- Email: [email protected]
Cardiac Transplantation
JANUARY 1987, VOL.45, NO 1
AORN JOURNAL
Cardiac Transplantation ORGAN PROCUREMENT TO PATIENT DISCHARGE
Diane M. Rudolphi, RN; Kathleen M. Nagy, RN; Debra J. Verne, RN
A
59-year-old male was admitted to The Hershey Medical Center, Pennsylvania State University, with a diagnosis of endstage idiopathiccardiomyopathy.He had sustained a left ventricular myocardial infarction in 1977, and underwent triple coronary artery bypass grafts in 1980. Five years later, the patient developed a flu-like illness followed by increased difficulty with chest pain, shortness of breath, and fatigue.
Diane M. Rudokhi
Evaluation revealed progressive deterioration of cardiac function, requiring heart transplantation. After a battery of tests, the patient was found to be a good candidate for heart transplantation. Within six months, a donor organ became available, and he underwent a cardiac transplant without complications. The patient remained in the intensive care unit (ICU) for five days and was then transferred to the transplant nursing floor
Kathleen M. Nagy
DebraJ. Verne
Diane M. Rudolphi, RN, BSN, is an operating room nurse in cardiothoracic surgery, The Hershey Medical Center, Pennsylvania State University. She received her bachelor of science degree in nursing f r o m Texas Christian University, Fort Worth.
Debra J. Verne, RN, MPA, h a primary nurse clinician, Z3e Hershey Medical Center, Pennsylvania State University. She received both a bachelor of science degree in nursing and a master’s degree in public adminhtration from Pennsylvania State University, Middletown
KathleenM. Nagy, RN,BSN, C C M ,LYa nursing staff development instructor, The Hershey Medical Center, Pennsylvania State University. She received her bachelor of science degree in nursing from the Universiry of Delaware, Newark.
The authors wish to thank Joanne Berg, physician assistant; John Pennock, MD, transplant surgeon;and John Waldhausen,MD, and William Pierce, MD, editors, for their contributions to this manuscript.
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for 18 days before discharge. The patient was started on immunosuppressive therapy at the time of transplantation. The patient had cardiac biopsies periodically to evaluate the effectiveness of the therapy in preventing rejection. One year after the transplant, repeat cardiac biopsies revealed no necrosis of endomyocardial tissue.
Recipient, Donor Criteria
T
o ensure that the cardiac transplantation will be successful, both the recipient and donor must meet certain criteria. Both must meet age requirements and undergo tests to ensure that the recipient and the donor heart are physically compatible. Recipient. A candidate must have end-stage heart disease (with symptoms at rest), have a pulmonary vascular resistance less than eight Wood units, have normal function of kidneys, liver, and lungs, have a negative T-lymphocyte cross-match with the donor (this indicates no preformed antibodies against the donor), be less than 55 years of age, be free of infection, peptic ulcer disease, malignancy, and insulindependent diabetes mellitus, and understand the surgery and complications, and be able to give an informed consent. A good family support system is important to help the patient cope and comply with the lifelong regimen. Before transplantation, all potential recipients and their families receive psychiatric evaluations. Transplant patients experience a range of psychological reactions from steroid-induced euphoria to cabin fever and depression. These patients have many concerns and fears about their new hearts and life-styles. After working through their feelings, most patients develop positive outlooks on life. Donor. Most states have passed laws that define death as an irreversible cessation of all functions of the entire brain or of the circulatory and respiratory functions in accordance with accepted
medical standards.' After brain death has been determined, the donor cardiac status is evaluated via history, physical, chest x-ray, and electrocardiogram (ECG) to determine compatability. If there are any questions about the suitability of the donor heart, a cardiac catheterization or coronary angiography is done. Other criteria the donor must meet include having a blood type compatible with the recipient, a direct cross-match of donor cells with recipient serum (only with patients that have unusual antibodies present), approximately the same weight and height as the recipient, and being less than 35 years of age for males or 40 years of age for females. The donor must be declared brain dead and be on a life-support system in ICU because of his or her unstable cardiac status. Periods of hypotension before removal of the heart have been associated with poor postoperative graft function in the recipient.*
Intraoperative Procedure
N
o more than four hours should lapse between excision and implantation; a donor heart is the first organ excised in a multiple-organ procurement case. The heart is arrested with a 4 "C (-15.56 O F ) high potassium cardioplegia solution and 1 L to 2 L of cold topical saline potassium solution. After the organ is procured, it is packed in an ice cooler to help preserve it during transportation. While the donor heart is being harvested in another OR or hospital, the surgical team is setting up for transplantation, which is the same as for a routine open heart procedure. The recipient is brought to the operating room and greeted by the surgical team. The nurse assesses the patient, reviews the record, and verifies information. The patient will probably not have received any preoperative narcotics because of his or her compromised cardiac status, and therefore, will be anxious. The perioperative nurse can help decrease the patient's stress with effective communication skills. After the donor heart is deemed compatible,
