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CPPT II > FINAL: UNIT 5: Heart and Lung Transplants > Flashcards

FINAL: UNIT 5: Heart and Lung Transplants Flashcards

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1
Q

With organ transplants there is always a

Native Organ–belongs to pt, needs to be replaced

Donor Organ—-organ coming from somewhere/someone else

A

see pics

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2
Q

PTs Role in:

Pt waiting for transplant

Pt receiving transplant

Pt recovering from transplant

A

see pics

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3
Q

Donors can supply up to ____ organs

A

8

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4
Q

Selection Guidelines: For all transplants

*Recipients

A
  • MUST BE Ambulatory w/ Rehab potential
  • Satisfactory nutritional status w/ Normal BMI
    • ​b/w 18-30
  • Appropriate Mental State
    • ​NO intellectual disability
    • Must comprehend and accept procedure, risks an complications
    • satisfactory psychosocial profile & good support system
    • *Downs pts do NOT qualify
  • Motivated and compliant w/ tx
  • Adequate financial resources for meds and follow
    • ​$10,000 liquid in bank
  • Absence of contraindications
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5
Q

EXCLUSION Criteria

A
  • Active/Recent malignancy (<5yrs cx free)
  • Other end-organ failure or dysf
  • Current smoking or subs abuse (past 6mos)
  • Untreated psychiatric disorders
    • ​ex. Bipolar
  • Known active infection
    • ​TB, HIV, Sepsis
  • Hx of non-compliance
  • Unsatisfactory nutritional status
    • ​Obesity or severe malnutrition
  • Lack of social support
  • Poor rehab pot.—–> THIS IS WHERE PT COMES IN!!!
    • ​PT can SHOW the pt is functional and has ability to rehab
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6
Q

Hx Transplantation Milestones

A
  • 1963
    • first lung transplant
    • 18d survival
  • 1967
    • ​first heart transplant
    • 18d survival
  • 1980-1990​
    • Long term survival achieved***
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7
Q

AFTER Transplant……what is req’d???

A

Lifetime immunosuppressant*

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8
Q

Immunosuppressive Therapy for ANY transplant

3 Modalities of Therapy:

A
  1. Induction
  2. Maintenance
  3. Rejection
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9
Q

Immunosuppressive Therapy for ANY Transplant

1. Induction

A

Used in the IMMEDIATE PERI-TRANSPLANT Pd.

*when risk of rejection is HIGHEST and potent immunosuppression is needed

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10
Q

Immunosuppressive Therapy for ANY Transplant

  1. Maintenance
A

Cont’d for recipient’s lifetime w/ reduced doses of drugs

*every 12hrs vs. 2x/day

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11
Q

Immunosuppressive Therapy for ANY Transplant

3. Rejection

A

IF recognized, higher doses and potent IV immunosuppressants are used

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12
Q

Meds for ANY transplant

***

A

Immunosuppressants

  • Ex. Prednisone—–Steroid
    • ​REMEMBER W/ STEROIDS
      • ​Main MSK SE==> Myopathy

*ALL meds begin as IV and are changed to PO when approp.

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13
Q

Other Meds for ANY transplant other than immunosuppression

A
  • Antifungal prophylaxis
  • Corticosteroids

*Immunosuppression is a lifelong commitment —–> prevents rejection while min. SEs

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14
Q

Heart Transplant Eligibility:

3 Dis’s that lead to transplant:

A
  • 1. Cardiomyopathy
    • ​Dilated
    • Hypertrophic
    • Restrictive
    • Preserved EF
    • Reduced EF
  • 2. HF
    • ​Preserved EF
    • Reduced EF
  • 3. Congenital Heart Dis.
    • ​ALL UNIT 4 DIS’S
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15
Q

Heart Transplant Eligibility

Eligibilty Checklist

A
  • Adv’d HF or MAX medical therapy
  • Freq. hospitalizations
  • Deterioation of clinical status
  • Poor prognosis w/out transplant
    • agree <2 yrs to live w/out transplant
  • NO add. medical options
  • All other guidelines met
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16
Q

Evaluation Testing for Heart Transplant

FULL WORK UP

Ex’s:

A
  • 24 hr urine screen—-assess kidney function
  • chest x-ray
  • colonoscopy
  • blood tests
    • type
    • electrolytes
    • Infectious dis’s
  • mammogram
  • PSA—-Prostate Specific Antigen
  • Dental exam
  • Echo
  • cardiac cath
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17
Q

Listing System

Heart Transplant

1A:

A

*Considered FIRST

  • Pts are HIGHEST priority
  • Must stay in hospital due to meds or machine
  • LVAD, BiVAD, ECMO
  • Vent. dependent
  • IV Inotrope (strength)
  • Limtd life expect w/out transplant
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18
Q

Listing System

Heart Transplant

1B Status

A

*Considered 2nd IF NO 1A Match

  • 2nd highest priority
  • Can live outside hospital
  • May req. sm amts of IV meds or LVAD
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19
Q

Listing System

Heart Transplants

Status 2

A

NO IV meds

NOT hospitalized

Clinically stabe BUT terminal dx

CHDs

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20
Q

Listing System

Heart Transplants

Status 7

A

Pts are listed for transplant BUT have been removed from active list

infection, life event, insurance, finances

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21
Q

Factors influencing Compatibility

Heart transplants

5:

A
    1. Blood Type, ABO compatibility
    1. Listing Status (1A, 1B, 2)
      * LONGER wait==HIGHER priority
    1. Days on waiting list
    1. Cavity Size
    1. Geographic Loc.
      * *Heart can be stored for 4-6hrs*****

*NOTE: More MEN are donors—> more risky behavior

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22
Q

2 Sx Approaches

Heart Transplant

A
    1. Anterior Axilla Approach
      * ​MOST COMMON
      * **RIB 4
    1. Sternotomy
      * ​*Sternal Precautions
      • ​NO lifting
      • NO overhead
      • NO valsalve
      • NO using just one arm to get up or move—-USE BOTH
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23
Q

What is the BIGGEST PROBLEM AFTER Heart Transplant?

Study These Flashcards
A

Denervated heart****

*takes awhile for the heart to become stim’d w/out help from SA Node…..

*WARM-UP IS KEY!!!

24
Q

POST Heart Transplant Complications

Complications assoc’d w/ Sx:

Study These Flashcards
A
  • Rejection
  • Infection
  • Ischemic injury
25
Post Heart Transplant Complications ## Footnote **Comps assoc'd _w/ Transplantation:_**
* INC susceptibility to **infections** * Cx \*\*BOTH are bc **you are on immunosuppressants for LIFE**
26
Post Heart Transplant Comps **Comps assoc'd** **_w/ Immunosuppressive Drugs_:**
* MYOPATHY\*\*\* * PT plays huge role in this/recognizes it!!! * SEs of **long term oral glucosteroids and other immunosuppress drugs (SEE ABOVE)** * **​Osteroporosis/penia**
27
PTs Role in Heart Transplant ## Footnote **Rehab Phases** **POST-Transplant** **In general key points**
* Expect a **blunted HR response** to EX **due to lack of SNS activation/_denervation of heart_-----\> WARMUPS!!!** * **_​_**DELAYED **sinus tachy** * DELAYED **INC SBP** * DELAYED **tolerance to ex.** * Pts CAN obtain **partial reinnervation of the ANS over time\*** * CONSTANTLY check for s/s of **infection/rejection** * ADDRESS WHOLE PATIENT!!!!!
28
PTs Role in Heart Transplant Rehab Phases POST-Transplant **Other key things to remember Dr. Macfarlane mentioned**
* Only terminate Warm-up **when you see an INC in HR** * **​means the heart is finally stimulated** * **\*remember the heart will act like the body is RESTING when its NOT** * We NEED an INC in HR to INC blood flow to body\* * ADDRESS WHOLE PATIENT, not just endurance * EX. **Quad strength in CV pts linked to long-term success!!!**
29
Explain this slide ## Footnote **Denervated Heart vs. Innervated Heart**
* **Denervated Heart** * **​expect blunted HR response ----\> just like BetaBlockers** * **\*REMEMBER** * **​**The denervated heart is now going to rely on **circulating Epi and NE to _attach_ to the SA node receptors bc ANS NOT ATTACHED TO SA Node** * _Catecholamines:_ Wait to kick SA node in * Expect **Delayed recover after Ex. \*\*\***
30
S/S of **Rejection/Infection** **Heart Transplant** **SIGNS ARE THE SAME----this is what makes it difficult and why it is IMPERATIVE you monitor this!!!**
* HEART **Specifically:** * **​S3 gallop--\> Lub, Dub, Dub****​** * **​**S3 sound blood hits walls of HEART, not VALVES * Arrhythmias * JVD * OTHER: * Fever \>100 degs/fever/chills * Changes in BP * Resp distress * Dyspnea * Fatigue * DECd EX **tolerance and capacity** * Wt. gain * Edema \*\*Remember these all look A LOT like signs of infection/sickness too!!!
31
Lung Transplantation Eligibility Broken down by **Categories of Diseases**
See pics
32
Lung Transplant Eligibilty ## Footnote **General List**
* **End Stage lung dis.** on **max med. therapy** * **FREQ. hospitalizations** * Deterioration of clinical status/ADL * O2 dependency * **Poor prognosis W/OUT transplant** * NO add. medical options * **All other guidelines met** **see pics for guidelines broken down by Dis. Category**
33
Lung Transplant Listing System **PT Eval** **What are the components of this?**
* Ht * Wt * Lung Dx code * **Functional status and 6MWT---PT** * assisted ventilation * Supp. O2 * Current ABG
34
Lung Transplant Listing System uses **what score?**
Lung Allocation Score **LAS** **HIGHER score===HIGHER on list**
35
Lung Transplant Listing System **Disease specific categories**
* **_COPD_****:** * **​**%Predicted FVC: **\<60% w/ hypoxemia** * **FEV1 \<25%** * **NOTE:** Obstructive, LOOW * _**Pulm HTN**:_ remember NORM Pulm aa SBP \<25 * \>55mmHg w/ life exp \<3yrs * Pulm AA mean press & systolic press * **_IPF:_** **Idiopathic Pulm Fibrosis** * **​**\<60% Vital Capacity
36
Factors influencing **Compatibility** **Lung Transplant**
* 1. Blood type, ABO compat. * 2. Listing status (LAS score) * 3. Days on waiting list * 4. Thoracic cavity size * 5. Geographic Loc.
37
**Lung Transplant** **Sx approaches**
* 1. Clamshell Incision * **ONLY RESTRICTION post transplant is _NO driving_ and _NO sitting in front of air bag_ for 6mos** * 2. Mediansternotomy * **\*Sternal Precautions** * **​**NO lifting \>10lbs * NO valsalve * NO bending/twisting * NO using just one arm to get up, USE BOTH
38
Post Lung Transplant Comps **Comps assoc'd _w/ Sx:_**
* Rejection * Infection * Ischemic injury * **Bronchial issues** * **​anastomoses dysf-----**no collateral blood supply * **Atrial arrhythmias** * **​A-fib COMMON\*\*\***
39
Post Lung Transplant Comps ## Footnote **Comps assoc'd _w/ Transplant:_**
* INC susceptibility to **infections (PNA)** * **Cx** * Diaphragmatic dysf * **SLT:** Single Lung Transplant--**Complications\*** * Initially **dec perfusion to donor lung** * Chronic **native lung** hyperinflation causing **displaced mediastinum, DEC V/Q of donor lung**
40
Post Lung Transplant Comps **Comps assoc'd w/ Immunosuppressive Drugs**
* SEs of long term oral **glucosteroids and other immunosuppress. drugs** * **​MYOPATHY!!!** * **osteoporosis/penia**
41
