Advancements in immunosuppression, transplant techniques, antimicrobials, postoperative management and support, bridging techniques, and extracorporeal life support have had an enormous impact on morbidity and mortality of transplant recipients over the past few decades.
Although some generalizations can be made regarding the management of transplant patients, organ-specific considerations based on the particular allograft transplanted are critically important.
Infections can reactivate in an immunocompromised recipient who has been previously exposed. Alternatively, a naïve recipient may acquire an infection following the transplant of an organ from a seropositive donor. Infections in transplant recipients can progress rapidly and hence must be promptly recognized and appropriately treated.
Risks and benefits of sustained immunosuppressive therapy must be balanced in transplant recipients. Though immunosuppressive drugs are essential to prevent allograft rejection, they also increase the risk of infection and neoplasm.
Immunosuppressive drugs have significant side effects and many have important drug-drug interactions that must be recognized by the intensivist.
Organ transplantation has become a cornerstone in the management of end-stage organ dysfunction. Since the 1960s, important scientific advances have greatly improved our understanding of transplant immunology. Innovations in transplant techniques have allowed for a remarkable change in survival of this population. Immunosuppressive and antimicrobial therapies have markedly decreased the incidence and severity of allograft rejection and overwhelming infection.
In the early decades of transplant, all forms of organ transplantation necessitated intensive postoperative monitoring; however, in recent years, some organ transplants (eg, kidney and pancreas) no longer require routine postoperative admission and monitoring in an intensive care unit. Lung, liver, and heart transplantation, however, remain challenging from a surgical and anesthesia perspective with risk for hemodynamic and respiratory complications intraoperatively and in the perioperative period. Their long-term outcome depends on the immediate postoperative management in the intensive care unit and recent advances in survival have been directly due to improvements in early postoperative care.
Given the burden of immunosuppression that these patients face throughout their posttransplant lives, they are at increased risk of developing severe standard and opportunistic infections prompting admission to an intensive care unit. Their lives are further complicated by acute and chronic rejection that could necessitate intensive care support. Knowledge of unique presentations of common illnesses or unique illnesses that present with common clinical syndromes is imperative for the early recognition and timely initiation of appropriate treatment. The consequences of missing rejection or infection include death, or graft failure and return of the patient back to a state characterized by the sequelae of end-organ dysfunction.
This chapter focuses on the indications, outcomes, postoperative management, and postoperative complications of lung, liver, and heart transplant. For the transplant intensivist, optimization of the postoperative care and knowledge of the potential complications are necessary to enhance outcome. For the nontransplant intensivist, knowledge of indications for transplant, supportive care, and optimization of function prior to transplant is important. An understanding of bridging techniques and ...