, piggyback technique

  • recipient’s heart is left in place and donor’s heart is placed next to it in the right chest

• may see two p waves in either approach

surgical procedure - pancreas

• placed heterotopically in the right iliac area

• may be performed in combination with kidney transplant for recipients with end-stage renal disease secondary to diabetes mellitus

surgical procedure - lungs

• posterior lateral thoracotomy for single-lung transplantations, median sternotomy incision or a clamshell incision for double-lung transplantations

• surgeons telescope the recipient’s bronchus into the donor lung or vice versa, or perform an end-to-end anastomosis with omentopexy in which an omental flap is wrapped around the tracheal anastomosis to increase blood supply to the area

• patient will come back on ventilator

post operative phase - general

• vs, oxygenation and ventilator settings, hemodynamics

  • in renal transplants, take bp on an extremity that does not have a functioning vascular access site because even momentary interference with arterial blood flow may lead to access malfunction

• patient’s level of consciousness and degree of pain

• number of iv and arterial lines, noting the site, type of solution, and flow rate

• abdominal or chest dressing for drainage, noting the presence of drains and amount and type of drainage

• presence of bladder and possible ureteral catheters and patency and urinary drainage

• attachment of nasogastric tube to appropriate drainage system and amount and character of drainage

• most recent hemodynamic and intraoperative laboratory results

• bowel sounds, lung sounds

postoperative phase - kidney

• observing the function of the transplanted kidney

• monitoring fluid and electrolyte balance

• helping avoid sources of infection

• detecting early signs of complications

• supporting the patient and family through the recovery phase

• patency and the vascular access used for dialysis

  • place either fingers or a stethoscope directly over the access site and feel or listen for a characteristically loud, pulsating noise called a bruit

renal graft function

• urine output produced by the donor kidney varies from a large amount (200 - 1,000 mL/hr) to small amounts (less than 20 mL/hr)

• degree of renal function is related to ischemic injury in the donor kidney, usually from either a hypotensive period in a cadaveric donor or from the time the kidney is stored outside the body (preservation time)

  • renal function is better when the kidney preservation time is less than 24 hours

  • most dysfunction is reversible, but may take up to 4 weeks to return to normal

• assessment of renal function includes periodic bun and creatinine levels and, in some centers, a beta-2-microglobulin level

urinary drainage problems

• when a change in urinary output occurs, such as a large volume in 1 hour and a diminished amount in the next, mechanical factors that interfere with urinary drainage should be expected

• clotted, kinked, or compressed tubing in the urinary drainage system may be the cause of the decreased output

• when the catheter is occluded by a clot, the patient may complain of pain, feel an urgency to void, or have bloody leakage around the catheter

• milking is the preferred way to dislodge clots because irrigation, even under aseptic techniques, increases the risk for infection

urinary leakage

• urinary leakage on the abdominal dressing and severe abdominal discomfort or distention may indicate retroperineal leakage from the uteral anastomosis site

• important to report decreased urinary output or severe abdominal pain in the presence of good renal function and adequate pain medication because technical and surgical complications can result in loss of graft function

hyperkalemia

• most frequent electrolyte disturbance in the acute post-operative phase is hyperkalemia

• if the graft functions and excretes a high volume of urine, it is usually able to excrete the excessive serum potassium created by surgical tissue damage

• if the patient is oliguric or anuric after surgery, the serum potassium may increase to unacceptable levels

• interventions include administration of glucose and insulin to transport potassium into the cell and administration of oral polystyrene sulfonate

postoperative phase - liver

• hemodynamic stability, adequate oxygenation, fluid and electrolyte balance, adequate hemostasis, and graft function

• an arterial line and pulmonary artery catheter are in place

• vasopressors and additional fluid boluses may be required in the first 24 to 36 hours

• hypotension is most often caused by intra-abdominal bleeding

• an increase in abdominal girth or excess bloody drainage from jackson-pratt drains is indicative of a serious problem

  • call surgeon!

liver - oxygenation

• adequate ventilation is crucial for graft perfusion and helps reduce the risk of pulmonary complications

• monitor arterial and mixed venous oxygen saturations

• pulse oximetry may be used but severe jaundice may interfere with saturation measurements

• postoperative pleural effusion is common owing to the presence of ascites and risk of injury to the diaphragm during surgery

  • a chest tube may be required for drainage

liver - coagulation

• monitor pt, ptt, fibrinogen, and factor v along with the amount, color, and consistency of bleeding from the incision and drainage tubes

• patient may need infusions of platelets, rbcs, or cryoprecipitate

• blood products should be leukocyte reduced to avoid introduction of cmv especially if the patient is negative for cytomegalovirus

liver function

• liver function is initially assessed by bile production, coagulation factors, and later by liver function tests

• measuring bile production from the biliary drainage tube helps assess the excretory function of the liver and is a good early indicator of graft function

• pt and inr provide a measure of the synthetic function of the liver

• aminotransferases (alanine aminotransferase and aspartate aminotransferase) provide information about the degree of hepatic injury related to preservation

