文檔 C10.Transplantation2[向陽教學(xué)]

1、Chapter 10 Transplantation 1基礎(chǔ)教學(xué) - Transplantation celltissue organ - 2基礎(chǔ)教學(xué) It is the act or process of moving a whole or partial organ from one body to another by surgery for the purpose of replacing the recipients damaged or failing organ. Organ transplantation 3基礎(chǔ)教學(xué) Classification-1 4基礎(chǔ)教學(xué) Classif

2、ication-2 Orthotopic transplantation: grafts occupy their normal anatomical site Auxiliary transplantation: grafts occupy their ectopic site 5基礎(chǔ)教學(xué) Viable transplantation Structural transplantation Classification-3 6基礎(chǔ)教學(xué) Classification-4 Single transplantation Combined transplantation Multiple organ

3、transplantation 7基礎(chǔ)教學(xué) Preparation A. Donor selection B. Organ preservation C. Criteria for recipient D. ICU 8基礎(chǔ)教學(xué) A. Donor selection Sibling or parent -survival rate of kidney is greater; preferred for transplantation. Cadaver -greater rate of rejection following transplantation, although majority o

4、f transplantations are with cadaver organs. 9基礎(chǔ)教學(xué) B. Organ preservation Hypothermic preservation Preservation solution HTK solution UW solution 10基礎(chǔ)教學(xué) B. Organ preservation limit of cold ischemia Pancreas 20h Kidney 25h Liver 12h Heart 5h 11基礎(chǔ)教學(xué) C. Criteria for recipient Irreversible kidney function

5、 Under 70 yr of age Patent and functional lower urinary tract Free of serious cardiovascular complications 12基礎(chǔ)教學(xué) D. ICU 13基礎(chǔ)教學(xué) Rejection The recipients body fails to accept a transplanted tissue or organ as the result of immunological incompatability, i.e. immunological resistance to foreign tissue

6、. 14基礎(chǔ)教學(xué) Rejection and immunosuppression Rejection process Cellular immunity mechanisms(T. B cell lymphocytes) Humoral immunity mechanisms(circulating antibody) Important compatibility system ABO blood group HLA (human leukocyte antigen) class leukopenia; anemia. (c) Development of malignant neoplas

7、ms. (d) Infection. (e) Liver damage. 19基礎(chǔ)教學(xué) (2)Prednisone -believed to affect lymphocyte production : anti-inflammatory action helps prevent tissue damage if rejection occurs. Side effect: (a) Stress ulcer with bleeding (give with food). (b) Decreased glucose tolerance (hyperglycemia). (c) Muscle we

8、akness. (d)Osteoporosis. (e) Moon faces. (f) Acne and striae (g) Depression and hallucinations. 20基礎(chǔ)教學(xué) (3) Cyclosporine (Neoral, sandimmune) -polypeptide antibiotic used to prevent rejection of kidney, liver, or heart allografts; PO dose given with room temperature chocolate milk or orange juice in

9、a glass dispenser. Side effect: (a) Nephrotoxicity (increased BUN, creatinine). (b) Hypertension. (c) Tremor. (d) Hirsutism, gingival hyperplasia. (e) GI-nausea, vomiting, anorexia, diarrhea, abdominal pain. (f) Infections-pneumonia, septicemia, abscess 21基礎(chǔ)教學(xué) Types of organ transplant CausesPrognos

10、is Renal transplantation Chronic glomerulonephritis Chronic pyelonephritis Diabetic nephropathy Current long term graft survival rate is 80% to 90% Liver transplantation Cirrhosis secondary to viral hepatitis Biliary cirrhosis Fulminant liver failure Congenital biliary atresias Hemorrhage and biliar

11、y complications; Opportunistic infections; 80% 1-year survival Cardiac transplantation Viral cardiomyopathy Ischemic heart disease Pre-existing cardiac illness; Sepsis; 80% 1 year survival Pulmonary transplantation Chronic fibrotic lung disease Chronic obstructive airways disease Chronic pulmonary s

12、epsis Pulmonary hypertension Rejection and infection 60% 1 year survival Pancreas transplantation Prevent the complications of type 1 diabetes mellitus 80% remain insulin independent Small bowel transplantation Massive small bowel resection who can no longer be treated by total parenteral nutrition

