RUFAIDA COLLEGE OF NURSING

JAMIA HAMDARD

ASSIGNMENT

ON

ICU PSYCHOSIS & STRESS MANAGEMENT

SUBMITTED TO: Ms Saliqua Sehar

Tutor

SUBMITTED BY: Diksha Malhotra

M.Sc. Nursing 2nd year

SUBMITTED ON: 14/12/23

Introduction to ICU Psychosis

• Advances in medical science and technology have prompted the establishment of many
highly specialized units (ICUs) providing intensive patient care.
• ICU psychosis /Delirium in the intensive care unit is a serious problem that has recently
attracted much attention.
• As the number of intensive care units and the number of people in them grow, ICU
psychosis is perforce increasing as a problem.

Definition to ICU Psychosis

• Eisendrath defined "ICU Syndrome" /"ICU psychosis" as an acute organic brain

syndrome involving impaired intellectual functioning and occurring in patients treated
within a critical care unit.
• ICU Psychosis include mainly two mental conditions that is Delirium and Dementia.

Incidence of ICU Psychosis

• It is commonly found in the critically ill with a reported incidence of15-80%

• By some estimates, 80% of elderly intensive-care patients develop the condition, which
frequently leads to nursing home stays and a hastened death.

Etiological/ Predisposing factors to ICU Psychosis

a. Sensory overload
b. Sleep deprivation
c. Immobilization
d. Severe emotional stress
e. Unfamiliar environment
f. Dehydration
g. Low Haemoglobin level
h. Pain
i. Infection
j. Drugs
k. Prolonged stay in ICU and advancing age

Clinical manifestations to ICU Psychosis

a. Sudden onset of impairment in cognition

b. Disorganized thinking or Difficulty in concentrating
c. Problems with orientation in time and/or place and/or person
d. Altered affect, often with emotional liability
e. Altered perception of external stimuli o Impairment of memory
f. Changes in sleep-wake cycle
g. Hallucinations
h. Agitation or change in activity levels

Diagnostic Evaluation
 a. History taking
b. Physical Examination
c. Mental status examination
d. Mini mental status examination
e. Confusion assessment test

Management

Non pharmacological management

a. The management strategy is to "wait and watch".

b. Non- Drug Management
c. Continuity of health care personal
d. Clear concise communication
e. Repeated verbal reminders of time, place and person.
f. Clock, calendar, TV, newspaper, radio readily accessible as a means of orientating in
time.
g. Simplify the environment, single room when available, reduce noise levels, remove
unnecessary equipment
h. Adjust lighting according to day and night cycle.
i. Keep familiar objects.
j. Flexible visiting hours.
k. Allow maximum periods of uninterrupted sleep.
l. Encourage mobilisation and increase activity levels.
m. Relaxation techniques like music therapy and massage may also help.

Pharmacological management

a. Antipsychotic agents such as haloperidol is commonly used.

b. Olanzapine and Risperidone have been used as they are less sedating and have fewer side
effects.
c. Benzodiazepine would be beneficial, and lorazepam is the drug of choice.

Other therapeutic interventions

a. Adequate pain management

b. Avoid offending drugs
c. Correct fluid and electrolytes
d. Treat infection
e. Administer oxygen
f. Correct Hypoglycemia
g. Treat underlying cardiac problems
Introduction to stress

• Stress is the emotional and physical strain caused by our response to pressure from the
outside world.
• Common stress reactions include tension, irritability, inability to concentrate,
frustration and a variety of physical symptoms that include headache and a fast
heartbeat.

Definition to stress

• Stress is often termed as a twentieth century syndrome, born out of man's race towards
modern progress and its ensuing complexities. – BENJAMIN FRANKLIN
• Stress can have a big impact on your body, in ways that are felt by just you, and in way
that the world can see. One of the more visible potential by-products of stress is weight
gain--many people find themselves to be "emotional eaters" who react to stress by
reaching for something--often the wrong thing-- to eat. Stress can also create a loss of
appetite, which can be a problem as well.

