Care of the Organ Donor and Transplant Recipient

Care of the Organ Donor and Transplant Recipient a candidate on the waiting list has an ABO blood type that is compatible with that of the donor and the candidate and donor both have all six of the same HLA-A, B, and DR antigens when this occurs, the kidney must be offered to that indevidual - ANS-zero antigen mismatch AB blood - ANS-universal recipient absence of cerebral motor response in all extremities in response to noxious stimuli spina or deep tendon reflexes may be present - ANS-signs of coma no spontaneous movement no decorticate or decerebrate posturing accurate I&O and daily weights BP serum levels of electrolytes, BUN and creatinine CBC Evaluation for indications of a UTI ultrasound of the bladder if postvoiding residuals are suspected renal transplant ultrasound - ANS-assessment of kidney transplant patient acute rejection early graft failure vascular thrombosis biliary stricture or leak infection nonfunction of graft-evident immediately in OR absence of bile production and continuation of coagulation problems - ANS-liver transplant problems allograft nonfunction acute rejection viral reinfection recurrent hepatic malignancy lymphoporliferative disease PTLD-ANS-nonmechanical complications of liver transplant an aggressive diffuse form of arteriosclerosis, is also common after heart transplant primary cause of late transplant failure can affect the entire length of an artery in the transplanted heart often presents as silent MI, arrhythmia, or sudden death only treatment is reimplantation - ANS-cardiac allograph vasculopathy CAV antihuman antibodies in the blood that would react with the tissue of a potential donor results in loss of the transplanted organ - ANS-hyperacute rejection atelectasis from spending the long surgical procedure in supine position mechanical ventilation necessary for period postop predisposing patient to pulmonary infection patient immobile for extended period pleural effusion common on right side - ANS-pulmonary complications of liver transplant avoid excessive fluid replacement to prevent atelectasis if using donor's lungs review ventilator setting carefully maintain CVP of 6-8 or PAWP 8-12 to prevent fluid overload and limit pulmonary edema suction frequently and give vigorous pulmonary hygiene maintain PaO2 greater than 70, 02 sat greater than 98-99%, tidal volume 8-12, FiO2 less than 60%, PEEP less than or equal to 5 use bronchodilators and antibiotics to improve transplant success - ANS-management of ventilation be sensitive to what the family is feeling explain or reinforce that the time of death was when the patient was declared dead and not when the patient was taken to the OR give family time and privacy to say goodbye - ANS-care of the donor's family biopsies are essential because the patient bay e asymptomatic until late in the process when the ejection fraction drops and the patient develops heart failure and dysrhythmias acute rejection treated with corticosteroids - ANS-heart transplant management body temperature fluctuates with the temperature of the environment - ANS-poikilothermic cleared by insurance must attend education session assessed for preexisting diseases or disorders complete a psychosocial evaluation - ANS-kidney transplant criteria coma or unresponsiveness absence of brainstem reflexes apnea - ANS-three cardinal findings in brain death complete evaluation and manage care of prospective donor reassure family that the cost of evaluation and management is covered by the organization and not the family - ANS-OPO representatives responsibilities connect pulse ox and disconnect ventilator deliver 100% O2, 6L/min into trachea watch closely for respiratory movement for 8-10 min measure ABGs 8 min later and reconnect ventilator if movements are absent and arterial CO2 is greater or equal to 60 mm HG: apnea test is positive and supports brain death diagnosis if movements observed, apnea test negative and brain death has not occured - ANS-the steps for apnea testing continually assess for pain give nutrition support by providing adequate protein and energy from cabrohydrates or fats equivalent to or slightly less than patients energy expenditure - ANS-nursing care for liver transplant decreases the risk of organ rejection because it can be scheduled in advance, the recipient can begin taking immunosuppressant drugs a day or two before surgery, usually a better tissue match - ANS-living donors depletes lymphocytes, modulates T cell activation dose 1.5 mg/kg/day IV for 3-14 days may cause fever, chills, dyspnea, joint pain, headache, Gl disturbance, hypertension, thrombocytopenia and neutropenia nursing responsibilities: administered by central line with a filter over 6 hrs for first dose and over 4 hours for the rest - ANS-Rabbit Antithymocyte Globulin determine if they are medically suitable as an organ donor death will most likely occur within an hour of withdrawal of life support - ANS-evaluation of donor develops because of insufficient levels of ADH serum sodium greater than 150 typical findings include urine output greater than 300 mL/hr urine specific gravity less than 1.010 measure urine output hourly, administer vasopressin if output is over 300 ml/hr -ANS-management of diabetes insipidus DI absent urine glucose disruption of flow through the hepatic artery, portal vein or inferior vena cava biliary complications - ANS-mechanical complications of liver transplant donation after brain death donation after cardiac death - ANS-two types of donation from deceased donor donations after cardiac death, do not meet the criteria for brain death but are gravely ill and dying sustained a nonrecoverable neurological injury that did not result in brain death -ANS-nonheatbeating donors educate patient to notify provider if unable to take the immunosuppressants or if dose skipped notify provider of any medication changes notify md with temp above 100F, immediately if over 101.5F notify md of persistent, unusual weakness or fatigue, SOB, sudden weight gain with swelling in hands or