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The staffing ratio is 2:1, which allows one nurse to constantly remain with the patient. the anesthetist slowly induces the recipient and monitors vital signs closely. A central venous pressure line, an arterial line, a peripheral line, and a Foley catheter are put into place. A central venous pressure line is used to avoid introducing an invasive line (ie, a pulmonary artery line) through the newly transplanted heart. The OR nurses prepare and drape the patient for a median sternotomy. After systemic heparinkation (dose is based on the patient’s weight), the surgeon makes an incision to expose the heart and inserts three cannulas: one into the aorta, one into the inferior vena cava, and one into the superior vena cava. The recipient is placed on cardiopulmonary bypass and the aorta is cross clamped. Venous blood passes through the venous cannulas to the bypass equipment where the blood is filtered, oxygenated, and cooled before returning to the body via the aortic cannula. The recipient heart is excised with the atria cut posterior to the atrioventricular groove, which preserves the orifices of the veins entering the atria. The incision extends across to the great vessels distal to the aortic and pulmonary valves.3 Both hearts are trimmed leaving both donor and recipient sinoatrial nodes intact. The surgeons anastornose the left atrium and the right atrium of the donor heart to that of the recipient using a 54-inch double-armed 3-0 polypropylene suture (Fig 1): Next, the surgeons anastornose the aorta using a continous running double-armed 4-0 polypropylene suture (Fig 2).5 Before closing the aorta, the surgeons manipulate the heart to expel air. The aortic cross clamp is removed after the aorta is closed. Coronary artery perfusion then occurs, which decreases the danger of myocardial ischemia. Rewarming is also in progress; as the heart rewarms, electrical activity begins and ventricular fibrillation may occur. The surgeons then anastornose the pulmonary artery using a 4-0 polypropylene double-armed suture (Fig 2): It 84
takes approximately 45 minutes to complete the four anastomoses. Next, the surgeons defibrillate the heart using internal paddles to restore cardiac rhythm and put epicardial pacing wires into place. The sternum is closed using #6 sternal wires, and absorbable sutures are used for the fascia and subcutaneous layers. The entire procedure takes approximately 3%to four hours. During the intraoperative procedure, the circulating nurse calls the ICU nurse three times: (1) after the patient is taken off bypass, (2) at the start of closure, and (3) when the patient leaves the OR. The patient’s family is also kept informed during the intraoperative procedure by the surgeon.
Postoperative Care
B
efore the patient arrives in the ICU, the room has been thoroughly cleaned and cleared of airborne dust particles and bacteria. An air filter, which affects the air exchange, is used throughout the patient’s hospitalization to clean the air. Also, all equipment and supplies used for patient care are sterilized. The care given to the cardiac transplant patient is similar to the postoperative cardiac surgery patient with the addition of more staff and isolation precaution^.^ The staffing ratio is 2:1, which allows one nurse to constantly remain with the patient while the other nurse runs for equipment and supplies. Measures to isolate the patient are used; at Hershey Medical Center, full isolation requires that transplantation team members wear caps, masks, gowns, gloves, and shoe covers when caring for the patient for the first several days. Full isolation varies in length of time depending on the patient’s condition. Only masks and handwashing are required after full isolation is lifted.* One reason for the less restrictive isolation is that with the
JANUARY 1987, VOL. 45, NO 1
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Donor left atrium
Donor right atrium
C
Fig 1. (a) The first anastomosis joins the left atrium of the donor to that of the recipient. (b) and (c) The donor’s right atrium is anastomosed to the recipient’s right atrium. (Reproduced with permission from J. A . Wuldhausen, W S. Pierce, Johnson’s Surgery of the Chest, f i f h ed. Copyright @ 1985 by Year Book Medical Publishers, Inc, Chicago)
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i
Fig 2. (a) The aortic anastomosis is completed and (6) the final anastomosis is that of the pulmonary artery, (Reproduced with permissionfrom J. A. Waldhausen, W S. Pierce, Johnson’s Surgery of the Chest,jfih ed Copyright @ 1985 by Year Book Medical Publishers, Inc, Chicago)
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Most transplant recipients had enlarged and dilated hearts before surgery as a result of cardiac disease, so the pericardial sac is enlarged. use of cyclosporine for immunosuppression, the body's natural defense mechanisms are maintained and the patient is less susceptible to infection? The patient will be intubated and mechanically ventilated. He or she will have two mediastinal chest tubes, a nasogastric tube, and a Foley catheter. The patient is usually extubated within 24 hours. Upon extubation, the patient is encouraged to ambulate from bed to chair and to perform pulmonary exercises, which prevent atelectasis and pneumonia. Also, orthostatic hypotension may occur without reflex tachycardia secondary to loss of autonomic innervation.'O The chest tubes are discontinued when drainage has decreased to less than 20 mL per hour. Most transplant recipients had