• improvement in the clearance of lactate, encephalopathy, and glucose metabolism are also assessments of liver function

postoperative phase - heart

• care is similar to any cardiac surgery

• remnant p waves

  • may see two p waves on ecg

• effects of denervation

  • higher heart rate (90-110), sympathetic stimulation is absent, medications mediated by autonomic nervous system have abnormal effects

  • digoxin will not slow it down and atropine will not speed it up

    • calcium channel blockers or beta blockers in place of digoxin

    • dobutamine and epinephrine along with temporary epicardial pacing in place of atropine

• potential for ventricular failure

  • tx with drugs to decrease right heart afterload

  • with exercise, hr and cardiac output increase gradually over 3 to 5 minutes and remain elevated longer after exercise

  • prolonged warmup before and cooldown after exercise help compensate for these changes

• change positions slowly for orthostatic hypotension

• denervation prevents transmission of pain so patient does not experience angina

  • ecg stress testing and annual coronary angiography or coronary vascular ultrasonography are usually performed

postoperative phase - pancreas

• monitor blood glucose, insulin drip

• prevent infection

• ngt

• enteral/parenteral feedings

• urinary tract infections, reflux pancreatitis, metabolic acidosis, and hyperinsulinemia is a result of surgical approach

postoperative phase - lung

• mechanical ventilation for 24-36 hours

• loss of cough reflux due to denervation

• reperfusion injury may cause pulmonary edema

• maintain hypovolemic state for first few days

• prophylactic antibiotic

• good oral care

• respiratory and chest physiotherapy

• continuous pulse oximetry

• washing hands, aseptic technique

• avoid interactions with active infections

• encourage physical activity

assessment and management in hematopoietic stem cell transplantation

• autologous versus allogenic

• involves replacing diseased, destroyed, or nonfunctioning hematopoietic cells with healthy progenitor cells also called stem cells

• stem cells are primitive hematopoietic cells capable of self renewal; they are pluripotent, meaning that they are capable of maturation into an rbc, wbc, or platelet after engraftment

• these stem cells may be collected directly from the bone marrow spaces by a bone marrow harvest procedure or from the peripheral blood by aphaeresis

autologous stem cell transplantation

• stem cells come from the patient’s own bone marrow or peripheral blood

allogenic stem cell transplantation

• stem cells come from a donor (sibling, matched unrelated donor, or cord blood)

infection prevention

• most common posttransplantation complications

• early detection and treatment

• hand hygiene, aseptic technique

• causative agents are often from the patient’s own flora, particularly from the gi tract and integumentary system

  • bacteria, fungi, viruses, and even protozoa

  • opportunistic

• patients placed on broad-spectrum antibiotics and antifungal treatments when they nadir (wbc at lowest point) and have a fever higher than 100.3

• neutropenic fever is a clinical emergency

• assessment, blood cultures, and starting new antibiotics should be completed within an hour

immunosuppressive therapy

• suppresses immune response so the transplanted organ is accepted

• provides the recipient with adequate immunosuppression without undue toxicity, unfavorable reactions, and excess susceptibility to opportunistic infections

• several drugs may be necessary

• triple therapy is a combination of low-dose prednisone, azathioprine or mycophenolate mofetil, and cyclosporine a or tacrolimus

• quadruple therapy or sequential is a combination of the same drugs used in triple therapy plus antithymocyte antibody preparations or

infection

• most common posttransplant complication

• pretransplant conditioning and alterations in mucosal barriers conducive to opportunistic infection

• caused by patient’s own flora

• catheter-associated infections

• high risk during first THREE months due to immunosuppressive therapy

• monitor for s/s of infection

• only encourage vaccinations by the discretion of hcp

  • when they are healthy then yes!

organ rejection

• the transplanted organ acts as an antigen or foreign substance to the recipient, it acts as an antigen or foreign substance and triggers the immune system to reject it

• can vary from mild to severe and may be irreversible

• may occur at any time but the risk is highest in the first THREE months after transplantation

• important to maintain therapeutic levels of immunosuppression and to provide patient and family education about the importance of taking all medications as instructed and the rationale for routine laboratory monitoring of the levels of immunosuppressive drugs

• the earlier and more severe the rejection episode, the worse the prognosis for graft survival

• biopsy of the transplanted organ is usually needed to diagnose rejection definitively

hyperacute rejection

• occurs in the operating room immediately after transplantation

• a humoral immune response in which the recipient has preformed antibodies that immediately react against antigens of the donor organ

• vascular damage occurs, resulting in severe thrombosis and graft necrosis

• in kidney and heart transplantation, results in graft failure and the need for re-transplantation

• uncommon and can usually be prevented by pre-transplantion crossmatching

accelerated rejection

• defined only in kidney transplantation and it occurs within 1 week after transplantation

• anuria, increased bun and creatinine levels, and pain at the graft site

• due either to preformed antibodies against the donor antigens in the recipient’s blood or to lymphocytes in the recipient that are already sensitized to some of the donor antigens