feet, aches, pains, or "not feeling right" - ANS-rejection management EEG somewhat unreliable because it assesses only cerebral not brainstem function - ANS-most commonly used confirmatory test encourage patient to have a warm up period prior to exercising and to cool down slowly to allow catecholamine levels to taper and HR to return slowly to baseline encourage to change position slowly to avoid orthostatic hypotension encourage enrollment in cardiac rehabilitation - ANS-heart transplant recovery evidence of acute neuro catastrophe, CT scan used to determine cause of brain death exclusion of complicating medical conditions absence of drug intoxication or poisoning core temp 90F normotension greater than or equal to 90 systolic BP - ANS-valid determinants of brain death fear of rejection of transplant deal with changes in physical appearance mood disorders like depression and anxiety dealing with complex posttransplant regimen integrating transplant experience managing economic and financial issues - ANS-common psychosocial and psychological issues for patients after transplant given for maintenance immunosuppression inhibits cytokine production by T cells metabolized by liver, narrow therapeutic window dose ranges between 0.075-0.15 mg/kg q12hr may cause insulin dependent diabetes mellitus, diarrhea and vomiting, nephrotoxicity, or neurological toxicity seen as a tremor, headache, numbness, or tingling nursing responsibilities: give PO because anaphylactic reactions occur more with IV, give on empty stomach, monitor BP, blood sugar and renal function regularly, educate on dietary modification, oral hypoglycemid medications or insulin - ANS-calcineurin inhibitors tacrolimus (FK-506, Prograf) good health previously less than 70 - ANS-qualifications of deceased donor graft failure cardiovascular disease infection malignancy - ANS-causes of death from liver transplant have at least one mechanical circulatory support device in place like a left and/or right ventricular heart assist device, an intra aortic balloon pump or a total artificial heart -ANS-severely ill heart candidate hemodynamic stability good tissue oxygenation normal electrolyte balance coagulation profiles within normal limits - ANS-goals of care for the donor include maintaining hyperacute rejection: rare, recipient has performed antibodies to donor antigens, develops almost immediately after the graft is transplanted accelerated rejection: occurs within first week, treated aggressively with steroids and immunosuppressants, poor prognosis for graft survival acute rejection: occurs during first year, cell mediated immune response results in T lymphocytes infiltrating donated organ, antirejection doses of immunosuppressants provided, usually reverse process for graft survival chronic rejection: occurs months to years later, involves combination of humoral and cell mediated immune responses, does not respond well to immunosuppression - ANS-four types of rejection immunosuppressant meds smoking alcohol adolescents most at risk - ANS-noncompliance of transplant patients in the iliac fossa because of its close proximity to major blood vessels and bladder old kidneys remain in place exceptions are for uncontrolled hypertension, tumors, recurrent infections or stones of the kidneys, then the old kidneys may be removed - ANS-kidney transplant location increased BUN and creatinine levels with decreased urine output weight gain, edema and increase BP fever, chills, elevated WBC graft swelling and tenderness - ANS-indications of acute rejection of kidney transplant induction immunosuppression, maintenance therapy and antirejection treatment - ANS-three types of immunosuppressive therapy infection or rejection of transplant - ANS-most common cause of death after heart transplant inhibits T cell proliferation and differentiation without affecting other immune cells absorbed erratically after PO administration metabolized in the liver dose ranges from 3-10/mg/kg/day may cause nephrotoxicity, hypertension, hyperlipidemia, neurological toxicity not as common as with tacrolimus, hirsutism nursing responsibilities: monitor drug levels because of narrow therapeutic window, monitor BP, weight, and kidney function at regular intervals, avoid contrast mediums drug reactions when taken with calcium channel blockers, antifungal agents (fluconazole, ketoconazole), antibiotics and grapefruit juice - ANS-cyclosporine (Neoral, Sandimmune) it is recommended to approach the family with the presumption that they will consent to organ donation. Don't give them the pros and cons, just focus on the good that the donation will do for other and the pride they will feel after saving multiple lives - ANS-presumtive approach know how to identify a potential donor, recognize when a patient meets definition of impending death, notify appropriate Organ Procurement Organization serve as advocate for the patients and families by honoring the patients last wishes, upholding the families right to be offered the option of organ donation, promoting compassionate communication between health care team and potential donor's families - ANS-nursing actions for transplants liver biopsy, liver function test, creatinine, urine output, prothrombin time, IND and bile drainage - ANS-assessment of liver transplant patient maintain sodium less than 150, potassium greater than 4, pCO2 of 30-35-ANS-management of electrolyte imbalance malaise, fatigue and fever abdominal discomfort with a swollen, tender graft cessation of bile flow, change in color of bile from golden to colorless dark or tea colored urine and clay colored stool jaundice elevated bilirubin, liver enzymes, and international ratio INR - ANS-indication of liver transplant rejection manage hypertension, diabetes, hyperlipidemia and obesity instruct patients to avoid the sun, examine skin and have skin evaluated by health care provider to prevent skin cancer - ANS-prevention of cardiovascular disease in post liver transplant patient MAP greater than 60 urine output greater than 1 ml/kg/hr ejection fraction greater than 45%