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![HISTORY[global]
Carrel and Guthrie first reported successful heterotopic cardiac
transplantation in dogs in 1905 .
1913 Mann and colleagues at Mayo Clinic reported successful
transplantation of the heart into the neck of dogs.
Medawar was the first to develop concepts of immunology applicable to
Transplantation.
Lower and Shumway first reported successful experimental orthotopic
cardiac transplantation in 1960.
Orman Shumway is widely regarded as the father of heart
transplantation although the world's first adult human heart transplant
was performed by a South African cardiac surgeon,Christiaan Barnard,
utilizing the techniques developed and perfected by Shumway and
Richard Lower.
In 1964, Hardy and colleagues performed the first heart transplant into
a human, using a chimpanzee heart.
The first human-to-human heart transplant (allograft) was performed in
Cape Town, South Africa, by on December 3, 1967.
The recipient was Louis Washkansky, a 53-yearChristiaan Barnard -old](https://image.slidesharecdn.com/cardiactransplantation-240319181429-6358c342/75/cardiac-transplantation-pptx-surgeries-4-2048.jpg)
![History [india]
At KEM Hospital, Mumbai, Dr PK Sen and his team performed
the first heart transplant in India in February 1968.
The Organ Transplant Bill 1994 was passed in the Indian
Parliament in May 1994 which cleared the way for organ harvest
from brain-dead patients.
Successively, Dr P Venugopal and his team performed the first
successful heart transplant on August 3, 1994. Hyderabad first
transplant was done in global hospital.
The full extent of the law and notification happened in 1995 after
which other centres in India performed the surgery successfully.
6 heart transplants have been done in NIMS ,INDIA .
Collectively, 129 heart transplants have been performed in India
since 1994 with 82 in Chennai, 33 at AIIMS and 14 at other
centres in India.](https://image.slidesharecdn.com/cardiactransplantation-240319181429-6358c342/75/cardiac-transplantation-pptx-surgeries-6-2048.jpg)
![Criteria For Determining Brain Death Clinical
Evaluation
Mechanism of brain injury is sufficient to account for irreversible loss of
brain function
Absence of reversible causes of CNS depression
CNS depressant drugs
Hypothermia (<32°C [85°F]) ,Hypotension (MAP <55 mmHg)
Absence of neuromuscular blocking drugs that may confound the results
of the neurologic exam
No spontaneous movements, motor responses, or posturing](https://image.slidesharecdn.com/cardiactransplantation-240319181429-6358c342/75/cardiac-transplantation-pptx-surgeries-19-2048.jpg)
![PREOPERATIVE TEACHING
We should teach the patient to increase his health by giving advices like
(a) stop smoking,
(b) maintain personal hygiene,
(c) deep breathing and coughing exercises
[d]active and passive exercise
SURGICAL PREPARATION OF THE SKIN
Skin preparation helps reduce the number of microorganism present on skin
and thus reduce the possibility of wound infection.
Shave the area and clean the area with antiseptic lotion/swab](https://image.slidesharecdn.com/cardiactransplantation-240319181429-6358c342/75/cardiac-transplantation-pptx-surgeries-27-2048.jpg)
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cardiac transplantation.pptx...surgeries
- 1.
- 2. introduction Cardiac transplantationis an accepted therapy for an end stage heart disease. Impressive improvements in survival, refinement of immunosuppressive therapy,and improvements in monitoring techniques have prompted many new centers to initiate cardiac transplantation programmes. A heart transplant removes a damaged or diseased heart replaced with a healthy one. Although heart transplant surgery is a life saving measure, it has many risks. Careful monitoring,treatment,and regular medical care can prevent or help manage some of these risks.