enlarged and dilated hearts before surgery as a result of cardiac disease, so the pericardial sac is enlarged. The donor heart is generally smaller, allowing more space potentially for blood to accumulate postoperatively.'' The nurse must monitor for signs and symptoms of cardiac tamponade. The nasogastric tube is discontinued when bowel sounds are present, and the patient is given a liquid diet that can be progressed to a low sodium, low cholesterol, high protein diet as tolerated. Cardiac monitoring. The postoperative patient frequently experiences sinus tachycardia because the denervated transplanted heart lacks autonomic influence and regulation. Junctional dysrhythmias and ectopic ventricular beats may also be seen. Bradycardia may also be present as the result of prolonged ischemic time before transplantation. Pacemaker support may be necessary for several days to assist in maintaining cardiac output. The high rate of the pacemaker may also decrease or abolish ventricular ectopy. The pacemaker rate is lowered after several days to allow the patient to adjust to his or her rhythm.12 The nurse may observe two P waves on the 88
ECG monitor. The sinus node of the recipient heart is still intact and under autonomic influence. This impulse cannot cross the suture lines, and therefore, does not depolarize the donor's myocardium, but does depolarize that section of recipient's atrium that was left in place. The sinus node of the donor heart is functional, and the impulses it generates will depolarize the entire myocardium.'3 The transplanted myocardium is sluggish initially because of edema, anoxic injury, and lack of sympathetic nervous stimulation. Cardiac output is lower, but it increases in several days unless rejection occurs. Usually, dopamine or isoproterenol is administered to increase contractility, heart rate, blood pressure, and perfusion.14 If vasoconstriction is neeeded, phenylephrine may also be administered. Evidence of ventricular failure may appear early in the postoperative period. Most recipients experience mild pulmonary hypertension, therefore, the right ventricle has an increased afterload against which to pump.'5 Sodium nitroprusside can be administered to decrease afterload and improve cardiac performance. Infection controUimmunosuppression. Removal of invasive lines, such as the Foley catheter, chest tubes, and arterial line, is done as soon as possible to reduce infection. Infection is a potential problem and a major cause of morbidity and/or mortality in the cardiac transplant patient.'6 Immunosuppressive agents to prevent organ rejection are started during the intraoperative period; the patient will continue to take these throughout his or her life. Cyclosporine, azathioprine, and prednisone are the primary drugs used. Cyclosporine inhibits T-cell function while leaving humoral immunity intact and without depressing cellular function of bone marrow. The use of cyclosporine allows small doses of azathioprine and steroids to be administered. The
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initial dose is 14 mm/kg/day to 18 mm/kg/day, and then is tapered to a maintenance dose of approximately 10 mm/kg/day.17 With cyclosporine, the opportunity for rejection is reduced and the patient has an increased chance of survival.l 8 Before cyclosporine, the one-year survival rate at Stanford (Calif) University Medical Center between 1974 and 1980 was 63%. With cyclosporine as the primary immunosuppressive agent, the survival rate has increased to 80%since 1980.19
Rejection
D
espite immunosuppressive therapy, rejection can occur. There are three types-hyperacute, acute, and chronic. The severity and timing of the rejection affects long-term graft survival. The first episode is usually the most severe. The earlier and more severe the rejection, the worse the ultimate prognosis for graft survival.20 Hyperacute rejection occurs in the operating room as the result of antigen-antibody reaction, but can be avoided with proper cross matching before the surgery.21The treatment for this type of rejection is retransplantation. Acute rejection occurs within the first six months after transplantation, usually within the first three weeks. Acute rejection is treated with pulse therapy, which is a large dose of corticosteroids and/or the administration of antilymphocytic globulin for three days. At Hershey Medical Center, the drug is administered through a central line with a special filter throughout a six-hour period. Chronic rejection occurs after six months of transplantation. It is a progressive low-grade rejection producing atherosclerosis of the graft and narrowing of the coronary arteries.** A cardiac biopsy is used to check if rejection is occurring. A bioptome is inserted under fluoroscopy via the right internal jugular vein into the right ventricular apex. It is done under local anesthesia with anesthesia standby. The bioptome obtains four to five samples approximately 1 mm in size. Although most rejection episodes are indicated by diffuse changes, several specimens
are taken because of possible focal rejection. The tissue specimens are immediately examined for edema, lymphocytic and mononuclear infiltrates, fibrinous exudates, myocyte change, or necrosis. After examination, the rejection is labeled mild, moderate, or severe.23 At Hershey Medical Center, a jugular line is left in place after each biopsy for easy access for biopsy and blood sampling. The jugular line is replaced after each biopsy. The first biopsy is performed at the end of the first week posttransplantation and is continued weekly for six weeks. The biopsies are then performed monthly for six months and bimonthly for another six months, unless signs and symptoms develop.