Types of stress

• Acute stress
• Chronic stress
• Episodic stress
• Eustress
• Distress

Causes of stress and indicators

• Internal causes
• External causes

§ Physiologic indicators
• Pupil dilates to increase visual perception
• Sweat production increased to control the elevated body heat
• The heart rate and cardiac output increase
• The rate and depth of respirations increase
• Urinary output decreases.
• Blood sugar increase because of release of glucocorticoids.
• Muscle tension increases

§ Psychological indicators
• Anxiety -state of mental uneasiness, apprehension or a feeling of helplessness related to
an impending or anticipated threat.
• Fear- Fear is an emotion or feeling of apprehension aroused by impending or seeming
danger, pain or other perceived threat.
• Depression -Depression is a common reaction to events that seem overwhelming or
negative.
 § Cognitive indicators
• Problem solving
• Problem solving involves thinking through the threatening situation, using specific steps
to arrive at a solution.
• Structuring
• Structuring is the arrangement or manipulation of situation so that threatening events do
not occur. For-example a nurse can structure or control the interview with client by
asking only
• Self-control/self-discipline assuming a manner and facial expression that convey a
sense of being in control or in charge.
• Suppression-suppression is consciously and wilfully putting a thought or feeling out of
the mind
• Fantasy- fantasy or day dreaming is likened make believe unfulfilled wishes and desires
and imagined as fulfilled or a threatening experiences reworked or replace so that it
ends differently from reality.

Adaptation of stress

• Adaptation is an on-going process as a person strives to maintain balance in his / her

internal or external environments.

1. General Adaption model:

2. Stuart stress model

 3. Transaction model of stress

Common stressors

§ Stressors related to personality

• Irrational beliefs, values and attitudes
• Perfectionistic attitude
• Poor time sense
• Poor decision making
• Poor habits

§ Personal stressors
• Improper life style
• Loneliness
• Marital conflicts
• Poor physical health
• Financial problems

§ Environmental stressors
• Pollution
• Noise
• Overcrowding
• Extreme heat or cold
§ Stressors related to job
• Poor knowledge of job
• Unwanted job
• Shift work
• Low salary
• Job insecurity

Sign/ symptoms of stress

§ Physiological and Physical

 • Increased heart rate
• Increased blood pressure
• Dilated pupil
• Muscle tension
• Nausea and dizziness
• Aches and pain

§ Cognitive symptoms
• Memory problem
• Inability to concentrate
• Anxious thoughts
• Constant worrying

§ Emotional symptoms
• Moodiness
• Irritability and short tempered
• Agitation or inability to relax
• Sense of loneliness

§ Behavioral symptoms
• Eating more or less
• Sleeping too much or too little
• Isolating yourself from others
• Neglecting responsibilities
• Using alcohol, cigarettes, or drugs to relax
• Nervous habits (e.g. nail biting, pacing)

Management of stress

• HOLMES AND RAHE STRESS SCALE

• Social Readjustment Rating Scale (SRRS)
• DEPRESSION ANXIETY STRESS SCALES (DASS)
• DASS, the Depression Anxiety Stress Scales is made up of 42 self-report items to be
completed over five to ten minutes, each reflecting a negative emotional symptom.
• The main purpose of the DASS is to isolate and identify aspects of emotional
disturbance.