- 3. definition Cardiac transplantationis a therapeutic procedure whereby the heart of a suitable donor is implanted into a recipient - TEXTBOOK OF CARDIAC NURSING Heart transplant is a surgical procedure performed to remove the damage heart from a patient and replace it with a healthy one from an organ donor - MOSER AND RIEGELS
- 4. HISTORY[global] Carrel andGuthrie first reported successful heterotopic cardiac transplantation in dogs in 1905 . 1913 Mann and colleagues at Mayo Clinic reported successful transplantation of the heart into the neck of dogs. Medawar was the first to develop concepts of immunology applicable to Transplantation. Lower and Shumway first reported successful experimental orthotopic cardiac transplantation in 1960. Orman Shumway is widely regarded as the father of heart transplantation although the world's first adult human heart transplant was performed by a South African cardiac surgeon,Christiaan Barnard, utilizing the techniques developed and perfected by Shumway and Richard Lower. In 1964, Hardy and colleagues performed the first heart transplant into a human, using a chimpanzee heart. The first human-to-human heart transplant (allograft) was performed in Cape Town, South Africa, by on December 3, 1967. The recipient was Louis Washkansky, a 53-yearChristiaan Barnard -old
- 5. Cont’d Three daysafter the Cape Town operation, Adrian Kantrowitz performed the second human heart transplant in Brooklyn. The recipient was an 18- day-old neonate with Ebstein anomaly, refractory heart failure, and previous aorticpulmonary shunt for severe cyanosis. Barnard performed the third human heart transplant on Philip Blaiberg, a 46-year-old dental surgeon with refractory heart failure, severe coronary artery disease, and a large left ventricular aneurysm. He became the first long-term survivor, living for 18 months. Norman Shumway performed the fourth heart transplant 4 days later, and this patient died 2 weeks later.
- 6. History [india] AtKEM Hospital, Mumbai, Dr PK Sen and his team performed the first heart transplant in India in February 1968. The Organ Transplant Bill 1994 was passed in the Indian Parliament in May 1994 which cleared the way for organ harvest from brain-dead patients. Successively, Dr P Venugopal and his team performed the first successful heart transplant on August 3, 1994. Hyderabad first transplant was done in global hospital. The full extent of the law and notification happened in 1995 after which other centres in India performed the surgery successfully. 6 heart transplants have been done in NIMS ,INDIA . Collectively, 129 heart transplants have been performed in India since 1994 with 82 in Chennai, 33 at AIIMS and 14 at other centres in India.
- 7. INDICATIONS The ACC/AHAguidelines include the following indications for cardiac transplantation: Refractory cardiogenic shock requiring intra-aortic balloon pump counter pulsation or left ventricular assist device (LVAD) . Cardiogenic shock requiring continuous intravenous inotropic therapy (i.e., dobutamine, milrinone, etc.). Peak VO2 (VO2max) less than 10 mL/kg per min. NYHA class of III or IV despite maximized medical and resynchronization therapy. Recurrent life-threatening left ventricular arrhythmias despite an implantable cardiac defibrillator, antiarrhythmic therapy, or catheter- based ablation. End-stage congenital HF with no evidence of pulmonary hypertension. Refractory angina without potential medical or surgical therapeutic
- 8. Severe symptoms,with dyspnoea at rest or with minimal exertion (NYHA class III or IV) Episodes of fluid retention (pulmonary or systemic congestion, peripheral edema) or of reduced cardiac output at rest (peripheral hypoperfusion) Objective evidence of severe cardiac dysfunction (at least one of the following). Left ventricular Ejection fraction less than 30%, • Pseudonormal or restrictive mitral inflow pattern on Doppler echocardiography. High left and/or right ventricular filling pressure .Severely impaired functional capacity demonstrated by one of the following Inability to exercise, 6-minute walk test distance less than 300 m (or less in women or patients who are age 75 and older), or peak oxygen intake less than 12 to 14 mL/kg/min One or more hospitalizations for HF in the past 6 months
- 9. Absolute contraindications Systemicillness with a life expectancy 2 year despite HT, including Active or recent solid organ or blood malignancy within 5 y (eg. leukemia, low-grade neoplasms of prostate with persistently elevated prostate-specific antigen) . AIDS with frequent opportunistic infections. Systemic lupus erythematosus, sarcoid, or amyloidosis that has multisystem involvement and is still active . Irreversible renal or hepatic dysfunction in patients considered for only HT. Significant obstructive pulmonary disease (FEV1 1 L/min) Fixed pulmonary hypertension • Pulmonary artery systolic pressure 60 mm Hg . Mean transpulmonary gradient 15 mm Hg .Pulmonary vascular resistance 6 Woods units.
