Emergency Department Evaluation And Treatment Of The Posttransplant Patient

Cardiac transplant recipients are susceptible to all of the acute illnesses that affect the general population. These patients should be treated in the same way as any other acutely ill or traumatized patient. In the assessment of such patients, however, the possibility that symptoms may be due to rejection, infection, or side effects of their immunosuppressive medications must always be considered. Patients on chronic steroids will have adrenal suppression and may need stress coverage if they are severely ill or in need of surgical intervention. Uninterrupted administration of immunosuppressive medications must be assured to avoid the development of acute rejection. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with extreme caution because of the potential exacerbation of underlying renal insufficiency secondary to cyclosporine or tacrolimus use.

The evaluation of patients presenting with signs and symptoms of congestive heart failure must include the consideration of rejection, myocardial ischemia, and fluid overload due to renal insufficiency. Echocardiography provides important information regarding cardiac performance and may demonstrate findings suggestive of rejection (global dysfunction) or ischemic dysfunction (segmental wall motion abnormality). Results of routine annual cardiac evaluations are useful in assessing whether echocardiographic abnormalities represent acute changes or chronic conditions. Similarly, the availability of old laboratory test results will aid in assessing the importance and acuity of renal impairment.

Any transplant patient presenting with an acute febrile illness warrants aggressive and complete evaluation. If a specific diagnosis cannot be established by history, physical examination, and readily available laboratory and radiographic tests in the ED, consultation with the infectious disease service is indicated. The patient should be admitted to the hospital for further invasive tests and broad-spectrum intravenous antibiotics until culture results are available and a specific diagnosis is made.

In the event that a transplant recipient presents to the ED in extremis, standard cardiopulmonary resuscitation should be performed. Etiologies for hemodynamic collapse related to the posttransplant state include severe acute rejection and myocardial ischemia due to advanced graft coronary disease. Sudden death due to an dysrhythmia may also result from rejection or ischemia. Because of sympathetic denervation, vagally induced bradycardias do not occur; therefore atropine has no role in the resuscitation of these patients. The empiric administration of high-dose steroids (methylprednisolone 1 g intravenously) may be beneficial if rejection is present. Finally, hyperkalemia due to chronic renal insufficiency may result in acute dysrhythmias and should be corrected with standard pharmacologic intervention.

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