• PERCEIVED STRESS SCALE

• The Perceived Stress Scale (PSS) is the most widely used psychological instrument for
measuring the perception of stress. It is a measure of the degree to which situations in
one's life are appraised as stressful.
• For each question choose from the following alternatives:
• 0-never 1 -almost never 2 -sometimes 3 -fairly often 4 very often
• Scores ranging from 0-13 would be considered low stress.
• Scores ranging from 14-26 would be considered moderate stress.
• Scores ranging from 27-40 would be considered high perceived stress

• KINGSTON CAREGIVER STRESS SCALE (KCSS)

• The Kingston Caregiver Stress Scale (KCSS) is primarily a scale used to monitor
change in a family caregiver's stress level over time.
Adaptive coping strategies

o Awareness
o Relaxation
o Meditation
o Interpersonal communication with each other
o Problem solving
o Pet therapy
o Music therapy
o Breathing exercise
o Guided imagery

• STRESS MANAGEMENT FOR NURSES

• Alter the situation
• Avoid unnecessary stress
• Adapt to the stressor
• Accept the things you can't change
• Set aside relaxation time.
 • Exercise regularly.
• Eat a healthy diet.
• Get adequate sleep
• Be organized
• Breathe
• Talk
• Learn to identify the feeling
• Evaluate and relies on spirituality
• Acquire skills in needed areas

References

• www.slideshare.net>icupsychosis
• www.slideshare.com>stressmanagement
• Navdeep Kaur Brar Textbook of Advance Nursing Practice published by Jaypee
brothers edition 2nd
 RUFAIDA COLLEGE OF NURSING
JAMIA HAMDARD

ASSIGNMENT

ON

MANAGEMENT OF PATIENTS AFTER

CARDIAC SURGERY

SUBMITTED TO: Ms Uzma Anjum

Tutor

SUBMITTED BY: Diksha Malhotra

M.Sc. Nursing 2nd year

SUBMITTED ON: 22/12/23

Introduction

Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed
by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for
example, with coronary artery bypass grafting); to correct congenital heart disease; or to treat
valvular heart disease from various causes, including endocarditis, rheumatic heart disease, and
atherosclerosis. It also includes heart transplantation.

Types of cardiac surgeries

Reparative cardiac surgeries are:

1)Closure of patent ductus arteriosus, atrial septal defect (ASD) and ventricular septal
defect (VSD).
2) Repair of Mitral stenosis or Tetralogy of Fallot.
3)Reconstructive cardiac surgeries are not always curative procedures. These procedures
are complex surgeries required re-operation.
4)Coronary artery bypass graft
5) Reconstruction of an incompetent mitral, tricuspid or aortic valves.

Substitutional cardiac surgeries are:

1)Substitutional cardiac surgeries are valve replacement, cardiac replacement by

transplantation or mechanical device ventricular replacement.
2) Substitutional surgeries are not usually curative procedures.

Oher cardiac surgeries are classified as:

1) Open cardiac surgeries

2) Closed cardiac surgeries

I. CARDIO-PULMONARY BYPASS:

o Cardio pulmonary bypass is used during cardiac surgery to divert the client
unoxygenated blood to a machine in which oxygenation and circulation occurs.
o Reoxygenated blood is then returned to the client's circulation.
o This technique, called extra corporeal circulation ECC.
o Thus with the help of Heart lung machine, surgeon can stop the heart and bypass the
blood flow into machine.

§ Functions of heart lung machine:

• Diverts circulation from the heart and lungs, providing the surgeon with a bloodless
operative field.
• Preforms all gas exchange functions.
• Filters, rewarms, or cools the blood.
• Circulates oxygenated, filtered blood back into the arterial into the arterial system.

§ Types of cannulations-
 o Venous cannulation- A cannula may be placed in the right atrium, superior vena cava,
inferior vena cava or femoral vein to drain the blood from the body to cardiopulmonary
bypass circuit ( heart lung machine).
o Arterial cannulation- A cannula may be placed in ascending aorta or femoral artery for
returning of oxygenated blood from the heart lung machine.

§ Components of coronary bypass circuit are:

II. Myocardial protection:

o Myocardial protection can be defined as the specific intraoperative strategies designed

to protect the myocardium, from the tissue damage resulting from ischemic state that
occurs with extracorporeal circulation.

III. Cardioplegia:

o Cardioplegia is infused to arrest the heart and provide a bloodless, motionless operative
field as well as protect the heart during cardiac surgery.
o Cardioplegic solution is infused into the aorta or coronary sinus or into the coronary
arteries themselves to cause cardiac arrest.

§ Types of cardioplegia are-

 § Temperature of cardioplegia are-

§ Techniques of delivering cardioplegia are-

a. Antegrade
b. Retrograde

IV. Coronary Artery Bypass Grafting:

o Coronary artery bypass surgery is an open heart surgery which involves the bypass of
a blockage in one or more the coronary arteries using saphenous veins, mammary artery,
or radial artery as conduits or replacement vessels.

§ Indications of CABG-

• Asymptomatic or mild angina

• Stable angina
• Unstable angina

A. Asymptomatic or mild angina:

 § Class I:
1. Stenosis
2. Proximal stenosis
3. Triple vessel disease
4. Vessel disease (+2 with LVEF <50%)

§ Class II:
1. Proximal LAD stenosis and +2 vessel disease

B. Stable Angina:
1. Triple vessel disease
2. Angina refractory to medicine
3. 2 vessels disease + LVEF <50%
4. Myocardium at risk with LAD stenosis

C. Unstable Angina:
1. Ongoing ischemia
2. +2 vessel disease & PCI not possible

Procedural steps:

Pre procedural steps are-

• Patient medical history of patient properly examined for factors that might predispose
to complications.
• Routine pre-operative investigation
• PREMEDICATION –
• The aim of premedication are to minimize myocardial oxygen demands by reducing
heart rate and systemic arterial pressureand to improve myocardial blood flow with
vasodilators.
• Patients on beta blocker and calcium channel blocker - sudden withdrawal can cause
tachycardia, rebound HTN and reduced coronary dilatation.
• Administration of temazepam immediately before CABG can decrease the risk of
tachycardia and hypertension resulting from anxiety regarding the operation.
• In operating room, intravenous administration of a small dose of midazolam before
arterial line insertion can also reduce anxiety, tachycardia and hypertension.
• In patients referred for CABG, aspirin should be continued up to the time of surgery,
especially in those who present with an acute coronary syndrome. In patients receiving
a thienopyridine (e.g. clopidogrel) in whom elective CABG is planned, the drug should
be withheld for either 5 days (clopidogrel) or 7 days (for prasugrel) before the
procedure.
• Each patient should be cross matched with 2 units of blood (for simple case) or 6 units
of blood, fresh frozen plasma, and platelets.
• Administration of tranexamic acid may be considered to reduce post-operative
mediastinal bleeding and blood product (i.e. red blood cell and fresh frozen plasma)
use.
• ANESTHESIA-
• Cardiac surgery makes use of the following 2 forms of neuro-axial blockade Intrathecal
opioid infusion & Thoracic epidural anesthesia.
 § Pre procedural nursing care-
• Endo tracheal intubation needed
• Interscapular region
• Anesthetic agent
• Central venous access should be done
• Positioning- supine and roll in interscapular region
• Monitoring -
• ECG, pulse oximetry, nasopharyngeal temperature, urine output, and gas analysis
• Arterial blood pressure monitoring
• Central venous pressure monitoring
• Transesophageal echocardiography
• Neurological monitoring

Intraprocedural steps are-

• Harvesting the conduit-

• The saphenous veins have an 80-90 percent of patency rate.
• The saphenous vein is generally acceptable as a conduit in the absence of other vascular
pathologies in the leg.
• The greater saphenous vein (GSV) can be procured either via an open harvest technique,
starting from either the ankle or groin and using a vein stripper, or via an endoscopic
technique.
• The legs and groin should be shaved, prepared, and draped in the operating room.
• Internal Mammary artery-
• The LIMA (left internal mammary artery) and the RIMA ( right internal mammary
artery) arises from respective subclavian arteries.
• LIMA is most commonly harvested as a pedicle .
• RIMA is generally skeletonized because a RIMA pedicle may interfere with sternal
wound healing.
• The LIMA is useful in left anterior descending (LAD) artery anastomosis and has good
patency rate- 98 percent at 1 year and 90 percent at 5 years. The RIMA has a good
patency rate when anastomosed to the LAD (96 percent at 1 year and 90 percent at 5
years) but a reduced rate when grafted to the circumflex artery or the right coronary
artery (75 percent at 1 year).
• Surgical procedures-
• Incision for CABG- midline sternotomy by ant. Thoracotomy for bypass of the LAD.
Lateral thoracotomy for marginal vessels may be used when off pump procedure is
being performed.
• Coronary artery bypass-
• First step - to cannulate the aorta and right atrium
• Aortic area for cannulation must be soft and non- atherosclerotic.
• Insertion of aortic cannula - unfractional heparin given and Systolic BP is lowered to 100
mm of Hg.
• Aortotomy- is done with a scalpel, the cannula is placed and purse string sutures are
tightened around it.
• Aortic cannula is secured and connected to arterial pump tubing.
• Venous cannula is tightened in right atrial appendage in similar pattern.
• The aorta is cross clamped distal to cannula.
• Cold cardioplegia is infused via aortic cannula in antegrade pattern. Blood cardioplegia
is mostly infused as it has lower intra operative mortality, postoperative myocardial
infarction and conduction defects.
• Placement of graft-
• On initiation of cardiopulmonary bypass-
• Distal to proximal First – anastomosis of the right coronary artery and the marginal
branches of the circumflex artery. The circumflex is accessed by retraction the
laterally
• The posterior descending artery and posterolateral circulation are accessed by retracting
the heart cephalically.
• The LIMA is usually anastomosed with the LAD. The saphenous vein can be grafted
to all coronary artery except LAD.

§ Techniques of anastomosis-

• Weaning from cardiopulmonary bypass -

• Rewarm the patient
• Initiation of mechanical ventilation
 • In case of bradycardia and heart block, epicardial pacing.
• Once the heart start beating, the CPB is stopped.
• Effect of anticoagulation is reversed by administration of Protamine.

§ Inflammation of aortic balloon pump-

i. It augment the coronary perfusion during diastole and reducing the afterload.
ii. It consist of a sausage shaped balloon that passed through the femoral artery and
positioned at descending thoracic artery just distal to the subclavian artery.
iii. The catheter is attached to a power console that inflates and deflates the balloon.
iv. Inflation- Blood is pushed back into the aorta, the coronary artery perfusion is
improved.
v. Deflation- Resistance is decreased and the workload of the heart is reduced.

§ Nursing care patient with CABG surgery-

• The following are the goals to be achieve while caring CABG patient in hospital-
• To prevent the negative effects of prolonged bed rest.
• To assess the client's physiologic response to exercise. To manage the psychological
issues related to recovery from CABG surgery.
• To educate the client and family concerning recovery and the adoption of risk reduction
behaviours.

o Nursing diagnosis -
o Decreased cardiac output related to alteration in preload/afterload/contractibility/heart
rate.
o Impaired gas exchange related to ventilation/perfusion mismatch or intrapulmonary.
o Ineffective airway clearance related to retained secretions and excess secretions.
o Risk for Haemorrhage related to inadequate haemostasis, disruption of suture line or
coagulopathy.
o Acute pain related to tissue trauma secondary to sternotomy and leg incision.
o Risk of post cardiotomy delirium or stroke.
o Risk of infection related to sternotomy incision, diabetes and obesity.

1. Decreased cardiac output related to alteration in preload/afterload/contractibility/heart

rate.

◦ Assess hemodynamic parameters (heart rate, CVP, RAP, BP, PAP, PAWP, CO)
◦ Monitor potassium and magnesium levels.
◦ Monitor weight daily and calculate change.
◦ Monitor for peripheral edema.
◦ Monitor I & O hourly.
◦ Monitor heart sounds every 4 hourly- ventricular gallop S3 sign of heart failure.
◦ Administer prescribed fluids, packed red blood cells, or colloids.
◦ Administer prescribed vasodilators- reduce afterload Warm the client to reduce
shivering - hypothermia can lead to depressed contractility
◦ Administer inotropic medication as prescribed - enhance myocardial contractibility
Protect external pacemaker wires from water and accidental exposure to electricity by
placing them in rubber gloves.

