Transplants

dorie43rn · Jul 1, 2008

HI, I work in a regular ICU, but I can relate my experience from my hubbys own liver Transpant.

When I first walked in after the surgery, I was shocked at the site. He was swollen, intubated, and multiple drains and and IV's running. He was sedated, but it wasn't working and he was bucking the vent. I hate to say this, but the nurse was actually mad at him for doing this. She also wasn't very nice to us. This is a huge transplant hospital this happened in.

Anyway, the good thing is, he did well, and the Central lines and Iv's came down quick. By the third day, they were fed up with him fighting the vent, so the pulled it and he did fine. He was transfered out of there on the 5th day. I was not happy with the care he recieved even after he went to the floor. These patients are immune suppressed, and their practices were not of the "clean" nature. They had my hubby roomed with a kidney transplant patient, and all kind of family and people coming in and out. The best of all, they had nurses aides come in and throw a roll of towels and washcloths on his bed, and didn't even help wash his back. He had tube hanging every where, which made it hard to get around.

Sorry to ramble, but if you become one of these nurses, please be compassionate with the paitent and the families. He couldn't help what he was doing, and doesn't even remember, and we didn't bother anyone for anything. There is no reason to be mean.

His pain was actually miminal now that I think back. He is one year post transplant, and is doing great, even going back to work.

I do know a nurse who worked in the transplant unit, and I guess things don't go as well as my hubbys most of the time, with rebleeds and all other kinds of nasty things. Good Luck

x455645 · Jul 2, 2008

Kidney transplants usually get ml/ml replacement for at least 12 hours so they can be intensive. All are immunocompromised so protection is important. So are they antirejection meds..............

NurseLay · Jul 2, 2008

Kidney transplants usually get ml/ml replacement for at least 12 hours so they can be intensive. All are immunocompromised so protection is important. So are they antirejection meds..............

This particular unit does kidney, liver, and pancreas transplants. If I'm not mistaken, they go to the stepdown unit straight from recovery so they aren't intubated or anything, but they still have drips and stuff. How different would the stepdown setting be from the ICU setting? Would it just be a matter of the vents?

Miss Poppy · Jul 3, 2008

In our hospital kidney and pancreas xp's go to a stepdown unit while the livers and lungs come to our ICU. Both pts will have CVC, A-line, SGC, multiple saline locks, chest tubes (lungs) and hemovacs (liver). We don't segregate or isolate our pts.

Lungs seem to have the most pain control issues, when it comes to venting, double lung XP's may have dual venting where both lungs are vented independantly of each other. The goal is to extubate them ASAP, getting them to CPAP by 0600 tube out by 0900 if gases are good, CT output isn't excessive and they have no hemodynamic issues. They are kept with us 24 hours post extubation and sent to the floor.

Livers seem to do either really well or really poorly depending on their pre-op status. Some come to us, we shoot one set of outputs when they get there, a second 4 hours later, then if they're stable, pull the SGC. B/W Chem 11, LFT's CBC, Coags get done a minimum of Q8H X 48 hours. The goal is to wean to extubate the following morning. That however is the ideal and doesn't always happen. I've seen people come to us that are so coagulopathic that we can't pour in the products fast enough to keep up with the losses. People that have been chronically ill for many years and were in ESLD and received an 11th hour organ can takes weeks to wean due to general weakness and pre-op malnutrition and muscle wasting.

It's amazing though to look after someone who's in a hepatic coma, jaundiced to the color of the top of the page, send them off to the OR and see the difference within 24-48 hours .

sockov, ADN, ASN, BSN, CNA, LVN · Aug 27, 2008

My liver trnasplants come back with two a-lines, swan, two introducers, a RIC line, intubated, usually on EPI, but I cut if off after transport. Sedated on propofol or versed, depending on b/p. Fentanyl for pain control. Inuslin gtt for tight glycemic control, monitoring svo2. Lots of blood products, FFP, platletts etc.

Some do bad, most do very well.

They are usually 1:1 the frist 12 hours and depending on acuity and staffing after that.

Sometimes the livers can't get off vents, or stay on CRRT for hepatic-renal syndrome. Then they get septic, and get really sick, and usually the hepatic artery clots off and they get re-listed. If they get another "good window"

:cool:

sicushells, RN · Aug 28, 2008

HI, I work in a regular ICU, but I can relate my experience from my hubbys own liver Transpant.
When I first walked in after the surgery, I was shocked at the site. He was swollen, intubated, and multiple drains and and IV's running. He was sedated, but it wasn't working and he was bucking the vent. I hate to say this, but the nurse was actually mad at him for doing this. She also wasn't very nice to us. This is a huge transplant hospital this happened in.
Anyway, the good thing is, he did well, and the Central lines and Iv's came down quick. By the third day, they were fed up with him fighting the vent, so the pulled it and he did fine. He was transfered out of there on the 5th day. I was not happy with the care he recieved even after he went to the floor. These patients are immune suppressed, and their practices were not of the "clean" nature. They had my hubby roomed with a kidney transplant patient, and all kind of family and people coming in and out. The best of all, they had nurses aides come in and throw a roll of towels and washcloths on his bed, and didn't even help wash his back. He had tube hanging every where, which made it hard to get around.
Sorry to ramble, but if you become one of these nurses, please be compassionate with the paitent and the families. He couldn't help what he was doing, and doesn't even remember, and we didn't bother anyone for anything. There is no reason to be mean.
His pain was actually miminal now that I think back. He is one year post transplant, and is doing great, even going back to work.
I do know a nurse who worked in the transplant unit, and I guess things don't go as well as my hubbys most of the time, with rebleeds and all other kinds of nasty things. Good Luck

I'm so sorry this was your experience. Based on my own experiences I can say that immediate post-op can be the most stressful time for the RN. That doesn't make it easier for the families, but it sounds like she might have been overwhelmed, especially if your husband wasn't doing well right afterwards. I'm glad to hear he's doing well now!

To answer some of the questions originally posted, pain control is always something to address post-op. In my experience any abdominal surgery or sternotomy is especially painful. We often use PCAs if they patient is fairly stable, extubated, relatively oriented. Stable kidney transplants get q1h urine output checks, with 1:1 IV fluid repletion (for example, if the urine output for 1500 is 300 mL, the IVF rate for 1500 is 300 mL). Goal urine output for live donors is usually >200mL/h in the immediate post-op phase, >100 the next day. Immunosuppression is started and titrated post-op day 1. Pancreas transplants often get q1h blood glucose checks. Liver transplants get frequent liver func. test, cbcs, and chemistries (surgeon discretion, but the most frequent I've had is q4h). When transplants do well they are extubated quickly, sometimes in OR. They can go to PACU for recovery, but usually they come to the Surgical ICU

In my experience, kidneys that don't do well don't make adequate urine despite fluid/diuretics. Pancreas transplants that don't do well need frequent titration of the insulin gtt (Usually it's a kidney/pancreas trans, but I've had just one organ fail and the other take). The surgeon may decide to take the patient back for removal of the organ if it's looking necrotic. Liver transplants that don't do well are VERY unstable, multiple blood products, intubated, CVVH, electrolytes, hemodynamic support(levo/epi), at least q4h Cardiac outputs if swanned. It can be 1:1 staffing, but if they're fresh from the OR, we usually will have two patients. Which can make being calm while the ventilator's alarming every 15 secs, and the family is asking for information very stressful. Taking the time to inform family members is absolutely necessary, but it can't be first priority over stabilizing the patient... sad but true:twocents: