Intensive Care Management of Combined Organ Transplant
Kareem AbdelhamedElmeslemany;
Abstract
Improvements in organ preservation, surgical techniques, and immunosuppressive therapies have allowed the development of multiorgan transplantations in patients in need of both organs: heart-kidney or liver-kidney. The combined transplants with the liver involve three associations: liver-kidney, heart-liver, and liver-intestine. The most numerous series is liver-kidney transplants.
Kidney transplantation combined with other solid organs is now a good therapeutic option for patients with coexistence of irreversible kidney and other solid organ damage, such as the liver or the heart. This type of transplantation is gradually expanding in number, thereby lengthening the life of patients with chronic liver or heart disease.
As with any other preoperative assessment, a thorough history, physical examination, and consultation with the surgeon regarding the planned procedure will serve as the foundation of the preoperative evaluation of the transplant candidate. To avoid missing important information, a systematic approach to the history and examination is imperative. The patient’s medical, surgical, social, and anesthetic histories are elucidated, and the patient’s medication use and drug allergies are noted. Airway examination and an accurate review of the patient’s cardiopulmonary function are the cornerstones of any preanesthetic evaluation .
Successful transplantation requires that appropriate equipment is available to insure that the patient receives the best care possible. In addition to the standard anesthetic delivery equipment, hemodynamic monitors that include continuous cardiac output and mixed-venous oxygen saturation are generally used as well as the monitors capable of simultaneously displaying four pressure channels. The use of intraoperative transesophageal echocardiography has become common place and serves as an excellent monitor for assessment of preload and ventricular wall motion.
Massive blood loss is not uncommon and a rapid infusion device as well as blood salvage equipment are essential. Point of care testing equipment with the ability to analyze arterial blood gases, electrolytes, glucose, hemotocrit, prothrombin time, partial thromboplastin time and thromboelastography should be immediately at hand. Given the frequent physiologic changes that occur during transplantation, point of care testing equipment available in the operating room significantly reduces the time to receive results (compared with hospital laboratory services), allowing the anesthesiologist to make rapid appropriate clinical interventions .
Adequate perfusion and oxygenation of the transplanted graft, prevention of infections, and surveillance for rejection, immunosuppressive therapy, hydroelectrolyte management, and nutritional support are the main problems observed in the postsurgical period .
It is recognized that combining transplantation of two organs might reduce the risk of acute rejection of each of them: simultaneous pancreas and kidney transplantation results in higher pancreas survival than if the pancreas is transplanted alone and in heart-lung transplant recipients, cardiac rejection is less common than pulmonary rejection, and pulmonary grafts respond more rapidly to antirejection therapy than isolated cardiac grafts.This suggests that any organ transplant combination may facilitate graft tolerance or reduce host immunoresponsiveness.
Potent immunosuppressive agents have dramatically reduced the incidence of rejection of transplanted organs while increasing patients’ susceptibility to opportunistic infections. The majority of clinically important infections occur within the first 6 months post transplant and the risk periods can be divided into 3 intervals: early (0-30 days after transplantation); intermediate (30-180 days after transplantation); and late (more than 180 days post transplantation).
Neurological complications are common after organ transplantation and are associated with significant morbidity. Approximately, one-third of transplant recipients experiences neurologic alterations with incidence ranging from 10% to 59%. The most common neurological complication seen with all types of transplanted organ is neurotoxicity attributable to immunosuppressive drugs, followed by seizures, opportunistic central nervous system (CNS) infections, cardiovascular events, encephalopathy and de novo CNS neoplasms.
The treatment of immunosuppressive neurotoxicity consists of correction of electrolyte imbalance and hypertension, immunosuppressant dose reduction and switching from cyclosporine to tacrolimus or vice versa if necessary. Treatment of seizures in transplant recipients can be difficult because of the interference between most antiepileptic and immunosuppressive drugs and the usual need of intravenous therapy. Phenytoin is the preferred intravenous anticonvulsant, while gabapentin and levetiracetam should be considered as oral anticonvulsants for their efficacy and lack of hepatic enzyme induction.
Acute kidney injury is another post transplant complication that can occur due to the critical clinical state before transplant, intraoperative hemodynamic disturbances, massive transfusion, and many post-operative adverse events, such as infections. Surgical re-exploration, and radiological investigations are frequently involved in the development of acute renal failure. The indications for renal replacement therapy in multiple organ transplantation are the same as in other patient populations. Peritoneal dialysis is not an option in the patient after extensive abdominal surgery with removal of the peritoneum. Continuous venovenous hemodiafiltration is preferred to intermittent dialysis to avoid the large fluid shifts associated with the latter that can lead to hypotension and reduced organ perfusion.