Discharge Planning
A
fter the patient is stable (usually one week), he or she is transferred from the adult critical care complex to a surgical floor specializing in the care of cardiac transplant patients. The patient is encouraged to participate in his or her own care because a nurse is not present 24 hours a day. Protocols, such as weekly biopsies and isolation procedures (ie, limited personnel, air filter, handwashing with povidoneiodine, and masks) are continued. Nursing care includes cleansing the jugular line, applying povidone-iodine ointment, and covering the site; taking throat, urine, blood, and sputum cultures on a weekly basis; blood samples on a daily basis; and monitoring the patient for signs of infection. Blood samples (ie, complete blood count, electrolytes, blood urea nitrogen, creatinine, glucose, platelets) are used to monitor routine labs and adjust immuosuppressive drug protocols as necessary. Specifically, azathioprine affects the white blood count and antilymphocytic globulin affects the platelet count Besides primary nursing care, the nurse helps the patient prepare for rehabilitation and discharge. The nurse teaches the patient about infection control: use of antibiotics before invasive procedures or dental work, notification of physician upon signs of infection, and avoiding family or friends who are ill. Other aspects include teaching the patient about medication, weight 89
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control, exercise, and elimination of smoking. The overall goal is to assist the patient to return to as normal a life-style as possible. The patient is given a three-month supply of medication at the time of discharge, instructions on how to use them, and a flow sheet on which to record times and dosages. Dipyridamole may be added to the regimen in an effort to decrease the incidence of chronic rejection because it prevents platelet aggregation.24 The patient is readmitted to the hospital on a yearly basis for blood work, cardiac biopsy, cardiac catheterization with coronary arteriograms, and a complete physical. These tests assess the well-being of the patient and detect chronic rejection.
Summaly
T
he care of the cardiac transplant patient is complex, yet rewarding. During the hospital stay, the patients, families, and nurses develop close-knit relationships that last after discharge. The cardiac transplant patients at Hershey Medical Center have formed a support group. To promote organ donation, they wear Tshirts, hats, and coats with the logo, “I got my heart at HMC,” (Hershey Medical Center). This not only increases awareness of the need for organ donation, but also gives Hershey Medical Center recognition for its cardiac transplantation program. 0 Notes 1. Providing for Determination of Death, Pennsylvania Public Act #1982-323. 2. A K Ream, R P Fogdoll, Acute Cardiovascular Management Anesthesia and Intensive Care (Philadelphia: J B Lippincott, 1982) 556. 3. J Johnson, Johnsonk Surgery of the Chest, fifth ed, eds. J A Waldhausen, W S Pierce, (Chicago: Year Book Medical Publishers, 1985) 5 16-519. 4. Ibid 5. Zbid 6. Zbid 7. G A Painvin et al, “Cardiac transplantation: Indications, procurement, operation, and management,” Heart and Lung 14 (September 1985) 485; M Funk, “Heart transplantation: Postoperative care during the acute period/CE quiz,” Critical Care Nurse 6 (March/ April 1986) 32.
8. W M Nauseef, D G Maki, “A study of the value of simple protective isolation in patients with granulocytopenia,” New England Journal of Medicine 304 (Feb 19, 1981) 448453; Painvin et al, “Cardiac transplantation,” 484485. 9. Painvin et al, “Cardiac transplantation,”484-485. 10. Funk, “Heart transplantation,” 36. 11. Zbid 12. Ibd 32, 35. 13. Zbid 14. E B Stinson et al, “Hemodynamic observations in the early period after human heart transplantation,” Journal of Thoracic and Cardiovascular Surgery 69 (February 1975) 264-270; R D Leachman et al, “Response of the transplanted, denervated human heart to cardiovascular drugs,” American Journal of Cardiologv27 (March 1971) 272-276. 15. D C Thornby, “Cardiac transplantation: Nursing during the acute period,” Dimensions in Critical Care Nursing 2 (July/August 1983) 212-224. 16. J G Losman, “Hearttransplantation: A challenge for the eighties,” Acta Cardiologica (Bruxelles) 38 (1983) 174. 17. A L Covner, J A Shinn, “Cardiopulmonary transplantation: Initial experience,” Heart and Lung 12 (March 1983) 131-132; C H Harwood, C V Cook, “Cyclosporine in transplantation,” Heart and Lung 14 (November 1985) 532; Funk, “Cardiac transplantation,” 37-42;Losman, “Heart transplantation,” 171-172. 18. Painvin et al, “Cardiac transplantation,” 485486; Harwood, Cook, “Cyclosporine in transplantation.” 19. Ream, Fogdoll, Acute CardiovascularManagement: Anesthesia and Intensive Care 549-564. 20. J L Pennock et al, “Cardiac transplantation for the future: Survival, complications, rehabilitation, and cost,” Journal of Thoracic and Cardiovmcular Surgery 83 (February 1982) 170-171. 21. Funk, “Heart transplantation,” 36. 22. Ibiri; Losman, “Heart transplantation,” 175; Pennock et al, “Cardiac transplantation,” 171-172. 23. P K Caves et al, “Transvenousintracardiac biopsy using a new catheter forceps,” Heart and Lung 4 (JanuaryIFebruary 1975) 71-73. 24. Funk, “Heart transplantation,” 37.