- 10. REFERRAL AND EVALUATIONOF POTENTIAL CANDIDATES Patient with advanced persistently symptomatic heart failure despite optimal medical therapy may be refferred for cardiac transplantation. Referral can be initiated by a primary Cardiologist,Internist,Family practitioner,The patient and the family member. Referral usually made up to nearest heart transplant centre with the beneficial insurance companies.
- 11. EvALuation protocol forcardiac transplantation General Complete history and physical examination Nutritional status evaluation Blood chemistry evaluation Hematology and coagulation profile Lipid profile Urine analysis 24 hour urine for creatinine clearance test Nuclear renal scan with measurement of effective renal plasma flow PFT and ABG Ventilation perfusion scan Mammography Prostate specific antigen
- 12. Abdominal USG,Carotid USG Social evaluation Psychiatric evaluation dental evaluation X-Ray PNS CARDIOVASCULAR ECG Chest X-ray PA and lateral view Two dimensional ECHO with Doppler study Exercise testing Cardiac catheterization Myocardial Biopsy Holter monitor Radionuclide Angiogram Nuclear imaging study
- 13. IMMUNOLOGY ABOblood type and Antibody screen Panel reactive antibody screen Human leukocyte antigen typing INFECTIOUS DISEASE SCREENING Serology for HepatitisA,B,C,Herpes virus,HIV,Toxoplasmosis,Varicella,Rubella,Ebstein Barr virusVDRL,Histoplasmosis, Throat swab Urine culture and sensitivity Stool for Ova and parasites purified protein derivatives skin test with control
- 14. Listing patient forcardiac transplantation Once evaluation completed the information are compiled and presented to the team meeting to decide whether or not placed on the waiting list Candidates are listed as per UNOS It depends upon three factors The severity of a patient’s heart disease Absence of absolute contraindications to transplantation Exclusion of other surgical therapeutic options
- 16. MANAGEMENT OF PATIENTSAWAITInG CARDIAC TRANSPLANTATION Regular follow up Unstable heart failure patient may require hospitalization until transplantation Management by pharmacological and non pharmacological theraphy.
- 17. Donor selection Donor-RecipientSize Matching Matching Donor and Recipient Donor-Recipient Size Matching Because ischemic time during cardiac transplantation is crucial donor recipient matching is based primarily not on HLA typing but on the severity of illness ABO blood type (match or compatible) response to PRA, donor weight to recipient ratio (must be 75% to 125%), geographic location relative to donor length of time at current status
- 18. Cardiac donor criteria Brain death Consent Age generally less than 55 ABO blood type compatibility Compatible donor recipient weight Absence of active infection Absence of malignancy except primary brain tumour Absence of pre existing heart disease or cardiac tumour Negative serology test Acceptable left ventricular function
- 19. Criteria For DeterminingBrain Death Clinical Evaluation Mechanism of brain injury is sufficient to account for irreversible loss of brain function Absence of reversible causes of CNS depression CNS depressant drugs Hypothermia (<32°C [85°F]) ,Hypotension (MAP <55 mmHg) Absence of neuromuscular blocking drugs that may confound the results of the neurologic exam No spontaneous movements, motor responses, or posturing
- 20. No gagor cough reflexes No corneal or pupillary light reflexes No oculovestibular reflex (cold calorics) Confirmatory Tests Apnea test for minimum of five minutes showing No respiratory movements PCO2 >55 mmHg pH <7.40
- 21. Principles in donormanagement Restoration and maintanence of adequate hemodynaemic stability Maintenance of adequate oxygen perfusion Treatment of brain death related complication Donor Selection And Management Acceptance of the concept of irreversible brain death, both legally and medically. Patients with irreversible brain injury accompanied by the intent to withdraw life support are considered to be potential organ donors.