Kidney transplantation combined with other solid organs is now a good therapeutic option for patients with coexistence of irreversible kidney and other solid organ damage, such as the liver or the heart. This type of transplantation is gradually expanding in number, thereby lengthening the life of patients with chronic liver or heart disease.
As with any other preoperative assessment, a thorough history, physical examination, and consultation with the surgeon regarding the planned procedure will serve as the foundation of the preoperative evaluation of the transplant candidate. To avoid missing important information, a systematic approach to the history and examination is imperative. The patient’s medical, surgical, social, and anesthetic histories are elucidated, and the patient’s medication use and drug allergies are noted. Airway examination and an accurate review of the patient’s cardiopulmonary function are the cornerstones of any preanesthetic evaluation .
Successful transplantation requires that appropriate equipment is available to insure that the patient receives the best care possible. In addition to the standard anesthetic delivery equipment, hemodynamic monitors that include continuous cardiac output and mixed-venous oxygen saturation are generally used as well as the monitors capable of simultaneously displaying four pressure channels. The use of intraoperative transesophageal echocardiography has become common place and serves as an excellent monitor for assessment of preload and ventricular wall motion.
Massive blood loss is not uncommon and a rapid infusion device as well as blood salvage equipment are essential. Point of care testing equipment with the ability to analyze arterial blood gases, electrolytes, glucose, hemotocrit, prothrombin time, partial thromboplastin time and thromboelastography should be immediately at hand. Given the frequent physiologic changes that occur during transplantation, point of care testing equipment available in the operating room significantly reduces the time to receive results (compared with hospital laboratory services), allowing the anesthesiologist to make rapid appropriate clinical interventions .
Adequate perfusion and oxygenation of the transplanted graft, prevention of infections, and surveillance for rejection, immunosuppressive therapy, hydroelectrolyte management, and nutritional support are the main problems observed in the postsurgical period .
It is recognized that combining transplantation of two organs might reduce the risk of acute rejection of each of them: simultaneous pancreas and kidney transplantation results in higher pancreas survival than if the pancreas is transplanted alone and in heart-lung transplant recipients, cardiac rejection is less common than pulmonary rejection, and pulmonary grafts respond more rapidly to antirejection therapy than isolated cardiac grafts.This suggests that any organ transplant combination may facilitate graft tolerance or reduce host immunoresponsiveness.
Potent immunosuppressive agents have dramatically reduced the incidence of rejection of transplanted organs while increasing patients’ susceptibility to opportunistic infections. The majority of clinically important infections occur within the first 6 months post transplant and the risk periods can be divided into 3 intervals: early (0-30 days after transplantation); intermediate (30-180 days after transplantation); and late (more than 180 days post transplantation).
Neurological complications are common after organ transplantation and are associated with significant morbidity. Approximately, one-third of transplant recipients experiences neurologic alterations with incidence ranging from 10% to 59%. The most common neurological complication seen with all types of transplanted organ is neurotoxicity attributable to immunosuppressive drugs, followed by seizures, opportunistic central nervous system (CNS) infections, cardiovascular events, encephalopathy and de novo CNS neoplasms.
The treatment of immunosuppressive neurotoxicity consists of correction of electrolyte imbalance and hypertension, immunosuppressant dose reduction and switching from cyclosporine to tacrolimus or vice versa if necessary. Treatment of seizures in transplant recipients can be difficult because of the interference between most antiepileptic and immunosuppressive drugs and the usual need of intravenous therapy. Phenytoin is the preferred intravenous anticonvulsant, while gabapentin and levetiracetam should be considered as oral anticonvulsants for their efficacy and lack of hepatic enzyme induction.
Acute kidney injury is another post transplant complication that can occur due to the critical clinical state before transplant, intraoperative hemodynamic disturbances, massive transfusion, and many post-operative adverse events, such as infections. Surgical re-exploration, and radiological investigations are frequently involved in the development of acute renal failure. The indications for renal replacement therapy in multiple organ transplantation are the same as in other patient populations. Peritoneal dialysis is not an option in the patient after extensive abdominal surgery with removal of the peritoneum. Continuous venovenous hemodiafiltration is preferred to intermittent dialysis to avoid the large fluid shifts associated with the latter that can lead to hypotension and reduced organ perfusion.
Other data
| Title | Intensive Care Management of Combined Organ Transplant | Other Titles | علاج الرعاية المركزة لمرضي زراعة مجموعة متعددة من الأعضاء | Authors | Kareem AbdelhamedElmeslemany | Issue Date | 2015 |
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