AORN JOURNAL
Cardiac Transplantation ORGAN PROCUREMENT TO PATIENT DISCHARGE
Diane M. Rudolphi, RN; Kathleen M. Nagy, RN; Debra J. Verne, RN
A
59-year-old male was admitted to The Hershey Medical Center, Pennsylvania State University, with a diagnosis of endstage idiopathiccardiomyopathy.He had sustained a left ventricular myocardial infarction in 1977, and underwent triple coronary artery bypass grafts in 1980. Five years later, the patient developed a flu-like illness followed by increased difficulty with chest pain, shortness of breath, and fatigue.
Diane M. Rudokhi
Evaluation revealed progressive deterioration of cardiac function, requiring heart transplantation. After a battery of tests, the patient was found to be a good candidate for heart transplantation. Within six months, a donor organ became available, and he underwent a cardiac transplant without complications. The patient remained in the intensive care unit (ICU) for five days and was then transferred to the transplant nursing floor
Kathleen M. Nagy
DebraJ. Verne
Diane M. Rudolphi, RN, BSN, is an operating room nurse in cardiothoracic surgery, The Hershey Medical Center, Pennsylvania State University. She received her bachelor of science degree in nursing f r o m Texas Christian University, Fort Worth.
Debra J. Verne, RN, MPA, h a primary nurse clinician, Z3e Hershey Medical Center, Pennsylvania State University. She received both a bachelor of science degree in nursing and a master’s degree in public adminhtration from Pennsylvania State University, Middletown
KathleenM. Nagy, RN,BSN, C C M ,LYa nursing staff development instructor, The Hershey Medical Center, Pennsylvania State University. She received her bachelor of science degree in nursing from the Universiry of Delaware, Newark.
The authors wish to thank Joanne Berg, physician assistant; John Pennock, MD, transplant surgeon;and John Waldhausen,MD, and William Pierce, MD, editors, for their contributions to this manuscript.
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for 18 days before discharge. The patient was started on immunosuppressive therapy at the time of transplantation. The patient had cardiac biopsies periodically to evaluate the effectiveness of the therapy in preventing rejection. One year after the transplant, repeat cardiac biopsies revealed no necrosis of endomyocardial tissue.
Recipient, Donor Criteria
T
o ensure that the cardiac transplantation will be successful, both the recipient and donor must meet certain criteria. Both must meet age requirements and undergo tests to ensure that the recipient and the donor heart are physically compatible. Recipient. A candidate must have end-stage heart disease (with symptoms at rest), have a pulmonary vascular resistance less than eight Wood units, have normal function of kidneys, liver, and lungs, have a negative T-lymphocyte cross-match with the donor (this indicates no preformed antibodies against the donor), be less than 55 years of age, be free of infection, peptic ulcer disease, malignancy, and insulindependent diabetes mellitus, and understand the surgery and complications, and be able to give an informed consent. A good family support system is important to help the patient cope and comply with the lifelong regimen. Before transplantation, all potential recipients and their families receive psychiatric evaluations. Transplant patients experience a range of psychological reactions from steroid-induced euphoria to cabin fever and depression. These patients have many concerns and fears about their new hearts and life-styles. After working through their feelings, most patients develop positive outlooks on life. Donor. Most states have passed laws that define death as an irreversible cessation of all functions of the entire brain or of the circulatory and respiratory functions in accordance with accepted
medical standards.' After brain death has been determined, the donor cardiac status is evaluated via history, physical, chest x-ray, and electrocardiogram (ECG) to determine compatability. If there are any questions about the suitability of the donor heart, a cardiac catheterization or coronary angiography is done. Other criteria the donor must meet include having a blood type compatible with the recipient, a direct cross-match of donor cells with recipient serum (only with patients that have unusual antibodies present), approximately the same weight and height as the recipient, and being less than 35 years of age for males or 40 years of age for females. The donor must be declared brain dead and be on a life-support system in ICU because of his or her unstable cardiac status. Periods of hypotension before removal of the heart have been associated with poor postoperative graft function in the recipient.*
Intraoperative Procedure
N
o more than four hours should lapse between excision and implantation; a donor heart is the first organ excised in a multiple-organ procurement case. The heart is arrested with a 4 "C (-15.56 O F ) high potassium cardioplegia solution and 1 L to 2 L of cold topical saline potassium solution. After the organ is procured, it is packed in an ice cooler to help preserve it during transportation. While the donor heart is being harvested in another OR or hospital, the surgical team is setting up for transplantation, which is the same as for a routine open heart procedure. The recipient is brought to the operating room and greeted by the surgical team. The nurse assesses the patient, reviews the record, and verifies information. The patient will probably not have received any preoperative narcotics because of his or her compromised cardiac status, and therefore, will be anxious. The perioperative nurse can help decrease the patient's stress with effective communication skills. After the donor heart is deemed compatible,
