transplant emergencies
TRANSCRIPT
Now #1 in Everything!
Now #1 in Everything!
Now #1 in Everything!
TRANSPLANT
EMERGENCIESFor the non-transplant ED
Andrew Schmidt, DO, MPHUF Jax ED - TraumaOne
I have
NOTHING
to disclose
58% 21%
8% 5%Organ transplant numbers
What could possibly go wrong?
InfectionRejectionMedicationGraft vs Host …. And More!
Infection
Infection
25-80% in
first year
Infection
Most common
reason for
admission
Infection
Rejection
Immunosuppressants
Infection timeline
Donor-derivedBacteria (MRSA)
Fungi (Candida)
Parasite (Toxo)
Nosocomial/surgeryAsp pneumonia
Site infection
UTI
C-diff
1
M
O
N
T
H
ACUTE
Infection timeline
Donor-derivedBacteria (MRSA)
Fungi (Candida)
Parasite (Toxo)
Nosocomial/surgeryAsp pneumonia
Site infection
UTI
C-diff
OpportunisticPneumocystisHistoplasmaCryptococcusCMVTB
ReactivationCMV, HSV, EBV
1
M
O
N
T
H
6
M
O
N
T
H
S
ACUTE INTERMIDIATE
Infection timeline
Donor-derivedBacteria (MRSA)
Fungi (Candida)
Parasite (Toxo)
Nosocomial/surgeryAsp pneumonia
Site infection
UTI
C-diff
OpportunisticPneumocystisHistoplasmaCryptococcusCMVTB
ReactivationCMV, HSV, EBV
Community AcquiredResp virusesS PneumoLegionellaListeriaInfluenza
1
M
O
N
T
H
6
M
O
N
T
H
S
ACUTE INTERMIDIATE LATE
Infection timeline
Infection Pearls
FEVER is most common presentation…May be absent in ½ patients
Transplant patient tend to demonstrate LOWER temps and WBC counts
Tissue biopsies often needed for definitive dx
Infection Pearls
FEVER is most common presentation…May be absent in ½ patients
Transplant patient tend to demonstrate LOWER temps and WBC counts
Tissue biopsies often needed for definitive dx
Infection Pearls
FEVER is most common presentation…May be absent in ½ patients
Transplant patient tend to demonstrate LOWER temps and WBC counts
Tissue biopsies often needed for definitive dx
Infection management
Go BROAD
CBC, Lactate
Blood Cultures (Bacterial/fungal)
Urinalysis with culture
Viral PCR
Chest x-ray
No specified source
Infection management
Go BROAD
Pulmonary CT if concern and CXR negative
Urine respiratory antigens
Sputum acid-fast bacilli
CMV PCR
Infection management
Go BROAD
Diarrhea Stool for WBC, culture
Ova, parasites
C-diff
Infection management
Go BROAD
CNS Head CT, MRI if negative
LP with CSF studies
Infection management
Go BROAD
Diffuse Lymphadenopathy EBV, CMV PCR
Bartonella, Toxoplasmosis
CT neck/chest/abd/pelvis
REJECTION
Approximately
20% rejection
SIGNS/SYMPTOMSMay be asymptomatic
Fever, malaise, oliguria
Hypertension
20-70% rejection most in first 6 wks
SIGNS/SYMPTOMSHepatomegaly, ascites
Fever, malaise
Abd pain
Up to 30%
RejectionUsually acute
SIGNS/SYMPTOMSOrthopnea, periph edema
Dyspnea, palpitations
GI sxs (RV involve)
Dysrhythmias
Chest pain MAY be absent
due to denervation
Rejection
1/3 of rejections
in first year
Rejection
SIGNS/SYMPTOMSSOB, cough most common
Resp distress/failure
Stridor, wheezing
Rejection Treatment
MEDICATION
Medication timeline
Transplant Induction
Maintenance
• Triple therapy
• Followed by withdrawal of at least 1 med
3 mos 12 mos
Medication effects
Medication effects
Metabolic Syndrome is common
Medication effects
Insulin resistance
Hyperlipidemia
Hypertension
Obesity
Medication effects
Medication effects
Calcineurin InhibitorsCyclosporin
Tacromlius
P450
Cytochrome P450 interactionsIncreased nephrotoxicity
Calcium channel blockers
Amnioglycosides
Amiodarone
Antifungal
Cytochrome P450 interactionsIncreased clearance (rejection)
Carbamazepine
Phenytoin
Rifampin
Isoniazid
