VOL: 98, ISSUE: 28, PAGE NO: 34
Neil Wrightson, RGN, is transplant coordinator;Alison Blake, RGC, is ward sister;Lisa English, RGN, is ward sister, Freeman Hospital, Newcastle-upon-Tyne
When a donor becomes available the prospective recipient is rushed to hospital as an emergency and prepared for theatre. There follows an anxious period, waiting to hear whether the donor heart is suitable. If it is acceptable, the patient is transferred to theatre and given an anaesthetic, intubated, and has lines inserted.
In the immediate postoperative period - until haemostasis and haemodynamic stability are achieved - the patient will be nursed in a designated cardiac ICU. Extubation is usually rapid, and done once arterial blood gases are found to be satisfactory. Management of the patient usually includes monitoring intra-arterial blood pressure, central venous pressure (CVP), left atrial pressure (LAP) and pulmonary artery pressures (PAP).
Following transfer, ECG monitoring and routine observations will be sustained. In addition, invasive blood pressure and CVP monitoring will continue for a day or two. Mediastinal drains are usually removed soon after transfer when drainage is minimal.
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.
- Abnormal liver function;
- Bone-marrow suppression;
- Post-transplant lymphoproliferative disease;
- Increased incidence of skin cancer/malignancies;
- Acne/moon face/facial hair;
- Weight gain;
- Low grade temperature;
- Lethargy/general malaise;
- Shortness of breath;
- Soft heart sounds/S3 gallop.
Patients taking immunosuppressive 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).
Good pain 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 can be made, if necessary.
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.
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. In the early postoperative period, a diet high in protein and calories is encouraged to aid recovery and tissue repair (Verity, 1996).
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.
- Thorough explanations of the need for medication and clinic visits (even when the patient feels well);
- The planning of medication regimens to fit into the person's lifestyle, through mutually acceptable times, (Cramer, 1991);
- The creation of opportunities to discuss emotional issues, for example, hospital helplines;
- Good rehabilitation (DeGeest et al, 1996).
Rehabilitation and education are ongoing processes following the operation, culminating in discharge into hospital accommodation or home within two to three weeks of transplantation.