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The staffing ratio is 2:1, which allows one nurse to constantly remain with the patient. the anesthetist slowly induces the recipient and monitors vital signs closely. A central venous pressure line, an arterial line, a peripheral line, and a Foley catheter are put into place. A central venous pressure line is used to avoid introducing an invasive line (ie, a pulmonary artery line) through the newly transplanted heart. The OR nurses prepare and drape the patient for a median sternotomy. After systemic heparinkation (dose is based on the patient’s weight), the surgeon makes an incision to expose the heart and inserts three cannulas: one into the aorta, one into the inferior vena cava, and one into the superior vena cava. The recipient is placed on cardiopulmonary bypass and the aorta is cross clamped. Venous blood passes through the venous cannulas to the bypass equipment where the blood is filtered, oxygenated, and cooled before returning to the body via the aortic cannula. The recipient heart is excised with the atria cut posterior to the atrioventricular groove, which preserves the orifices of the veins entering the atria. The incision extends across to the great vessels distal to the aortic and pulmonary valves.3 Both hearts are trimmed leaving both donor and recipient sinoatrial nodes intact. The surgeons anastornose the left atrium and the right atrium of the donor heart to that of the recipient using a 54-inch double-armed 3-0 polypropylene suture (Fig 1): Next, the surgeons anastornose the aorta using a continous running double-armed 4-0 polypropylene suture (Fig 2).5 Before closing the aorta, the surgeons manipulate the heart to expel air. The aortic cross clamp is removed after the aorta is closed. Coronary artery perfusion then occurs, which decreases the danger of myocardial ischemia. Rewarming is also in progress; as the heart rewarms, electrical activity begins and ventricular fibrillation may occur. The surgeons then anastornose the pulmonary artery using a 4-0 polypropylene double-armed suture (Fig 2): It 84
takes approximately 45 minutes to complete the four anastomoses. Next, the surgeons defibrillate the heart using internal paddles to restore cardiac rhythm and put epicardial pacing wires into place. The sternum is closed using #6 sternal wires, and absorbable sutures are used for the fascia and subcutaneous layers. The entire procedure takes approximately 3%to four hours. During the intraoperative procedure, the circulating nurse calls the ICU nurse three times: (1) after the patient is taken off bypass, (2) at the start of closure, and (3) when the patient leaves the OR. The patient’s family is also kept informed during the intraoperative procedure by the surgeon.
Postoperative Care
B
efore the patient arrives in the ICU, the room has been thoroughly cleaned and cleared of airborne dust particles and bacteria. An air filter, which affects the air exchange, is used throughout the patient’s hospitalization to clean the air. Also, all equipment and supplies used for patient care are sterilized. The care given to the cardiac transplant patient is similar to the postoperative cardiac surgery patient with the addition of more staff and isolation precaution^.^ The staffing ratio is 2:1, which allows one nurse to constantly remain with the patient while the other nurse runs for equipment and supplies. Measures to isolate the patient are used; at Hershey Medical Center, full isolation requires that transplantation team members wear caps, masks, gowns, gloves, and shoe covers when caring for the patient for the first several days. Full isolation varies in length of time depending on the patient’s condition. Only masks and handwashing are required after full isolation is lifted.* One reason for the less restrictive isolation is that with the
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Donor left atrium
Donor right atrium
C
Fig 1. (a) The first anastomosis joins the left atrium of the donor to that of the recipient. (b) and (c) The donor’s right atrium is anastomosed to the recipient’s right atrium. (Reproduced with permission from J. A . Wuldhausen, W S. Pierce, Johnson’s Surgery of the Chest, f i f h ed. Copyright @ 1985 by Year Book Medical Publishers, Inc, Chicago)
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i
Fig 2. (a) The aortic anastomosis is completed and (6) the final anastomosis is that of the pulmonary artery, (Reproduced with permissionfrom J. A. Waldhausen, W S. Pierce, Johnson’s Surgery of the Chest,jfih ed Copyright @ 1985 by Year Book Medical Publishers, Inc, Chicago)
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Most transplant recipients had enlarged and dilated hearts before surgery as a result of cardiac disease, so the pericardial sac is enlarged. use of cyclosporine for immunosuppression, the body's natural defense mechanisms are maintained and the patient is less susceptible to infection? The patient will be intubated and mechanically ventilated. He or she will have two mediastinal chest tubes, a nasogastric tube, and a Foley catheter. The patient is usually extubated within 24 hours. Upon extubation, the patient is encouraged to ambulate from bed to chair and to perform pulmonary exercises, which prevent atelectasis and pneumonia. Also, orthostatic hypotension may occur without reflex tachycardia secondary to loss of autonomic innervation.'O The chest tubes are discontinued when drainage has decreased to less than 20 mL per hour. Most transplant recipients had enlarged and dilated hearts before