A Qualitative Study to Explore the Needs of Lung Transplant Caregivers.

INTRODUCTION: Providing support throughout the lung transplant process is an intensive task, which requires a dedicated caregiver. The needs of caregivers who must relocate with their loved one receiving the transplant are currently unknown. The objective of this study is to explore experiences and perceptions of lung transplant caregivers identified from a satellite clinic to inform the development of educational resources. METHODS: A qualitative study with a phenomenology approach was undertaken with individuals who have taken on the role of a caregiver for lung transplant candidates or recipients and must travel to the specialized transplant center. Semistructured interviews were conducted with 12 caregivers. Interviews conducted by phone were audio-recorded and then transcribed verbatim. NVivo software was used to code the data and identify emerging themes. RESULTS: Ideas were classified into the following 4 themes: (1) the stress of being a caregiver, (2) caregivers undertake a variety of roles, (3) caregivers require support, and (4) satisfaction with health care providers. Even though the caregivers lived an average of 7.1 (standard deviation 2) hours from the surgical transplant center, all expressed satisfaction with the level of care that they received. Caregivers identified several stressors during the transplant process and described various strategies for coping. CONCLUSION: Caregivers shared their experiences on the transplant process. It was evident that being a caregiver was a stressful and supports were necessary for those undertaking this role. These insights will help inform the development of a new educational resource for patients and caregivers.

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant: Considerations for Critical Care Nursing Practice.

TOPIC: Candidates waiting for lung transplant are sicker now than ever before. Extracorporeal membrane oxygenation has become useful as a bridge to lung transplant for these critically ill patients. CLINICAL RELEVANCE: Critical care nurses must be prepared to care for the increasing number of lung transplant patients who require this advanced support method. PURPOSE OF PAPER: To provide critical care nurses with the foundational knowledge essential for delivering quality care to this high-acuity transplant patient population. CONTENT COVERED: This review describes the types of extracorporeal membrane oxygenation (venovenous and venoarterial), provides an overview of the indications and contraindications for extracorporeal membrane oxygenation, and discusses the role of clinical bedside nurses in the treatment of patients requiring extracorporeal membrane oxygenation as a bridge to lung transplant.

Lung Transplant for the Critical Care Nurse.

Lung transplantation is an established treatment of select patients with end-stage pulmonary disease. Lung transplantation should be considered for patients with end-stage pulmonary disease who have an expected 2-year survival of less than 50% without lung transplant and an expected 5-year survival of greater than 80% after transplant. This article reviews routine postsurgical intensive care unit management, along with management of complications such as acute kidney injury, atrial arrhythmias, deep vein thrombosis, primary graft dysfunction, hyperammonemia syndrome, and thrombocytopenia. Finally, management of long-term issues, including diabetes mellitus, hypertension, and bronchial stenosis, is discussed.

Characteristics, Trends, and Predictors of Specialty Palliative Care Utilization after Lung Transplantation.

Background: Lung transplant recipients who experience serious illness could benefit from specialty palliative care (SPC), but evidence suggests that referral has been rare. Objective: Examine the characteristics of post-transplant SPC encounters, utilization trends, and patient characteristics associated with SPC at a center with established SPC services. Design: Retrospective cohort study of SPC utilization by 597 lung transplant recipients transplanted between 2010 and 2015. We collected data on pretransplant demographics and post-transplant SPC encounters, including timing, location, and referral reasons. Cumulative incidence of SPC and patient characteristics associated with SPC were examined by competing risks methods. Utilization in the first two post-transplant years was compared between subcohorts defined by year of transplantation. Results: SPC cumulative incidence was 27% and 43% at one and five years. More than 60% of encounters occurred in the first post-transplant year including 34% during the index transplant hospitalization. Over 90% of encounters occurred in the inpatient setting. The majority of consults were for symptom management. From 2010 to 2015 inpatient utilization in the first two post-transplant years increased from 23% to 42%, and outpatient utilization increased from 2% to 16%. Accounting for increasing utilization, pretransplant SPC and double-lung transplantation were associated with greater incidence of post-transplant SPC. Conclusions: Lung transplant recipients may have palliative care needs early after transplantation. Increasing utilization suggests greater awareness of or changing attitudes about the utility of SPC for lung transplant recipients. Understanding transplant recipients' palliative care needs and transplant physicians' views of SPC is critical to improving the provision of SPC in lung transplantation.

Brief Overview of Lung, Heart, and Heart-Lung Transplantation.

Lung transplantation, heart transplantation, and heart-lung transplantation are life-saving treatment options for patients with lung and/or cardiac failure. Evolution in these therapies over the past several decades has led to better outcomes with application to more patients. The complexity and severity of illness of patients in the pretransplant phase has steadily increased, making posttransplant intensive care unit management more difficult. Despite these factors and the pervasive complications of immunosuppressive therapy, outcomes continue to improve.