Cytochrome P450 interactionsRhabdomyolysis
Statins
GRAFT-vs-HOST
GRAFT-vs-HOST
Graft-vs-Host
Primarily in hematopoietic stem cell transplantation
Can be majority of pts based on typeCan occur in solid organ transplant
Graft-vs-Host
Dermatitis
Hepatitis
Enteritis
100
Days
Graft-vs-Host
Dermatitis
• Usually first
• Maculopap
• Puritis/pain
Hepatitis
Enteritis
100
Days
Graft-vs-Host
Dermatitis
Hepatitis
• Jaundice
• Pruritus
• Coma rare
Enteritis
100
Days
Graft-vs-Host
Dermatitis
Hepatitis
Enteritis
• Diarrhea
• GI Bleed
• Abd pain n/v
• Ileus
100
Days
Graft-vs-Host
No specific acute treatmentProper prophylaxis is key
COMPLICATIONS
Complications
Complications
Complications
Complications
Urinary Tract Infection (MC)Early (1st 6 months) more dangerous
Common bugs are common
Flouroquinolones
Complications
Urinary Tract Infection (MC)
Asymptomatic Bacteriuria
Treat if within first 1-3 months
Otherwise avoid unless inc creatinine
Complications
Urinary Tract Infection (MC)
Mild Symptomatic Bacteriuria
Empiric oral tx x 5-7 days
Flouroquinolone, Amox-Clav, 3rd Gen Cef
Complications
Urinary Tract Infection (MC)
Mod Symptomatic Bacteriuria
Cipro, Ceftri, or Amp-Sul
Complete 14 days after Cx results
Complications
Urinary Tract Infection (MC)
Sev Symptomatic Bacteriuria
Piper-Tazo, Cefipime
Consider MDR (VRE)
Complications
Renal Artery ThrombosisUsually immediately post-op
Sudden cessation
urine output
Diagnosis: CTA or dopp US
Complications
Peritransplant HematomaUsually early
Pain over site,
dec Hb, inc creatinine
Diagnosis: CT
Complications
Complications
Most common acute emergencies are
Mechanical
Complications
Hepatic artery thrombosisRejection
Artery kinkingAnastomotic failure
Complications
Hepatic artery thrombosis
High mortality
Complications
Hepatic artery thrombosis
VascularTransplant
Complications
Biliary complicationsLeaks
StonesStrictures
Complications
Biliary complications
Complications
Biliary complications
GITransplant
Complications
Within the first year
Graft failure
Rejection
Infection
Complications
After the first year
Vasculopathydue to rapid atheroscleorosis
Complications
After the first year
Complications
May have no symptoms
Baseline ECG abnormalities
Dysrhythmias
Complications
Complications
Complications
Premature Ventricular Complex
Most common post-op (up to 100%)
Complications
Atrial Fib / Flutter
Most common atrial arythmia
Complications
Complications
Complications
Dysrhythmias
Complications
Dysrhythmias
Complications
TREATMENTBRADYCARDIA
Atropine may be effective
Temporary pacemaker
TACHYCARDIAS
Cardioversion if indicated
Cardiology consultation
TREATMENTSVT
Inc sensitivity to Adenosine
Do not give to ”uncover”
Start dose at 3mg
Cardiology consultation
Complications
Complications
Airway Causes
Bronchial stenosis/necrosis
Fistulapneumothorax
Tissue hyperplasia
Complications
Vascular Causes
Stenosis/kinking
Thrombosis
• Dyspnea, tachypnea
• Hypotension
• Edema
• Signs of R heart strain
Complications
Other Causes
Phrenic nerve dysfunctionMore common with combined cardiac-lung
• Dyspnea
• Hypoxia
• Tachypnea
• Atelectasis
• Elevated hemidiaphragm
Complications
Diagnosis
CT Scan
Bronchoscopy
US (right heart strain)
Complications
Complications
Otherwise, I will response as soon as I return.
Refs
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487371/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711495/
GVHDhttp://emedicine.medscape.com/article/429037-overview#a4
Add in
Adenosine in heart transplant
Rejection Tx (AJEM)