Management Of Posttransplant Patients

Transplant patients are managed by a multidisciplinary team comprising transplant surgeons, pulmonologists, nurse coordinators, pharmacists, physical therapists, dietitians, psychologists, and social workers. At each transplant center, a nurse coordinator is on call to address concerns regarding the care of posttransplant patients in the ED. Patients tend to be well educated and well informed about their disease, but the nurse coordinator may be able to provide additional information regarding recent infection history, medication doses, rejection history, and potential complications in a specific patient. Coordinators should always be called early in the course of patient assessment and management.

Posttransplant patients are at risk for several complications related to their underlying disease, medication side effects, and immunocompromised state. Most centers use cyclosporine, azathioprine, and prednisone for maintenance immunosuppression. In addition, prophylaxis against Pneumocystis carinii pneumonia is undertaken with trimethoprim-sulfamethoxazole (TMP-SMX). Prophylaxis against herpes simplex virus (HSV) and CMV is indicated based on the specific immunologic status of the donor and recipient. Patients learn to measure their pulmonary function (FEV1 and FVC), systemic blood pressure, and temperature daily. They carry a diary with daily vital signs, present medications and doses, names of hospital contacts, and guidelines for contacting the nurse coordinator. Bronchoscopy is necessary to diagnose subclinical rejection and infection. Each transplant center has a protocol concerning bronchoscopy indications. Common warning signs of a fever (>37°C), cough, sputum, or FEV1 decline >10 percent for over 48 h would prompt a call or visit to the transplant center. Since most patients return to their home communities 2 to 3 months following surgery, they may initially be treated and stabilized in their hometown ED prior to transfer back to the transplant center.

The most frequent complications in the lung transplant patient presenting to the ED are infection and rejection, and they are difficult to differentiate clinically. The patient should be placed in respiratory isolation. Initial assessment is similar to that in the pretransplant patient with regard to stabilization and supportive care. In addition to the standard evaluation of airway, respiratory, and circulatory status, initial assessment should include a chest radiograph, arterial blood gas, complete blood count with differential, serum electrolytes, magnesium, creatinine, and cyclosporine level.

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