2. Ineffective airway clearance related to retained secretions and excess secretions.

 ◦ Monitor lung sounds- accumulation of fluid in alveoli
◦ Monitor coughing efforts.
◦ Administer supplemental oxygen to maintain saturation levels above 93%.
◦ Maintain the comfort using prescribed opioids.
◦ Splint the incision with "heart pillows" or pillows.
◦ Early ambulation
◦ Use of incentive spirometry.

3. Risk for Haemorrhage related to inadequate haemostasis, disruption of suture line or

coagulopathy.

◦ Monitor mediastinal chest tubes for output hourly.

◦ Report excess volumes and/or institute prescribed treatments for blood loss.
◦ Retransfuse blood from mediastinum as ordered.
◦ Keep chest tubes positioned without kinks and/or gently strip them
◦ Monitor for manifestation of cardiac tamponade- elevated
◦ CVP, decreased CO, muffled heart sound and sudden cessation of chest tube drainage.

Post operative health education and rehabilitative programs(CABG):

◦ The following are the goals to be met in this phase

◦ To restore clients to a desirable exercise capacity appropriate to their health status,
lifestyle, and occupation
◦ To provide additional education and support to the client and family for adoption of risk-
reduction behaviours
◦ To meet the psychosocial needs of clients and family, restore confidence, and minimize
anxiety and depression.
◦ To promote early identification of medical problems through close observation and
monitoring of clients during exercise.
◦ To assist clients in returning to occupational and leisure activities.
◦ To institute long term, follow up of risk reduction behaviour change.
◦ To encourage clients to take responsibility for continuing lifestyle change.
◦ Outpatient exercise training usually takes place in a facility that provides continuous
ECG monitoring.
◦ Exercise therapy should be conducted three times weekly for 2-3 months.
◦ The duration of aerobic exercise ranges from 20 -30 minutes.
◦ After exercise heart rate, blood pressure, respiration is checked.
◦ A nutritionist may counsel for proper diet and psychologist for stress management and
adoption of risk prevention behaviours.
◦ In home visit periodic ECG examination is done.
◦ Cardiac rehabilitation

VALVE SURGERY:

§ Valvuloplasty

Valvuloplasty is the reconstruction or repair procedure done for a diseased heart valve. It is
repair of the valve leaflet or related structure. v The different methods of valvuloplasty includes
patching the perforated portion of the leaflet, resection of excess tissues and debriding
vegetation and calcification.
Advantage of valve repair are -
1. Higher survival rate
2. Fewer cardiac complication
3. Lesser mortality and morbidity
4. Reduced need for anticoagulation
5. Less costly

• Pre operative care-

• Review the patient's condition.
• Rule out the medical, psychiatric and surgical history. Rule out whether patient is habitual
to alcohol intake and smoking. Pre operative lab investigations to be done.
• Evaluate the medication therapy of patient- digoxin, diuretics, anti-hypertensive,
psychotropic and herbal supplement.
• Preparation of events in the post operative period.
• Informed consent to be taken.
• Shave and preparation of surgical site. Give sedative before going to operating room if
ordered.

§ REPARATIVE SURGERIES

• Commissurotomy is an open-heart surgery that repairs a mitral valve that is narrowed

from mitral valve It is also called open commissurotomy.
• During this surgery, a person is put on a heart-lung bypass machine.
• Open commissurotomy is performed through median sternotomy and right anterolateral
thoracotomy.
• The surgeon removes calcium deposits and other scar tissue from the valve leaflets.
• The surgeon may cut parts of the valve structure. This surgery opens the valve.
• It is used for people who have severe narrowing of the valve and aren't good for balloon
valvotomy.