Bridging to Lung Transplantation.

Lung transplantation is the gold standard for treating patients with end-stage lung disease. Such patients can present with severe illness on the waitlist and may deteriorate before a lung donor is available. Bridging strategies with extracorporeal membrane oxygenation (ECMO) are valuable for getting patients to transplant and provide a chance at survival. The current article describes the indications, contraindications, and techniques involved in bridging to lung transplantation with ECMO.

Perioperative Management of the Lung Graft Following Lung Transplantation.

Perioperative management of patients undergoing lung transplantation is one of the most complex in cardiothoracic surgery. Certain perioperative interventions, such as mechanical ventilation, fluid management and blood transfusions, use of extracorporeal mechanical support, and pain management, may have significant impact on the lung graft function and clinical outcome. This article provides a review of perioperative interventions that have been shown to impact the perioperative course after lung transplantation.

Renal Complications Following Lung Transplantation and Heart Transplantation.

Renal complications are common following heart and/or lung transplantation and lead to increased morbidity and mortality. Renal dysfunction is also associated with increased mortality for patients on the transplant wait list. Dialysis dependence is a relative contraindication for heart or lung transplantation at most centers, and such patients are often listed for a simultaneous kidney transplant. Several factors contribute to the impaired renal function in patients undergoing heart and/or lung transplantation, including the interplay between cardiopulmonary and renal hemodynamics, complex perioperative issues, and exposure to nephrotoxic medications, mainly calcineurin inhibitors.

Infections in Heart and Lung Transplant Recipients.

Infections in heart and lung transplant recipients are complex and heterogeneous. This article reviews the epidemiology, risk factors, specific clinical syndromes, and most frequent opportunistic infections in heart and/or lung transplant recipients that will be encountered in the intensive care unit and will provide a practical approach of empirical management.

Recovery after lung transplantation from a patient perspective - proposing a new framework.

AIMS: The aims of this study were two-fold: to develop the concept analysis by Allvin et al. from lung recipients' perspective of their post-transplant recovery process and to identify the recovery trajectories including critical junctions in the post-transplant recovery process after lung transplantation. BACKGROUND: Lung transplantation is an established treatment for patients with end-stage lung disease. The recovery process after lung transplantation is very demanding. Today, patients are expected to play an active role in their own recovery but require ongoing support during the process. DESIGN: A deductive, retrospective interview study using directed content analysis and Allvin's recovery concept analysis. METHOD: Fifteen adult lung transplant recipients who were due their 12-month follow-up were consecutively included and interviewed during 2015. Patients who were medically unstable or had difficulties speaking Swedish were excluded from this multi-centre study. FINDINGS: Allvin's concept analysis is partly applicable to the context of lung transplantation. The recipients' experience of the post-transplant recovery process could be confirmed in the main dimensions of the concept analysis, while several sub-dimensions were contradictory and were excluded. Six new sub-dimensions emerged; symptom management, adjusting to physical restraints, achieving an optimum level of psychological well-being, emotional transition, social adaptation and reconstructing daily occupation. CONCLUSION: The concept analysis by Allvin et al. was possible to expand to fit the lung transplantation context and a new contextual definition of post-transplant recovery after solid organ transplantation was developed. Recovery and health were viewed as two different things.

Cirurgia de transplante pulmonar intervivos: atuação da enfermagem no período transoperatório / Donor-related lung transplant surgeries: nursing practice in the transoperative period

Relatar a experiência de atuação da enfermagem no cuidado de transplante pulmonar intervivos. Método: Relato de experiência da atuação da equipe de enfermagem nas cirurgias de transplante pulmonar intervivos ocorridas no Centro Cirúrgico de um hospital de porto Alegre,RS, Brasil. Resultados: Foram realizados, entre 1999 e novembro de 2014, 33 transplantes de pulmão entre intervivos. Apresenta-se, neste trabalho, o relato em quatro etapas: aspectos éticos e legais do transplante intervivos; preparo do Centro Cirúrgico; assistência de enfermagem no transoperatório; e encaminhamento dos pacientes para UTI. Conclusão: O transplante é um procedimento complexo, envolvendo muitos profissionais, demandando da enfermagem conhecimento, integração, dedicação e comprometimento. O transplante pulmonar intervivos torna-se um desafio ainda maior por envolver, além do receptor, dois doadores sadiso, gerando grande expectativa no sucesso da cirurgia e recuperação dos três pacientes...