13、Few long-term survival 22基礎(chǔ)教學(xué) Kidney transplantation 23基礎(chǔ)教學(xué) Quality of life: The longest-surviving kidney transplant recipients worldwide are 40 years after receiving a living- related kidney 34 years after receiving a cadaveric kidney transplant. 24基礎(chǔ)教學(xué) Preparation before kidney transplantation 25基

14、礎(chǔ)教學(xué) 1. Mental nursing: Relative knowledge: Nature of surgery; placement of kidney. Postoperative expectations: deep breathing, coughing, turning, early ambulation; reverse isolation. Medications: immunosuppressive therapy: purpose, effect. Confidence: encourage expression of feeling: origin of donor

15、, fear of complications, rejection 26基礎(chǔ)教學(xué) 2.General preparation: 1) Abrosia 2) Clean 3) Coloclysis 4) General test 5) ICU preparation 27基礎(chǔ)教學(xué) 3. Auxiliary examination: 1) Blood test 2) ECG 3) Chest X-ray 28基礎(chǔ)教學(xué) 4. Others : 1) Hemodialysis 2) Operation consent 3) Pre-operation injection 29基礎(chǔ)教學(xué) Operati

16、on Kidney transplantation: placement of a donor kidney(from sibling, parent, cadaver) into the iliac fossa of a recipient and the anastomosis of its ureter to the bladder of the recipient 30基礎(chǔ)教學(xué) Postoperative Care 31基礎(chǔ)教學(xué) 1. Strict isolation 1) Prohibition of family visit 2) Ultraviolet lamp irradiat

17、e ICU 3) Mask and lid, Wash hands 32基礎(chǔ)教學(xué) 2. Vital sign detection 1) Blood pressure Slightly high level:140-150/90-100 mmHg 2) Heart rate Predict the congestive heart failure 33基礎(chǔ)教學(xué) 2. Vital sign detection 3) O2 saturation Assess the respiratory function 4) Temperature A good sign of infections 34基礎(chǔ)教

18、學(xué) 3. Maintenance of fluid and electrolyte balance I (3)Chronic -occurs several months to years. 7. Rejection 40基礎(chǔ)教學(xué) Observe for signs of rejection Assessment: (a)Subjective data: (i)Lethargy, anorexia. (ii)tenderness over graft site. (b)Objective data: (i)Lab data: Urine: decreased-output, creatinin

19、e clearance, sodium; increased-protein. Blood: increased-BUN, creatinine. (ii)Rapid weight gain;. (iii)Vital signs: BP, temperature-elevated. 41基礎(chǔ)教學(xué) 8. Immunosuppressive therapy 1) Every patient should take immunosuppressive drugs. 2) A combination of different drugs. 3) Take immunosuppressive drugs

20、 actually and punctually. 42基礎(chǔ)教學(xué) 9. Health education 1) Daily life guidance 2) Medication: time, dose 3) self-inspection : temperature, blood pressure, I&O, weigh daily, urine specimen collection. 4) infection prevention 5) further consultation & Scheduled blood work 43基礎(chǔ)教學(xué) Live transplantation Live

21、r transplantation is surgery to remove a diseased liver and replace it with a healthy liver from an organ donor. 44基礎(chǔ)教學(xué) Post-Operative Considerations A.Hemodynamics Vasodilation followed by hypotension may occur during the warming phase of hypothermia. Hypovolemia hemorrhage, sepsis, low oncotic pre

22、ssure due to hypoalbuminemia, or complement activation after liver graft reperfusion Hypertension physiologic stress, shivering, anxiety, pain, hypothermia, cyclosporine therapy, or fluid overload in patients with renal failure. 45基礎(chǔ)教學(xué) B. Respiratory Status Extubation may be delayed by: Right hemidi

23、aphragm paralysis d/t surgical damage to the phrenic nerve Lung expansion/ventilation compromise d/t ascites, pulmonary edema, atelectasis, and the high incidence of pleural effusions, causing decreased compliance of the lungs. Oxygenation may be compromised by bacterial, viral, or pneumonia, smokin

24、g history, atelectasis, or ARDS. Post-Operative Considerations 46基礎(chǔ)教學(xué) C. GI and Nutrition Malnutrition d/t pre-existing liver failure. Monitor Albumin and prealbumin levels. These are usually low in liver patients. Contact Nutritional Support Services to consult. Post-Operative Considerations 47基礎(chǔ)教學(xué) D. Renal Status Patients who experience renal insufficiency/failure pre- op in