Transcript De-mystifying the Transplant Process

De-mystifying the Transplant
Process
Penny Viater, MSN, ANP-BC
Lung Transplant Nurse Practitioner
Referrals
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Outside Referrals
Within institution
Patient driven
The patient is contacted, information
packet mailed & phone interview done
Barring any absolute contraindications a
clinic appointment is made
Timing of Referral
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Less than 50% 2 year predicted survival
Blood type, size affect the timing of
transplant
Early referrals are ideal
Selection Criteria
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Severe end stage disease that is not
treatable
Absence of other serious medical illness
Rehabilitation potential
Acceptable nutritional state (>80 % to
<120% ideal body weight)
Selection Criteria
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Last resort therapy with all alternative
therapy being excluded.
Patient has an unacceptable quality of
life and a limited life expectancy.
Patient satisfies the general guidelines
for transplantation.
Contraindications
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Unresolvable psychological issues or
noncompliance
Lack of availability of social support system
Active tobacco use
Presence of drug or alcohol dependency
Acutely ill or unstable clinical status
Presence of HIV (Ongoing research)
Malignancy
Multi-organ or CNS dysfunction
** Notice NO age limit
The Basic “3” Rule
1) Do you need it
2) Do you want it
3) Do we want to give it to you
Do we want to give it to you?
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Is transplantation the only reasonable
option for success?
Is there a good chance of successful
outcome?
Is there anything the care providers need
to know prior to take better care of the
recipient after the transplant?
The Work-Up
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Hepatitis A Virus Antibody
Hepatitis B Core Antibodies
Hepatitis B Surface Antibodies
Hepatitis B Surface Antigen
Hepatitis C Antibodies
CMV IGG Antibody
EBV IGG Antibody
Toxoplasma Antibody
Varicella Zoster IGG Antibody
Herpes Simplex Virus Antibody
PRA
HLA
ABO, RH & Antibody Screen
RPR
HIV
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(Lungs)
Fasting Lipid Profile
PT/PTT
Chemistry Profile-CMP
CBC w/ Differential
IgE, IgM, IgA
PSA-only in men over 50 years of
age.
Serum Beta HCG for women <50
years of age.
Alpha 1 Antitrypsin- all obstructive
diseases
TPMT Thyopurine
methyltransferase level to check
prior to giving Imuran
The Work-Up
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Chest X-ray PA & Lateral
Psychosocial Evaluation
Nutrition Evaluation
Pap Smear – women 18 & older
Mammogram – women 35 & old
PPD skin test
Complete Pulmonary Function
Tests
Dobutamine Stress Echo – all
patients 35 years of age or older
Left Heart Cath & Right Heart
Catheterization for all patients 45
years or older.
Left Heart Cath & Right Heart
Catheterization under 45years, if
Dobutamine echo is abnormal,
cardiac symptoms are present or
if patient has a strong family
history of cardiac disease.
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(Lungs)
Right Heart Catheterization
except low risk patients who
should undergo a 2D
echocardiogram with Doppler
study
MUGA & Mini-MUGA
Quantitative VQ Scan
Carotid Duplex
DEXA Scan
Random urine cotinine for former
smokers - initially ,then every 3
months .
CT Scan of Chest - with & without
contrast
Six Minute Walk Test
Sputum C & S
Stool for Occult Blood X3
Colonoscopy if age greater than
45
EGD with pH manometry
The Team
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Medicine
Surgery
Psyche
Social Work
Infectious Disease
Endo
GI
Financial Coordinator
Procurement
Coordinator
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Social Worker
Dietician
Hematology
PharmD
Physical Therapy
Pathology
RN
APN
PA
Patient Education
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Work-up consent
Listing consent
Surgery consent
The Transplant process
The meds
Lifestyle changes
Transplantation may be
“trading in one disease for another.”
Listing Criteria
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ABO
Height
Weight
HLA (for some organs)
Listing with UNOS
Each organ is separate, but patients can be
listed for multiple organs
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Status on waitlist
Heart 1A, 1B, 2
Kidney: HLA + time
Lung LAS 0-100
Pancreas: HLA + time
Liver MELD 6-40
The Wait
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Different for each organ
Different for each Blood type
Based on Population
Seasonal
Dry runs
GETTING LONGER!!!
The Surgery
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Bilateral vs. Single lung
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Total between 4-16 hours
Recipient in OR & opened while
procurement in donor hospital going on
Timing is critical
Organ Specific Ischemic Times
CIT: Time donor heart stops to time organ is
reperfused in recipient
Heart = 4 to 6 hrs
Lungs = 4 to 6 hrs
Liver = 18 to 24 hours
Pancreas = 18 to 24 hrs
Kidney = 72 hrs
Lung Transplant
Hemodynamic Management
 Oxygenation
 Pain Control
 Chasing labs
 Rejection vs. infection
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Transplant Medications
- Immunosuppression
- Antibiotics
- Antivirals
- Antifungals
- Protozoan
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Diuretics
CCB, Dig
PPI
Anti-nausea
+ Pre-txp meds
Lung Transplant
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Infection
Leading cause of Lung Txp deaths
Donor source vs. recipient
Think rejection
Environmental exposure
Anastomosis sites
Prevent, Recognize, Treat
Post Transplant
Rejection
Hyperacute rejection occurs minutes to hours
after transplantation.
Acute rejection occurs weeks to months after
transplantation… sometimes years
Chronic rejection occurs progressively over years
Long-Term Care
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Lifestyle changes
Medication side-effects
Compliance
Rejection vs. infection
Vaccination concerns
Going back to work: the insurance fight
Having children after a transplant
Risk for Cancer
Other chronic health problems after transplant