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- 24. Preoperative nursing care PsychologicalPreparation The patient may tensed about his surgery because of ignorance, feet, etc. the nurses should give psychological support to the patient. Discuss with the patient to give feel information about the surgery such as: Type of surgery Consequence of surgery The problems to be faced Expected duration of hospitalization Expected time of resuming duty Cost of surgery Treatment done before surgery and if purpose
- 25. Eradicate Fear ofOperation from the Patient The means surgery operation itself make fear to the patient so for reducing that fear the nurses should Allow the patient to ask questions and clear all his doubts Introduce the patient to some ones who has similar surgeries and successfully recovered from the symptoms Explain how to get rid of pain after surgery Tell the patient when he can have meals Answer all questions soaked by the patients in a language he can understand Let the patient see the persons, places and equipment involved in the operation Always short the procedures with an example For many patients, their admission to the hospital is an experience in their times. In such situation, the nurses should make them feel at home in by eradicating their fear
- 26. OBTAIN INFORMED CONSENT Thenurses should get an informed consent from patient/guardian for each operation Never compel them to give their consent They should understand the language used in the consent form Explain the complications that may occur in the period of anaesthesia BUILD UP THE GENERAL HEALTH OF THE PATIENT AND CORRECTION OF THE DISEASE PROCESS FOR SPEEDY RECOVERY Assist the doctor to carry out thorough physical examination Collect all baseline dates Arrange for the blood donors Diet may be adjusted to correct underweight/overweight of the patient
- 27. PREOPERATIVE TEACHING We shouldteach the patient to increase his health by giving advices like (a) stop smoking, (b) maintain personal hygiene, (c) deep breathing and coughing exercises [d]active and passive exercise SURGICAL PREPARATION OF THE SKIN Skin preparation helps reduce the number of microorganism present on skin and thus reduce the possibility of wound infection. Shave the area and clean the area with antiseptic lotion/swab
- 28. PREPARATION OF THEPATIENT ON THE EVENING BEFORE OPERATION Remove the lipstick and nail polish Remove all jewelry and hand over them to the relatives shave the area to be operated Ask shaving, ask the patient to have a through bath and dress in clean clothes The patient should be reassured to prevent anxiety and fear of operation
- 29. PREPARATION OF THEPATIENT ON THE DAY OF SURGERY Help the patient for eliminaton and for mouth care Remove hair pins, clips, ornaments, false teeth, etc Comb and tie hair with a ribbon Remind the patient and his relative about the fasting before surgery Check the orders for bowel preparation Clean the operation site with soap and water thoroughly, dry the area with clean towel Cover the site with sterile towel and fix it by means of bandages Introduce nasogastric tube, urinary catheter if ordered Stop all medications unless specifically ordered by the surgeon
- 30. SENDING THE PATIENTTO OPERATING ROOM Administer the premedication to the patient one hour before surgery Check the vital signs Write the patients name, age, sex, ward, bed no, diagnosis, hospital number etc., on a identification card and fasten it on to the dress or as on arm to prevent mistaken identify Ask the patient on to void just before sending to operating room Transfer the patient on to a patient trolley and cover him with clean sheets to prevent draught Never leave the patient alone on trolley Always send the patients charts with all reports Always send the patient with an attended up to the operation theater
- 31. Pre operative nursingdiagnosis Ineffective Breathing Pattern related to end stage heart failure Fear/Anxiety related to Change in health status; threat of death Risk for Injury related to complications of drug therapy Risk for Infection related to Presence of pathogens/contaminants, environmental exposure, invasive procedures Risk for Imbalanced Body Temperature related to Exposure to cool environment Deficient Knowledge about surgical procedures related to lack of exposures Altered Sensory/Thought Perception related to Therapeutically restricted environments; excessive sensory stimuli Risk for Deficient Fluid Volume related to Restriction of oral intake
- 32. The heart transplantprocess The heart transplant process starts when doctors refer patients with end- stage heart failure to a heart transplant center for evaluation. Patients found to be eligible for a heart transplant are placed on a waiting list for a donor heart. Heart transplant surgery is done in a hospital when a suitable donor heart is found. After the transplant, patients are started on a lifelong health care plan involving multiple medicines and follow up.