surgery as a result of cardiac disease, so the pericardial sac is enlarged. The donor heart is generally smaller, allowing more space potentially for blood to accumulate postoperatively.'' The nurse must monitor for signs and symptoms of cardiac tamponade. The nasogastric tube is discontinued when bowel sounds are present, and the patient is given a liquid diet that can be progressed to a low sodium, low cholesterol, high protein diet as tolerated. Cardiac monitoring. The postoperative patient frequently experiences sinus tachycardia because the denervated transplanted heart lacks autonomic influence and regulation. Junctional dysrhythmias and ectopic ventricular beats may also be seen. Bradycardia may also be present as the result of prolonged ischemic time before transplantation. Pacemaker support may be necessary for several days to assist in maintaining cardiac output. The high rate of the pacemaker may also decrease or abolish ventricular ectopy. The pacemaker rate is lowered after several days to allow the patient to adjust to his or her rhythm.12 The nurse may observe two P waves on the 88
ECG monitor. The sinus node of the recipient heart is still intact and under autonomic influence. This impulse cannot cross the suture lines, and therefore, does not depolarize the donor's myocardium, but does depolarize that section of recipient's atrium that was left in place. The sinus node of the donor heart is functional, and the impulses it generates will depolarize the entire myocardium.'3 The transplanted myocardium is sluggish initially because of edema, anoxic injury, and lack of sympathetic nervous stimulation. Cardiac output is lower, but it increases in several days unless rejection occurs. Usually, dopamine or isoproterenol is administered to increase contractility, heart rate, blood pressure, and perfusion.14 If vasoconstriction is neeeded, phenylephrine may also be administered. Evidence of ventricular failure may appear early in the postoperative period. Most recipients experience mild pulmonary hypertension, therefore, the right ventricle has an increased afterload against which to pump.'5 Sodium nitroprusside can be administered to decrease afterload and improve cardiac performance. Infection controUimmunosuppression. Removal of invasive lines, such as the Foley catheter, chest tubes, and arterial line, is done as soon as possible to reduce infection. Infection is a potential problem and a major cause of morbidity and/or mortality in the cardiac transplant patient.'6 Immunosuppressive agents to prevent organ rejection are started during the intraoperative period; the patient will continue to take these throughout his or her life. Cyclosporine, azathioprine, and prednisone are the primary drugs used. Cyclosporine inhibits T-cell function while leaving humoral immunity intact and without depressing cellular function of bone marrow. The use of cyclosporine allows small doses of azathioprine and steroids to be administered. The
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initial dose is 14 mm/kg/day to 18 mm/kg/day, and then is tapered to a maintenance dose of approximately 10 mm/kg/day.17 With cyclosporine, the opportunity for rejection is reduced and the patient has an increased chance of survival.l 8 Before cyclosporine, the one-year survival rate at Stanford (Calif) University Medical Center between 1974 and 1980 was 63%. With cyclosporine as the primary immunosuppressive agent, the survival rate has increased to 80%since 1980.19
Rejection
D
espite immunosuppressive therapy, rejection can occur. There are three types-hyperacute, acute, and chronic. The severity and timing of the rejection affects long-term graft survival. The first episode is usually the most severe. The earlier and more severe the rejection, the worse the ultimate prognosis for graft survival.20 Hyperacute rejection occurs in the operating room as the result of antigen-antibody reaction, but can be avoided with proper cross matching before the surgery.21The treatment for this type of rejection is retransplantation. Acute rejection occurs within the first six months after transplantation, usually within the first three weeks. Acute rejection is treated with pulse therapy, which is a large dose of corticosteroids and/or the administration of antilymphocytic globulin for three days. At Hershey Medical Center, the drug is administered through a central line with a special filter throughout a six-hour period. Chronic rejection occurs after six months of transplantation. It is a progressive low-grade rejection producing atherosclerosis of the graft and narrowing of the coronary arteries.** A cardiac biopsy is used to check if rejection is occurring. A bioptome is inserted under fluoroscopy via the right internal jugular vein into the right ventricular apex. It is done under local anesthesia with anesthesia standby. The bioptome obtains four to five samples approximately 1 mm in size. Although most rejection episodes are indicated by diffuse changes, several specimens
are taken because of possible focal rejection. The tissue specimens are immediately examined for edema, lymphocytic and mononuclear infiltrates, fibrinous exudates, myocyte change, or necrosis. After examination, the rejection is labeled mild, moderate, or severe.23 At Hershey Medical Center, a jugular line is left in place after each biopsy for easy access for biopsy and blood sampling. The jugular line is replaced after each biopsy. The first biopsy is performed at the end of the first week posttransplantation and is continued weekly for six weeks. The biopsies are then performed monthly for six months and bimonthly for another six months, unless signs and symptoms develop.