**PTs Role in Lung Transplant** **Rehab Phases** **POST-Transplant** **In general key points**
* LUNGS ARE NOW **DENERVATED** * **DELAY in** **bronchodilation w/ onset of exertion due to _denervation nature of the lung_** * **​\***USUALLY DO NOT obtain partial reinnervation of the ANS like the heart * CONSTANTLY check for s/s of **infection/rejection** * **​**same as heart **except now INC in sputum prod.** * **ADDRESS WHOLE PATIENT, not just endurance** * **​\*90% anxiety in lung patho's** * **​pts scared**
42
**PTs Role in Lung Transplant** **Rehab Phases** **POST-Transplant** **Other key things to remember Dr. Macfarlane mentioned**
* WARM-UPS are ESSENTIAL for Lung Transplant * **Warmup must be LOWER MET lvl than your _intended Ex. MET lvl_** * \*remember LUNGS are now deinnervated * WARMUP * 2-5mins * LOWER intensity exercise as warmup * some endurance component
43
S/S Rejection/Infection Post Lung Transplant LUNG IS GENERAL
* **Sputum production** * DECd **lung function** * O2 **desat** * Altered **ABG** * **Hypoxemia----\> LOW O2** * **Hypercapnia----\> HIGH CO2** * **\*\*\*Lung biopsy** via **bronchoscopy===\> GOLD STANDARD for dx of rejection**
44
S/S Rejection/Infection Lungs Gen. List \***Remember these s/s look similar!!!!!**
* Fever\>100degs/fever/chills * Changes in BP * Resp distress * Dyspnea * Fatigue * DEC Ex tolerance and capacity * Wt Gain * Edema
45
LUNG/HEART Transplant ## Footnote **If LESS THAN 3yr Life Expectancy** **What things should you incorporate?**
* EDUCATE * Functional mobility * ID mm imbalances and strength * Strengthen MAJOR MM GROUPS---**Glutes/Quads** * **MM endurance** * **​**those awaiting heart transplant---\> "Cardiac Rehab parameters---REVIEW THESE * Optimize breathing patterns * Address anxiety/depression * yoga/mobilization w/ breathing * **Prevent sedentary lifestyle _despite_** **progressive deterioration of lungs** * **​**DEC strength and diaphragmatic impairments **adversely affect ex. capacity**
46
POST-OP Transplant Heart and Lung **Acute Care:**
* **Monitor VITALS** * **​_Conditional Breathlessness Dyspnea_--\>** usually related to **mm fatigue** and **anxiety** * **Skin care** * **Pulm mgmt/Chest PT/Segmental breathing** * **​**diaphragmatic breathing * INSP. hold----count insp, pause, exhale * biofeedback * pursed lip * airway clear. techs * **aspiration common----\>** assess BEFORE trendelenberg pos * **functional mobility** * **assist in weaning process off mech. vent.** * **strength train** * **EDUCATE** * **​**anxiety, coping mechs, breathing w/ mobility
47
POST-OP Heart/Lung Transplant ## Footnote **Acute Care:** **BED POSITIONING**
* HOB \>30degs to **prevent aspiration** * IF unable to get OOB, **place bed in chair pos when _hemodynamically stable_**
48
**POST-OP Heart/Lung Transplant** **Acute Care:** **SLT POSITIONING (**Single Lung Transplant)
* Pos. pt w/ **donor lung side UP, native lung DOWN to promote _DRAINAGE_** * **_​_**ex. L. lung transplant---lay on R. side
49
POST-OP Heart/Lung Transplant Acute Care: **DLT:** Double Lung Transplant **POSITIONING**
* Pos. pt **supine for and rotate ASAP, every 2hrs** * **​SAME W/ HEART TRANSPLANT**
50
**POST-OP Heart/Lung Transplant** **Acute Care:** **POSITIONING DURING REJECTION**
**Donor lung DOWN to optimize _perfusion_**
51
Acute Care POST-OP Heart/Lung Transplant POSITIOINING in gen.
**OUT OF BED AS SOON AS MEDICALLY STABLE**
52
Post-Op Heart/Lung Transplant ## Footnote **In-pt rehab**
* pts function optimized @ 3-6mos post-transplant * Functional mob. * UE/LE mm endurance/strength * posture training/scapular strength * Chest PT * Pt specific impairs
53
POST-OP Heart/Lung Transplant **Home PT**
\*Transition to OP PT ASAP bc pts function is **optimized @ 3-6mos post-transplant** **\*so after 3-6mos you want to get them into OP PT bc they are at the best their going to be w/ other PT methods**
54
Post-Op Heart/Lung Transplant **Outpatient PT**
* **Scar mgmt** * **​**avoid ST restrict/dec rib mob/chronic pain * **STM and rib mobs of T/S and ribcage** * \*mult studies have found DEC FEV1, DEC VO2max and DEC daily activity compared to healthy people of same age, ADDRESS IT * **DO NOT UNDERDOSE!!!** * **EXERCISE PRESCRIPTION:** * **​_Progressing_** aerobic endurance ex * INC mm strength * \*LE weakness is **one of primary cause of ex limitations----NOT dyspnea** * INC endurance tol and ADL function * spirometry vol's * GOALS: * community acts w/out fatigue * \***Risk of re-admission is high------- optimize function and pulm status _as early as possible_**
55
Phys Activity Levels After Lung Transplant
\*Take Home Message: **Ceiling effect reached 3-6mos** **\*DO NOT UNDERDOSE------ALWAYS ROOM FOR PROGRESSION!!!** **SEE STUDY BELOW**
56
POST-OP Care Heart/Lung transplant **Infection Control**
* Infection control is **KEY** * **​**hand washing * **Staff wears a mask in pt environment** * **​\*LUNG transplant** * avoid flowers & plants in room * NO lab jackets/coats in room ## Footnote **\*\*65% of pts post-op transplant will get an infection\*\***

CPPT II (6 decks)

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