- 34. Cardiac transplantation procedure It is important to carefully plan the entire operation to attempt to limit the donor ischemic time to less than 6 hours and preferably less than 4 hours. Ischemic times should also be limited to around 4 hours or less in situations where the donor heart is marginal (older donor) as well as in recipients with increased pulmonary vascular resistance. Both the bicaval and the biatrial technique can be safely performed with excellent long-term outcomes in patients with endstage heart failure. Numerous studies have been performed comparing both these techniques with varied results. The bicaval technique preserves normal atrial morphology, sinus node function, and valvular function.
- 35. As aresult, it has consistently been associated with a decreased incidence of atrial arrhythmias and the need for pacemaker implantation. However, potential disadvantages include an increased ischemic time and the possibility of narrowing of the caval anastomosis. Standard median sternotomy is Performed The vena cavae are also cannulated (preferably with right-angled metal tip cannulas) as distally as possible Recipient cardiectomy the aorta is cross-clamped cavo-atrial junction incision is ideally made : medially through the ostium of the coronary sinus and laterally through the floor of the fossa ovalis cuff of posterior left atrial tissue. BIATRIAL TECHNIQUE The SVC is doubly ligated and the right atrium is opened from the lateral IVC toward the right atrial appendage, to avoid the sinus node Donor heart The left atrial cuff Connecting incisions between each of the 4 pulmonary veins The superior vena caval cuff is trimmed at the level of the azygous vein opening and more if adequate recipient cuff is present
- 36. Orthotopic hearttransplantation: bicaval anastomosis technique Suturing the LA Superior and inferior vena caval anastomosis Pulmonary artery and aortic anastomosis. Orthotopic heart transplantation: biatrial anastomosis technique The right atrial anastomosis is initiated at the superior end of the atrial incision. A long 3-0 Prolene suture is used and the suture ends are carried both inferiorly and superiorly to first complete the septal anastomosis, and then they are joined at the lateral wall of the septum. Completed orthotopic heart transplantation Reperfusion Look for LA anastomotic site bleed RA RV site If need Inotropic support Vasodilators
- 37. CPB separation,May develop bradyarrythmias – Require direct acting sympathomimetics, pacing Most grafts recover normal ventricular function – Dysfunction secondary to ischemia – Concern with early recognition of right ventricular failure RV failure – PVR > 4 Woods units with little or no reversibility preop – Low CO with elevated CVP (> 15) and elevated PAP (> 40). PCWP may be low. The most common reason for failure to wean a heart transplant recipient from cardiopulmonary bypass is right-sided heart failure, evidenced by a low cardiac output despite a rising central venous pressure.
- 38. Heterotopic hearttransplantation Heterotopic heart transplantation involves a donor heart being connected in parallel with the recipient heart. The end result involves four surgical anastomoses: at the levels of the right atria, left atria, aortas, and pulmonary trunks. Advantages to the heterotopic technique compared with the traditional orthotopic approach.The native heart basically functions as an “assist device” and usually can maintain circulation during: recovery of donor heart function from ischemia sustained during transplantation. severe rejection episodes. The period of adaptation of a small donor heart to the demands of the circulation. The period of adaptation during which the PVR decreases after transplantation and A period of chronic rejection, while the patients awaits
- 39. There are,however, a few distinct disadvantages inherent in heterotopic transplantation that cannot be ignored. These include: I. the continuing risk of embolic episodes originating from thrombi in the poorly contracting native left ventricle; 2. angina, which may be secondary to persistent ischemia in the native myocardium, and 3. functionally significant right lower lobe atelectasis secondary to the position of the heterotopic heart. This can be a source of persistent pulmonary dysfunction and recurrent pneumonia.
- 40. Post transplant physiology Cardiac denervation is an inevitable consequence : a denervated donor heart. The atrial remnant of the recipient remains innervated, but no impulses will cross the suture line. As a result, the donor atrium is responsible for heart rate generation. The transplanted heart has a higher intrinsic rate and reduced rate variability. Resting heart rates range from 90 to 110 beats per minute. Normal responses to changes in position, e.g. orthostatic changes, are lost as are the variations in response to stimuli such as the Valsalva manoeuvre, carotid sinus massage.