• seen infrequently because of improved tissue typing and cross matching

• treated aggressively with immunosuppressants and usually results in loss of the transplanted kidney

acute rejection

• occurs within the first THREE months after transplantation

• most common type of rejection and most patients experience at least one episode

• occurs when antigens on the donor organ trigger lymphocytes to mature into helper t cells

  • helper t cells increase the production of cytotoxic killer t cells which bind to the transplanted organ and damage it by secreting lysosomal enzymes and lymphokines

• responds best to immunotherapy

chronic rejection

• combination of cell-mediated response and a response to circulating antibodies

• second in frequency to acute rejection

• usually occurs from THREE months to YEARS after transplantation

• accompanied by failing or deteriorating organ function

infection manifestations

• usual signs and symptoms may be absent

• a small increase in temperature (99 F) may be significant

• daily monitoring of the wbc count is necessary

• after organ transplantation, the leukocyte count is usually slightly elevated because of surgery and steroid treatment

• however, infection may be present if the elevation persists, a rapid elevation occurs after a decline, or there is an increase in the percentage of immature wbcs (bands) noted on the differential

• in hsct recipients, wbc levels do not respond typically to infections and therefore are not a reliable sign

nursing responsibilities for neutropenic precautions

• maintaining protective environments

• practicing consistent and thorough provider hand washing and good oral and skin hygiene

• monitoring vs frequently

• performing head-to-toe assessments

• protective isolation systems

• air filtration

• gut and skin decontamination

• low-microbial diet

complications - bleeding

• oozing from the surface of the transplanted organ, or the presence of hematoma or lymphocele may occur after surgery

• heart transplant is at risk because the pericardial sac has stretched to accommodate an enlarged heart

  • when a smaller, healthier heart is implanted, the larger pericardial sac becomes a reservoir that can conceal postoperative bleeding → cardiac tamponade

• long-term coagulation therapy

• liver congestion from pre-transplantation heart failure

• after liver transplantation, bleeding may occur as a result of coagulopathy because of liver dysfunction or from small vessels that continue to bleed after surgery

• when the bladder drainage technique is used → hematuria

complications - gi

• related to chronic steroid therapy → increases secretion of hcl acid and pepsinogen

• increased risk of peptic ulcer disease, erosive gastritis

• ppi or h₂ blockers

hsct complications - graft failure

• a complete absence of engraftment or a seemingly initial hematopoiesis after transplantation with later decreasing blood cell counts and an absence of hematopoiesis

• neutropenia, anemia, and thrombocytopenia occurring beyond the initial period expected as a result of high-dose chemotherapy or chemoradiation therapy

hsct complication - veno-occlusive disease of the liver

• complication of the conditioning regimen and usually develops within two weeks of transplantation

• most common in recipients who have had a lot of prior chemotherapy or have elevated liver function tests prior to transplant

• liver endothelium is damaged by the conditioning regimen, resulting in obstruction of small venules in the liver

• subsequently, portal hypertension, acute liver congestion, and destruction of liver cells develop

• clinical manifestations begin during the first three weeks after transplantation and are characterized by hyperbilirubinemia, rapid weight gain, ascites, right upper quadrant pain, hepatomegaly, splenomegaly, and jaundice

• gold standard diagnosis is a liver biopsy

hsct complication - pulmonary complications

• may result from infection, pulmonary edema, aspiration pneumonia, ards, and septic shock, as well as from lung damage from total-body irradiation or pulmonary toxic chemotherapy agents

graft versus host disease

• infused donor stem cells (graft) recognize the recipient (host) as foreign tissue

• the graft mounts an immunologic response attacking the host tissues, resulting in a t-cell mediated reaction in the skin (rash), gi tract (enteritis) and liver (elevated liver function test results)

  • macules and papules

  • nausea and vomiting

  • anorexia

  • cramping

  • large amounts of green watery diarrhea

  • liver involvement

  • high bilirubin, phophatase

• acute - 7 to 21 days

• chronic - 100 to 400 days

treatment and prophylaxis of graft versus host disease

• prevent it by optimal donor match

• t-cell depletion before transplantation

• immunosuppressive agents

• combination therapy

• corticosteroids are the mainstay of treatment

• salvage or secondary regimens

• monitor drug levels

long-term complications

• focus on monitoring the patient’s progress and adherence to the health care regimen

• patients must also be monitored for the development of late complications, including infections, hypertension and cardiovascular disease, chronic rejection, and recurrence of the original disease, such as hepatitis in liver transplantation and recurrent glomerulonephritis in kidney transplantation

• weight gain can be a complication after transplantation as a result of steroid use

• osteoporosis secondary to high steroid use

• hsct patients need to continue to follow up with the hsct team to screen and monitor for long-term side effects including secondary cancers, eye changes, increased dental caries, avascular necrosis, late infection, and relapse

• palliative care integrated → improvement in high-risk patients physical and psychosocial well-being