Tratamiento de la hipertensión arterial pulmonar / Treatment of pulmonary arterial hypertension

El tratamiento de la hipertensión arterial pulmonar ha presentado importantes avances en los últimos 20 años. En la actualidad, existen 3 grupos de fármacos que han demostrado su utilidad en el tratamiento de esta enfermedad: los bloqueantes de los receptores de endotelina, los inhibidores de la fosfodiesterasa y la prostaciclina y sus análogos. Se recomienda iniciar el tratamiento de los pacientes con uno de estos fármacos, la elección del cual dependerá de la gravedad inicial del paciente y de las preferencias del médico que trata. Cuando el paciente no presenta una respuesta satisfactoria, se suelen añadir nuevos fármacos que actúan por vías distintas a la del fármaco inicial. En este momento el médico que trata al paciente debe plantearse la necesidad del trasplante pulmonar como alternativa. Ante esta enfermedad rara se recomienda agrupar la máxima experiencia en lo que se conoce como centros expertos. El tratamiento ha mejorado la supervivencia de estos pacientes, pero aún queda un largo camino por recorrer hasta la curación de esta terrible enfermedad (AU)

Treatment of pulmonary arterial hypertension has achieved significant progress over the past 20 years. Currently, 3 groups of drugs have proven useful for the treatment of this disease: endothelin receptor antagonist, phosphodiesterase inhibitors and prostacyclin and its analogues. It is recommended to initiate treatment with one of these drugs, the choice depending on the initial severity of patient disease and the preferences of the treating physician. When the patient does not have a satisfactory response, new drugs acting at a different pathway are most commonly added. At this time, considering referral for lung transplantation could be an alternative. Most experts recommend grouping maximum experience in what is known as expert centers. Treatment has led to better survival in these patients, but there is still a long way to cure this life-threatening disease (AU)

Uso de la membrana de oxigenación extracorpórea en una paciente con trasplante pulmonar: cuidados de Enfermería / Uso da membrana de oxigenação extracorpórea em uma paciente pós-transplante pulmonar: cuidados de enfermagem / Use of extracorporeal membrane oxygenation in a post-lung transplant patient: nursing care

Se trata de un relato de experiencia de un caso sin precedentes en Brasil acerca de la sistematización de los cuidados de enfermería aplicados a una paciente en asistencia circulatoria mecánica con membrana de oxigenación extracorpórea en el postoperatorio de un trasplante de pulmón. Se establecieron 18 diagnósticos de enfermería y las 94 conductas implementadas abarcaron: cuidados con el circuito de asistencia, monitorización hemodinámica y control de las pruebas de laboratorio. Los principales resultados fueron que el paciente presentaba: un mejor intercambio de gases, mantenimiento de la estabilidad hemodinámica y ausencia de efectos adversos relacionados con el tratamiento, como el sangrado y reducción de la perfusión de la extremidad de la cánula venosa. La sistematización de la atención establecida mostró agregar conocimiento científico, orientación a la práctica clínica y atención integral (AU)

Trata-se de um relato de experiência de caso inédito no Brasil sobre a sistematização da assistência da Enfermagem aplicada a uma paciente em assistência circulatória mecânica com membrana de oxigenação extracorpórea no pós-operatório de transplante pulmonar. Foram estabelecidos 18 diagnósticos de Enfermagem e as 94 condutas implementadas envolveram: cuidados com o circuito da assistência, monitorização hemodinâmica e controle de exames laboratoriais. Os principais resultados esperados foram que a paciente apresentasse: troca gasosa melhorada, manutenção da estabilidade hemodinâmica e ausência dos efeitos adversos relacionados à terapia, tais como, sangramento e prejuízo à perfusão do membro de inserção da cânula venosa. A sistematização da assistência estabelecida mostrou agregar conhecimento científico, orientação à prática clínica e integralidade do cuidado

This is an experience report of unprecedented case in Brazil on the nursing care system applied to a patient in mechanical circulatory support with extracorporeal membrane oxygenation in postoperative lung transplantation. Were established 18 diagnoses and 94 nursing behaviors implemented involved: care assistance circuit, hemodynamic monitoring and control of laboratory tests. The main outcomes were that the patient had: improved gas exchange, maintenance of hemodynamic stability and absence of adverse effects related to treatment, such as bleeding and reduction in limb perfusion with cannula. The care system established showed aggregate scientific knowledge, guidance to clinical practice and comprehensive care (AU)

Adult cardiothoracic transplant nursing: an ISHLT consensus document on the current adult nursing practice in heart and lung transplantation.