- 41. Intrinsic functionssuch as cardiac impulse formation and conduction are intact. In the innervated heart, the normal acute response to a sudden reduction in intravascular volume is a simultaneous increase in both heart rate and contractility. In the denervated heart, however, the initial response via the Frank- Starling mechanism is an increase in stroke volume dependent on an adequate left ventricular end diastolic volume. The increased contractility secondary to heart rate is a secondary effect and is dependent on circulating catecholamines. The transplanted heart is, therefore, critically preload dependent; higher filling pressures are needed.
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- 53. Post operative nursingcare Haemodynamics monitoring Maintenance of a heart rate of 100-110bpm is an important aspect of early postoperative care that enables optimal cardiac output and adequate renal perfusion to be achieved. reduction of pulmonary vascular resistance is beneficial for right ventricular function. Isoprenaline is administered to achieve both of these, although temporary pacing via epicardial wires may be required. Additional inotropes/vasodilators such as milrinone/adrenaline or glyceryl trinitrate may be used, depending on the patient.
- 54. If thepatient’s cardiac function is satisfactory and adequate hydration is achieved. Maintaining adequate blood pressure is not usually a problem in the early postoperative period. Hypertension is common following cardiac transplant; this is often drug-induced and generally caused by anti-rejection therapy. ACE inhibitors and calcium channel blockers are common treatments. Life-threatening arrhythmias are rare postoperatively, even during acute rejection episodes . Atrial flutter/fibrillation is occasionally seen in patients and, if problematic, can be treated with overdrive atrial pacing, amiodarone or, more rarely, DC cardioversion.
- 55. Respiratory care Patientsrarely experience respiratory problems. Intense physiotherapy, observation of respiratory rate, oxygen saturations, and regular chest X-rays will allow early identification of pulmonary atelectasis. Precise fluid management will help prevent pulmonary oedema. Oxygen therapy will be weaned as the patient’s clinical condition allows. Fluid balance/renal function The assessment and management of a patient’s fluid balance following heart transplant can be challenging. It is essential to keep a fluid balance record, to check the patient’s weight daily, as well as make regular checks of their urea and electrolyte levels, and do clinical examinations. Patients are often oedematous, and this is caused by a combination of fluid overload and having low albumin levels preoperatively. Diuretics are frequently used but care must be taken not to cause hypovolaemia.
- 56. Most patientswill present with renal dysfunction at the time of transplant, secondary to heart failure. The insult of surgery, potential hypotensive episodes perioperatively and nephrotoxic anti-rejection therapy usually worsens renal function in the early days. Regular monitoring of urea and electrolyte levels, maintenance of optimal fluid balance and avoidance of unnecessary nephrotoxic drugs will help. Dialysis may, occasionally, be necessary. Renal-dose dopamine is no longer used routinely for all patients, as many studies have questioned its value Organ rejection Rejection following cardiac transplant is most common in the first six to 12 weeks, although it can occur at any time. Triple therapy anti-rejection treatment consisting of cyclosporin, azathioprine and prednisolone is most commonly administered postoperatively, but the drug regimen will vary from centre to centre. Agents such as tacrolimus, and mycophenolate mofetil can also be used.
- 59. Acute rejection biopsygrading
- 60. All anti-rejection therapyhas side-effects that include: Nephrotoxicity Abnormal liver function Hypertension Diabetes Osteoporosis Bone-marrow suppression Post-transplant lymphoproliferative disease Increased incidence of skin cancer/malignancies Acne/moon face/facial hair Shakiness/tremor
- 61. Signs and symptomsof rejection may include: Weight gain Low grade temperature Lethargy/general malaise Palpitations Shortness of breath Soft heart sounds/S3 gallop Balancing the dose of anti-rejection drugs is crucial both to minimise rejection and avoid a high level of side-effects
- 62. The mostaccurate way of determining rejection remains endomyocardial biopsy . This is initially carried out at weekly intervals and gradually reduced in frequency, according to individual need. Biopsy specimens are examined and graded according to the International Society of Heart . Forty per cent of patients will require treatment for rejection in the first six weeks, through intravenous administration of methyl prednisolone 10mg/kg for three days.
