Care before and after lung transplant and quality of life research.

Lung transplantation is a growing surgical option for patients with end-stage lung and pulmonary vascular diseases. After completing an extensive evaluation and meeting the selection criteria, patients are listed for either single or bilateral-sequential lung transplantation. Immediate postoperative management requires detailed attention to fluid management, monitoring for infection, reperfusion injury, pulmonary hygiene, and pain management. Length of stay depends on the patient's condition before transplant and postoperative complications. Discharge from the hospital can be as early as 7 days after transplantation. Newer immunosuppressive medications offer more options for treating and preventing rejection. Advanced practice nurses, such as coordinators, case managers, nurse practitioners, and clinical nurse specialists, are uniquely positioned to play key roles in coordinating the care of transplant patients across settings and both before and after the transplant procedure. The perioperative needs of lung transplant patients and the impact of this complex procedure on the recipients' and family's quality of life merit further investigation by clinicians and researchers.

Prospective study of functional status and quality of life before and after lung transplantation.

STUDY OBJECTIVES: To determine the impact of lung transplantation on patients' function and quality of life (QOL), 10 lung transplant patients were followed from before transplantation to 3 months after transplantation. The following variables were examined: (1) perceived functional status; (2) respiratory function; (3) moods; (4) satisfaction with overall QOL and health; and (5) thoughts about the decision to undergo lung transplantation. DESIGN: A longitudinal, small-group, repeated-measures design. SETTING: A large Midwest university medical center. MEASUREMENTS AND RESULTS: Several instruments were used to measure perceived health, QOL, functional status, and respiratory function. The perceived improvement in physical function after transplantation was accompanied by increased satisfaction with physical strength, current health, and QOL. In addition, dramatic improvements in pulmonary function were seen after transplantation (FVC, FEV(1), and forced expiratory flow at 25 to 75% of FVC); however, only the FEV(1) values significantly improved between 1 and 3 months after transplantation. For example, the FEV(1) (mean +/- SD) increased from 22 +/- 11% of predicted before transplantation to 46 +/- 12% and 55 +/- 14% of predicted at 1 month and 3 months after transplantation, respectively. Although the total number of psychological symptoms did not decrease significantly over time, the intensity and distress associated with the symptoms did. Psychological function scores did not change significantly. Ninety percent of the subjects reported being very satisfied with their transplant decision. CONCLUSIONS: Lung transplantation significantly improved the subjects' overall function and their satisfaction with their QOL and health status. However, since this report only addressed data for the first 3 months after transplantation, additional longitudinal research is needed to further elucidate the experiences and outcomes associated with lung transplantation.

Research on the quality of life of lung transplant candidates and recipients: an integrative review.

Although lung transplantation is one of the most rapidly growing areas of solid organ transplantation, there has been little research on the quality of life of lung transplant candidates or recipients. This review critiques and synthesizes the quality-of-life reports concerning these patients that have been published between January 1980 and January 1999. The purposes of this review of the literature were to (1) examine both the conceptual and operational definitions of quality of life used; (2) identify and list the instruments used to measure quality of life; (3) investigate methodologic issues; and (4) determine the state-of-the-art of research in this area. On the basis of this review, suggestions are made for future studies.

Symptom experiences of lung transplant recipients: comparisons across gender, pretransplantation diagnosis, and type of transplantation.

PURPOSES: To investigate symptom experiences of patients who have single and bilateral-sequential lung transplantation and to determine whether differences exist according to gender, pretransplantation diagnosis, and type of transplantation procedure. DESIGN AND METHODS: In the context of a descriptive, comparative survey design, surviving recipients of single and bilateral-sequential lung transplants (n = 56) were mailed a symptom frequency and distress questionnaire. The response rate was 85.7% (n = 48). The average time since the recipients' lung transplantations was 1.5 +/- 0.7 years. RESULTS: Recipients of lung transplants reported that several symptoms (eg, muscle weakness, shortness of breath with activity, and changed appearance) were both frequently occurring and quite distressing. Other symptoms were identified as being distressing, but not frequently occurring, or vice versa. Significant (P <.05) differences were found for symptom experiences among pretransplant diagnostic groups and between genders and types of transplant procedures. CONCLUSIONS: These findings elucidate the symptom experiences of recipients of lung transplants and suggest that subgroup differences exist. The data provide a basis for strengthening patient and family education and for developing symptom management strategies. Further investigation of the symptom experiences of the recipients of lung transplants is needed, especially in relation to subgroups.

Postoperative circadian rhythms and cortisol stress response to two types of cardiac surgery.

BACKGROUND: Although endocrine stress responses of coronary artery bypass patients have been reported, similar studies have not been conducted in patients undergoing implantation of an automatic cardioverter/defibrillator device. OBJECTIVES: To compare patterns and magnitudes of intra- and postoperative cortisol stress responses in patients undergoing two types of surgery; rate at which postoperative cortisol levels return to presurgical levels; and whether stressors associated with these two procedures affect postoperative circadian rhythms of cortisol, heart rate, and body temperature. METHODS: A time-series, small-group design was used to investigate 16 coronary artery bypass graft and 9 automatic cardioverter defibrillator patients. For the cortisol stress study, blood samples were obtained pre-, intra-, and postoperatively until day 6. For the circadian rhythm aspect, cortisol circadian rhythm aspect, cortisol levels, heart rate, and oral temperatures were measured every 2 hours for 24 hours beginning on postoperative day 1. RESULTS: Plasma cortisol levels increased significantly toward the latter part of surgery. Generally, no significant group differences were found in cortisol magnitude during and after surgery. Postoperative cortisol levels were significantly elevated from preoperative levels for both groups; however, the automatic cardioverter defibrillator group's cortisol levels declined at a slower rate. The stressors associated with these surgeries were sufficient to disrupt or abolish circadian rhythms for the measured variables. CONCLUSIONS: The elevated postoperative cortisol levels and altered circadian rhythms may contribute to increased vulnerability by dampening patients' anti-inflammatory and immunologic responses and adversely affecting their sense of well-being. The clinical significance of these findings is yet to be determined; more research is warranted.