Discharge Planning
A
fter the patient is stable (usually one week), he or she is transferred from the adult critical care complex to a surgical floor specializing in the care of cardiac transplant patients. The patient is encouraged to participate in his or her own care because a nurse is not present 24 hours a day. Protocols, such as weekly biopsies and isolation procedures (ie, limited personnel, air filter, handwashing with povidoneiodine, and masks) are continued. Nursing care includes cleansing the jugular line, applying povidone-iodine ointment, and covering the site; taking throat, urine, blood, and sputum cultures on a weekly basis; blood samples on a daily basis; and monitoring the patient for signs of infection. Blood samples (ie, complete blood count, electrolytes, blood urea nitrogen, creatinine, glucose, platelets) are used to monitor routine labs and adjust immuosuppressive drug protocols as necessary. Specifically, azathioprine affects the white blood count and antilymphocytic globulin affects the platelet count Besides primary nursing care, the nurse helps the patient prepare for rehabilitation and discharge. The nurse teaches the patient about infection control: use of antibiotics before invasive procedures or dental work, notification of physician upon signs of infection, and avoiding family or friends who are ill. Other aspects include teaching the patient about medication, weight 89
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control, exercise, and elimination of smoking. The overall goal is to assist the patient to return to as normal a life-style as possible. The patient is given a three-month supply of medication at the time of discharge, instructions on how to use them, and a flow sheet on which to record times and dosages. Dipyridamole may be added to the regimen in an effort to decrease the incidence of chronic rejection because it prevents platelet aggregation.24 The patient is readmitted to the hospital on a yearly basis for blood work, cardiac biopsy, cardiac catheterization with coronary arteriograms, and a complete physical. These tests assess the well-being of the patient and detect chronic rejection.
Summaly
T
he care of the cardiac transplant patient is complex, yet rewarding. During the hospital stay, the patients, families, and nurses develop close-knit relationships that last after discharge. The cardiac transplant patients at Hershey Medical Center have formed a support group. To promote organ donation, they wear Tshirts, hats, and coats with the logo, “I got my heart at HMC,” (Hershey Medical Center). This not only increases awareness of the need for organ donation, but also gives Hershey Medical Center recognition for its cardiac transplantation program. 0 Notes 1. Providing for Determination of Death, Pennsylvania Public Act #1982-323. 2. A K Ream, R P Fogdoll, Acute Cardiovascular Management Anesthesia and Intensive Care (Philadelphia: J B Lippincott, 1982) 556. 3. J Johnson, Johnsonk Surgery of the Chest, fifth ed, eds. J A Waldhausen, W S Pierce, (Chicago: Year Book Medical Publishers, 1985) 5 16-519. 4. Ibid 5. Zbid 6. Zbid 7. G A Painvin et al, “Cardiac transplantation: Indications, procurement, operation, and management,” Heart and Lung 14 (September 1985) 485; M Funk, “Heart transplantation: Postoperative care during the acute period/CE quiz,” Critical Care Nurse 6 (March/ April 1986) 32.
8. W M Nauseef, D G Maki, “A study of the value of simple protective isolation in patients with granulocytopenia,” New England Journal of Medicine 304 (Feb 19, 1981) 448453; Painvin et al, “Cardiac transplantation,” 484485. 9. Painvin et al, “Cardiac transplantation,”484-485. 10. Funk, “Heart transplantation,” 36. 11. Zbid 12. Ibd 32, 35. 13. Zbid 14. E B Stinson et al, “Hemodynamic observations in the early period after human heart transplantation,” Journal of Thoracic and Cardiovascular Surgery 69 (February 1975) 264-270; R D Leachman et al, “Response of the transplanted, denervated human heart to cardiovascular drugs,” American Journal of Cardiologv27 (March 1971) 272-276. 15. D C Thornby, “Cardiac transplantation: Nursing during the acute period,” Dimensions in Critical Care Nursing 2 (July/August 1983) 212-224. 16. J G Losman, “Hearttransplantation: A challenge for the eighties,” Acta Cardiologica (Bruxelles) 38 (1983) 174. 17. A L Covner, J A Shinn, “Cardiopulmonary transplantation: Initial experience,” Heart and Lung 12 (March 1983) 131-132; C H Harwood, C V Cook, “Cyclosporine in transplantation,” Heart and Lung 14 (November 1985) 532; Funk, “Cardiac transplantation,” 37-42;Losman, “Heart transplantation,” 171-172. 18. Painvin et al, “Cardiac transplantation,” 485486; Harwood, Cook, “Cyclosporine in transplantation.” 19. Ream, Fogdoll, Acute CardiovascularManagement: Anesthesia and Intensive Care 549-564. 20. J L Pennock et al, “Cardiac transplantation for the future: Survival, complications, rehabilitation, and cost,” Journal of Thoracic and Cardiovmcular Surgery 83 (February 1982) 170-171. 21. Funk, “Heart transplantation,” 36. 22. Ibiri; Losman, “Heart transplantation,” 175; Pennock et al, “Cardiac transplantation,” 171-172. 23. P K Caves et al, “Transvenousintracardiac biopsy using a new catheter forceps,” Heart and Lung 4 (JanuaryIFebruary 1975) 71-73. 24. Funk, “Heart transplantation,” 37.