- 63. Infection Patients takingimmunosuppressive drugs are inevitably at risk of infection. All patients are initially nursed in cubicles with restricted visiting. The focus of care to minimise infection risk is early extubation, the removal of lines and ambulation. Antibiotic therapy of flucloxacillin 500mg four times a day is given for 48 hours. In addition, short-term anti-infective treatment will include nystatin suspension (antifungal mouthwash); acyclovir 200mg three times a day (antiviral); and sulfamethoxazole trimethoprim 480mg once a day (to prevent Pneumocystis carinii infection). Any signs and symptoms of infection including pyrexia and raised white-cell count will be investigated and, where possible, an organism identified before further antibiotics are commenced; broad-spectrum antibiotics are rarely used. Patients are taught to take their own temperature and recognise signs and symptoms of common infections.
- 64. Pain control Goodpain control is essential to aid recovery from transplant and facilitate cooperation with physiotherapy (Coleman and Bucker-Milburn, 1996). Although all patients are assessed individually, patient-controlled analgesia (morphine) is commonly used, followed by oral dihydrocodeine and paracetamol. Patients are encouraged to express their needs. Referral to the specialist pain team. Mobility All patients are assessed for the risk of deep-vein thrombosis and will usually be prescribed low molecular weight anticoagulants once a day until they are mobile. Patients who develop thromboembolic problems may require formal anticoagulation therapy. n be made, if necessary.
- 65. Mobility andindependence are encouraged as the patient’s condition and confidence . They are encouraged to sit out of bed on day two, start walking around at four to five days postoperatively and attend the gym on day eight, following a satisfactory cardiac biopsy result. Each patient will require an individual exercise plan tailored to his or her needs . Nutrition and hydration As soon as adequate gastrointestinal function is established, patients are encouraged to eat and drink, and intravenous fluids are discontinued. A good fluid intake of 2L in 24 hours is optimal.
- 66. In theearly postoperative period, a diet high in protein and calories is encouraged to aid recovery and tissue repair . Early dietetic input is established, as patients may require advice on low- potassium, low-sugar or high-magnesium needs. Long-term advice will recommend patients adhere to a low-saturated fat diet, to prevent obesity and raised lipid levels. Constipation will be treated with basic interventions. he focus of care will shift to education and rehabilitation. It is often around this time that a patient’s emotional and psychosocial needs increase.
- 67. Postoperative psychological issues Although successful transplantations have much to do with advances in surgical technique, physical management and immunosuppression, a patient’s emotional and behavioural responses contribute significantly to long-term survival and progress following transplantation. The education process starts as soon as the patient is able to cope with it (three to seven days postoperatively). This is a structured programme that covers self-medication, awareness of side-effects, self-monitoring of signs and symptoms of rejection and infection, checking temperature and weight, and general health advice. Teaching is relaxed and informal and continues in the outpatient clinic. Donor guilt Social and marital problems Stress Body image and compliance
- 68. Side-effects from medication All patients will initially be started on a regimen of high-dose steroids which in themselves can result in depression even before the occurrence of side-effects such as obesity and excessive hair growth. Changes in body image It can affect the patient’s recovery and subsequent drug compliance. Non-compliance with drug therapy/clinic attendance can result in transplant rejection. Younger recipients often perceive themselves as victims, whereas older recipients are grateful for a second chance. Many adolescents have difficulty in coping with the altered body image caused by the medication. Multidisciplinary interventions used to improve compliance and patient recovery include: e
- 69. Rehabilitation and outpatientcare Rehabilitation and education are ongoing processes following the operation, culminating in discharge into hospital accommodation or home within two to three weeks of transplantation Outpatient visits are frequent in the early post discharge period, and medications, investigations and follow-up are adjusted on an individual basis. Within three months, the majority of patients will be able to lead a normal lifestyle and many consider returning to work. In this time of surgical and medical miracles, it is important to recognise that for the well-being and long-term survival of transplant patients, the multidisciplinary input of transplant coordinators, nurses, social workers, psychologists, physiotherapists, chaplains and even ward domestics is paramount.