Circadian rhythm changes in blood pressure and heart rate during the first year after heart transplantation.

Heart transplant recipients (n = 11) were studied before discharge from the hospital and 1, 3, 6, and 12 months after transplantation to (1) examine systolic and diastolic blood pressure and heart rate circadian patterns, (2) detect the presence or absence of nocturnal declines, and (3) describe changes in the mean levels of systolic blood pressure, diastolic blood pressure, and heart rate. An ambulatory blood pressure-monitoring system was used to record blood pressure and heart rate at 1-hour intervals for up to 48 hours. Data were analyzed with descriptive and independent t-test statistics, as well as cosinor analysis for rhythmicity. The majority of the patients had significant (p < 0.05) circadian rhythms for systolic and diastolic blood pressure and heart rate throughout the study, but at times the systolic and diastolic blood pressure acrophases were found to be phase shifted to earlier or later along the time axis (e.g., peak values occurring at 3 AM rather than later in the morning or early afternoon), such that no relationships were found between circadian rhythms and nocturnal declines. More "normal" circadian rhythms were observed for heart rate than for systolic and diastolic blood pressures. The development of hypertension (systolic/diastolic blood pressures > 140/90 mm Hg) was common and by 6 months and 1 year after transplantation 8 of the 10 patients remaining in the study were hypertensive. Increases in mean heart rate of approximately 18% (ranging from 2% to 46%) were also observed during the first postoperative year.

Circadian rhythms: implications for cardiovascular nursing and drug therapy.

A greater understanding of the role of biologic rhythms in cardiovascular functioning has recently been established. Circadian variations in ischemic events such as acute myocardial infarction, sudden cardiac death, and cerebrovascular emboli have been well documented. New approaches to therapy based on circadian fluctuations in physiology and pathology have led to better timing of drug administration and treatments to optimize desired outcomes and minimize untoward effects. This article discusses these emerging trends and gives examples related to beta-adrenergic blockade, nitrate and steroid therapy, and anticoagulation. Directions for future nursing research are suggested.

Body temperature and heart rate rhythms in acutely head-injured patients.

This descriptive pilot study investigated the circadian (24-hour) rhythms of heart rate and temperature in acutely head-injured patients and the relationships between these variables. The convenience sample consisted of 10 patients who were admitted to the hospital with the diagnosis of acute head injury. Patel's Method of Partition was used to estimate rhythmicity. Only one patient demonstrated circadian rhythms for body temperature and heart rate with the peaks occurring at appropriate times. While three other patients had significant rhythms for these variables, the rhythms had cycles of less than 24 hours and peaks occurring at inappropriate times. Although significant correlations were found between body temperature and heart rate rhythms, they were low.

Endocrine and psychologic responses of patients to cardiac pacemaker implantation.

The findings that all HPA and SAM indexes increased during the first postoperative days strongly suggest that transvenous, permanent cardiac pacemaker implantation is a stressor. Since the psychologic tests did not demonstrate marked changes in anxiety or affective mood states, and the former was only weakly related to the endocrine responses, psychologic stimuli cannot be ascribed a prominent role in causing the observed endocrine alterations. Thus, the data suggest that physiologic stressors, such as surgical trauma and the irritation of the tissue surrounding the pacemaker, were the primary stimuli that activated the HPA and SAM systems. Although the structured teaching program resulted in a marked improvement of the treatment groups's knowledge of the device and the follow-up care it requires, it did not affect the endocrine or psychologic responses of patients to cardiac pacemaker implantation.

The amount of blood withdrawn for diagnostic tests in critically ill patients.

This study involved the measurement of blood withdrawn from critically ill patients for diagnostic tests during their first 3 days in eight intensive-care units. The study was conducted over a 2 to 3 week period. Data were collected on the number of draws performed per day, the total volume of blood withdrawn per day, and the volume of blood per draw on 253 patients. The subject population was divided into four general diagnostic categories: Post-open-heart surgical, surgical, medical, and cardiac. Approximately 85 per cent of the blood samples were drawn via venipuncture with arterial and capillary samples performed less frequently. The results demonstrate that the total volume of blood withdrawn differed among the diagnostic categories and hospitals. The average amount ranged from 20 ml. per day in surgical patients to 50 ml. per day in post-open-heart surgical patients. The volumes withdrawn daily from the subjects were generally lower than the authors had anticipated.

The relation of hepatic in vitro inactivation of corticosteroids to the circadian rhythm of plasma corticosterone.

Plasma corticosterone levels and the in vitro capacity of the liver to reduce the delta(4)3-ketone group of corticosterone were ascertained at 4 hr intervals in male rats maintained on a normal lighting schedule (12L:12D). The rates of delta(4)3-ketone reduction, as well as wet liver weight, were highest during the early portion (08.00 hr) of the light period when liver protein and plasma corticosterone concentrations were low. Shortly (2000 hr) after the beginning of the dark period plasma corticosterone reached peak levels, while hepatic inactivation of corticosterone was markedly depressed. This inverse relationship suggests that the rhythmicity in the capacity of the liver to inactivate corticosterone may contribute to the circadian periodicity of plasma corticosterone.