Organ transplant questions!!

[rcon]

Hello all!

I am new to the SICU, past general Medical/Sugical ICU (more toward the MICU). I am transferring shortly to the SICU at a very large hospital. I was told a good amount of the patient population on the unit are post transplant patients. No heart and lung transplants, they go to the CTSICU. However, we get all abdominal organ transplants. I have no experience with transplants at all, my old ICU did general surgeries , cranis, and CABGs, but that is about it. Is there anything in particular I should know about the treatment of a patient after a liver or kidney transplant. I heard post livers are very unstable and come to the ICU with a swan and multiple pressors. I also read that these patients are at high risk for developing sepsis/some type of infection because of the immunosuppressant drugs. Also, if all goes well, are these patients up and moving with PT quickly as in a CABG. For kidney transplants, do most require CVVH/CRRT post op? I was told the RN has to exactly match intake to output and adjust IV fluids accordingly.

So basically I was hoping you all could impart your knowledge, anything you feel is worthy to know about caring for a transplant patient. All of your thoughts are greatly appreciated!

[BelgianRN]

Hey There,

From my experience in dealing with post transplants here are some things that came up in their time in ICU.

Liver transplants

Liver transplants generally come with a Swan and generally limited amount of pressors and some inotropy (generally norepi and dobutamine in our center). The toughest part of their surgery (in terms of stability) is when they unclamp the new liver into the circulation of the body of the patient. The flush of toxins and vasoactive mediators can be quite disruptive for the body of the patient. But best case scenario anesthesia has managed to stabilize the patient by the time it arrives in the ICU.

Another major concern is bleeding. Generally these patients arrive in our ICU with a rapid infusion system in place. Since the liver is so rich in bloodvessels these patients have required massive transfusions both as a replacement to volume loss and due to a lack of coag factors in the blood and low platelet count. On occasion these patients haven't fully stopped bleeding due to diffuse blood loss they require ongoing transfusions and coag correction.

In my opinion liver transplants are categorized the same as hearts and lungs. If it all works correctly you won't have a lot to do other than monitor and wean from respiratory in due time. But if it takes a turn for the worst you won't leave bedside, uhm ever...

Kidney or Kidney/Pancreas transplants

These patients don't generally come to the ICU in our center. So if they are in need of admission it can be for two reasons either their co-morbidities are to the extreme that warrants ICU admission or something went wrong during surgery.

I've very rarely seen CVVH/CRRT in our kidney transplant patients if they require additional dialysis after transplant (generally temporary) they'll receive their classic dialysis. Since they tend to be stable so CVVH/CRRT is deemed "too expensive" for their stability level. If they require CVVH/CRRT it is because of their general instability issue.

Generally with Kidney transplants they are on compensation. This means you watch the urine production per hour/2 hours and then based on that amount decide their base replenishing fluid for the next hour/two hours. Usually there is a directive what to do when urine output falls below X, CVD below Y, etc. Either up their base fluids or replenish with other fluids as per directive.

Something specific to the Kidney/Pancreas transplants is that the excretions of the pancreas that they would normally excrete in the bowel (pancreatic fluid) is redirected to the bladder. So their urine can be quite thick as it is mixed with this pancreatic fluid. So be very mindful to blockage of the Foley.

General

As with all transplant patients they'll have advanced directives which blood products they can and cannot receive (sometimes varies per transplant and per patient). They are on immunosuppresive medication so frequent draws of their blood levels is part of the routine. Vigorous monitoring for CMV and aspergillus antigens in the blood is also done in my center (usually once a week). They are in reversed isolation in our ICU, but I've heard of centers that no longer keep as strict rules to isolation as our center still does.

In my opinion post transplant patients are much more work for the receiving wards then the ICU they end up in. The instability of liver transplants is relative if your sepsis or trauma on the next bed is on 5 pressors 4 inotropes and a "crossing my fingers to make it another hour"-drip. As in all ICU patients In & Out is monitored anyway so it's not that much more work to do it in a kidney transplant.