- 70. Rehabilitation Management AndTreatments A multidisciplinary approach should be used in the treatment, management and rehabilitation of this population. Heart transplant candidates should initiate an exercise routine prior to surgery. Post transplant, patients will be deconditioned, with impaired functionally capacity, decreased cardiac output, and decreased maximal oxygen capacity.
- 71. At different diseasestages Pretransplant stage Left ventricular assist devices (LVADs) can serve as a viable bridge before transplantation, allowing an opportunity to recondition through aerobic training that can include treadmill or free ambulation. New onset/acute Physical conditioning should begin during the inpatient phase, once hemodynamic stabilization has been achieved. Exercise programs should include aerobic exercises in cycle-ergometer or walking with progressive increase on duration and intensity and articular mobility, flexibility, and resistance of large muscular groups. Monitoring should include HR and blood pressure, and subjective fatigue with the Borg Scale. The six-minute walk test measures functional exercise capacity. The Borg Rate of Perceived Exertion Scale determines the perceived exertion during various levels of exercise intensity.
- 72. Sub-acute19 Programs canbegin as early as 2 weeks post-surgery. Structured-supervised programs demonstrate superior outcomes over home-based programs in a physical work capacity and activities of daily living. Walking is recommended on alternate days Closed-chain resistive activities (bridging, half squats, toe raises), abdominal exercises (curl ups and pelvic tilts), flexibility exercises (chest expansion and thoracic mobility, side stretch, trunk twist, scapular squeezes, shoulder rolls), and aerobic exercises (treadmill walking or pedaling on bicycle ergometer). The duration and intensity shall progressively increase to meet the patient’s tolerance with a goal of 30 minutes of continuous aerobic exercise at moderate intensity for each session.
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- 85. Chronic/stable: Cardiac transplantpatients may survive for more than 25 years. Chronic immunosuppression may lead to infections, malignancy, and renal deterioration. Exercise routines should be adopted daily. Exercise must be halted if organ rejection is suspected. Preterminal or end of life care An interdisciplinary approach is used to address patient and family needs. Providers need to educate patient/family about disease progression, functional decline, advanced care planning, and end of life decisions. Goals are targeted to maximize quality of life, focusing on symptoms management. These include pain relief, affirming life and regarding dying as a normal process, and offering a support system to help patients live as actively as possible.
- 86. Patient & familyeducation Education to the patient and family is core to the short- and long-term process. After the heart transplant, the patient must monitor signs of infection, weight changes, pulse, changes in blood pressure and sugar levels. Patients must adhere to nutritional recommendations, medications and the exercise routine. Adjustment to the post-transplant process can require psychosocial support
- 87. HEALTH EDUCATION • Eatingplenty of fruits and vegetables each day • Eating whole-grain breads, cereals and other grains • Drinking low-fat or fat-free milk or eating other low-fat or fat-free dairy products, to help maintain enough calcium in your body • Eating lean meats, such as fish or poultry • Maintaining a low-salt diet • Avoiding unhealthy fats, such as saturated fats or trans fats • Avoiding grapefruit and grapefruit juice due to its effect on a group of immunosuppressant medications (calcineurin inhibitors) • Avoiding excessive alcohol • Staying hydrated by drinking adequate water and other fluids each day • Following food safety guidelines to reduce the risk of infection
- 88. POST OPERATIVE NURSINGDIAGNOSIS Decreased cardiac output related to blood loss and cardiac transplantation. Impaired gas exchange related to trauma of extensive chest surgery Risk for deficient fluid volume and electrolyte imbalance related to alterations in blood volume High risk for impaired tissue integrity related to multiple drains, Hypothermia. Risk of infection related to invasive procedure and exposure to pathogens. Risk for injury related to chemical, physical, and electrical hazards. Risk for alteration in fluid and electrolyte balance related to abnormal blood loss and NPO status.