BACKGROUND: The role of nurses in cardiothoracic transplantation has evolved over the last 25 years. Transplant nurses work in a variety of roles in collaboration with multidisciplinary teams to manage complex pre- and post-transplantation issues. There is lack of clarity and consistency regarding required qualifications to practice transplant nursing, delineation of roles and adequate levels of staffing. METHODS: A consensus conference with workgroup sessions, consisting of 77 nurse participants with clinical experience in cardiothoracic transplantation, was arranged. This was followed by subsequent discussion with the ISHLT Nursing, Health Science and Allied Health Council. Evidence and expert opinions regarding key issues were reviewed. A modified nominal group technique was used to reach consensus. RESULTS: Consensus reached included: (1) a minimum of 2 years nursing experience is required for transplant coordinators, nurse managers or advanced practice nurses; (2) a baccalaureate in nursing is the minimum education level required for a transplant coordinator; (3) transplant coordinator-specific certification is recommended; (4) nurse practitioners, clinical nurse specialists and nurse managers should hold at least a master's degree; and (5) strategies to retain transplant nurses include engaging donor call teams, mentoring programs, having flexible hours and offering career advancement support. Future research should focus on the relationships between staffing levels, nurse education and patient outcomes. CONCLUSIONS: Delineation of roles and guidelines for education, certification, licensure and staffing levels of transplant nurses are needed to support all nurses working at the fullest extent of their education and licensure. This consensus document provides such recommendations and draws attention to areas for future research.

Characteristics, interventions, and outcomes of lung transplant recipients co-managed with palliative care.

BACKGROUND: Lung transplantation (LT) recipients carry a high symptom burden. Palliative Care (PC) is a field of medicine focused on symptom control and psychosocial support, but transplant recipients are often referred to PC very late in the disease course, if at all. In our institution, the LT service has increasingly consulted PC to co-manage LT recipients with end-stage graft dysfunction or other terminal conditions. We present the characteristics, PC interventions used, and outcomes of these patients. METHODS: We conducted a single-center, retrospective, cohort study of LT recipients referred for PC consultation between January 2010 and May 2012. We collected patient demographics, timing and location of PC consultation, PC interventions, and patient outcomes. RESULTS: Twenty-four patients met the inclusion criteria. Sixteen (67%) had chronic allograft dysfunction. Reasons for referral were dyspnea (42%), end-of-life planning (42%), pain (29%), cough (4%), anxiety (4%), and depression (4%). Referral was made a median of 3.2 (range, 0.2 to 18) years from transplant and a median 14 days (range, 0 to 227 days) from death. Eighty-three percent of consultations occurred >48 hours from time of death. Ninety-two percent of patients were prescribed opioids over their course of treatment. Among the 12 (50%) who died in our center, 10 (83%) were receiving comfort medications. Eight patients (33%) initially requested full resuscitation at the time of PC consultation, but seven of these patients (or their surrogates) later agreed to a do not resuscitate (DNR) order; the eighth was still alive at last follow-up. No patient in this study received cardiopulmonary resuscitation (CPR) at the time of death. CONCLUSION: LT recipients referred for PC co-management typically receive comfort medications and avoid the aggressive end-of-life care usually reported for this population. The effect of PC interventions on patient quality of life requires further study.

Harlequin syndrome as a complication of epidural anesthesia.

Harlequin syndrome is a rare neurological condition that results in unilateral facial flushing and sweating. Although the syndrome is generally a benign condition with complete resolution if appropriate treatment is initiated, unilateral facial flushing can be a sign of several serious conditions and should be thoroughly investigated. Sudden onset of facial flushing related to harlequin syndrome developed in a patient who had bilateral lung transplant with postoperative epidural anesthesia for pain control. Differential diagnosis includes neurovascular disease (acute stroke), malignant neoplasm of brain or lung, Horner syndrome, idiopathic hyperhidrosis, and Frey syndrome. Harlequin syndrome is often easily treated by discontinuing the anesthetic or adjusting placement of the epidural catheter.

A randomized controlled trial comparing health and quality of life of lung transplant recipients following nurse and computer-based triage utilizing home spirometry monitoring.

BACKGROUND: Lung transplantation is now a standard intervention for patients with advanced lung disease. Home monitoring of pulmonary function and symptoms has been used to follow the progress of lung transplant recipients in an effort to improve care and clinical status. The study objective was to determine the relative performance of a computer-based Bayesian algorithm compared with a manual nurse decision process for triaging clinical intervention in lung transplant recipients participating in a home monitoring program. MATERIALS AND METHODS: This randomized controlled trial had 65 lung transplant recipients assigned to either the Bayesian or nurse triage study arm. Subjects monitored and transmitted spirometry and respiratory symptoms daily to the data center using an electronic spirometer/diary device. Subjects completed the Short Form-36 (SF-36) survey at baseline and after 1 year. End points were change from baseline after 1 year in forced expiratory volume at 1 s (FEV1) and quality of life (SF-36 scales) within and between each study arm. RESULTS: There were no statistically significant differences between groups in FEV1 or SF-36 scales at baseline or after 1 year.: Results were comparable between nurse and Bayesian system for detecting changes in spirometry and symptoms, providing support for using computer-based triage support systems as remote monitoring triage programs become more widely available. CONCLUSIONS: The feasibility of monitoring critical patient data with a computer-based decision system is especially important given the likely economic constraints on the growth in the nurse workforce capable of providing these early detection triage services.