§ Annuloplasty-
§ Excessive leaflet tissue may be resected, elongated chordae may shortened by incision of
papillary muscle and im-breating it with elongated chordae.
§ Annular dilation is treated by tightening the annulus, usually with placement of a support
ring to remodel annular shape without reducing orifice size.
§ Annuloplasty is used for stenotic or regurgitant valve.

§ Valve replacement –
§ Valve replacement is the excision of the valve leaflets and replacement of it with
mechanical or biological prosthetic. It is indicated, when valve is so stenosed and
calcified and heart circulatory function is seriously impaired. The outcome of valve
replacement is depend on patient general condition, heart function at the time of surgery
and type of valve used.

• Intra operative procedures-

• Incision of median sternotomy or in some case right thoracotomy incision.
• Initiation of cardiopulmonary bypass
• The diseased valve leaflets are excised at the annulus.
• The margin of the valve annulus are retained and sutured with prosthesis.
§ Post operative complication of valvular surgeries-
• Thromboembolism
• Bleeding
• Infection
• Congestive cardiac failure
• Dysrhythmias
• Haemolysis
• Mechanical obstruction of valve

§ Post operative care-

• Achieve and maintain normal body temperature.
• Monitor and optimize vital signs and hemodynamic status
• Monitor for presence of dysrhythmias
• Monitor drainage from the chest tube
• Reposition patient every 2 hours and increase activity level when stable
• Monitor the patient's respiratory rate and promote deep breathing exercise and coughing
to prevent atelectasis
• Monitor for and report any neurological changes from baseline
• Maintain adequate renal perfusion. Document daily weight and fluid intake and output.
Monitor serum electrolyte level. Avoid preload reduction
• Patient education-
• Teach the patient about long term use of anticoagulant (warfarin) and its importance
• Teach the patient about importance antibiotic prophylaxis to prevent bacterial
endocarditis before dental and surgical interventions.
• Advice the patient to have regular follow up with surgeon
• Advice the patient to check PT INR value monthly it should in the range of 2.5 to 3.5
• Counsel the patient against the pregnancy.

§ Cardiac Transplantation-

§ Cardiac transplantation is the effective treatment of choice for client with end stage heart
disease and significantly prolongs the life of the patient.
§ There is an acute shortage of hear donors.
§ While 50,000 need transplants every year, only 340 done in last 24 years. Delhi alone
needs 1000 heart transplants every year. Based on activity data analysed from 2008
for 104 countries, representing nearly 90% of the worldwide population, it is shown
that around 100, 800 solid organ transplants are performed every year worldwide: 69
400 are kidney transplants (46% from living donors), 20 200 liver transplants (14.6%
from living donors), 5 400 heart transplants, 3 400 lung transplants and 2400 pancreas
transplants.

• Indications for cardiac transplantation-

• Severe heart failure refractory to medical therapy
• Ischemia heart disease with not amenable to revascularization
• Recurrent symptomatic ventricular tachyarrhythmias refractory to medical therapy,
devices, or surgery
• Cardiac tumours
• Dilated cardiomyopathy
• Contra indication -
• Amyloidosis
• HIV infection
• Cardiac sarcoma
• Age greater than 70 years
• Fixed pulmonary hypertension
• Systemic illness that will limit survival despite transplantation
• Neoplasm other than skin cancer (less than 5 years disease- free survival)
• HIV/AIDS (CD4 count less than 200 cells/mm3)
• SLE or sarcoidosis that has multisystem involvement or is still active
• Irreversible renal or hepatic dysfunction

◦ Selection of heart donor-

◦ Brain death- Healthy young patients with complete unresponsiveness, unreceptive,
without reflex and spontaneous movements of breathing.
◦ Age - Younger than 55 years of age and in smoker less than 45 years of age.
◦ No cardiac arrest or profound hypotension after injury.
◦ Normal echo function
◦ No valvular lesion
◦ No wall movement abnormality
◦ No sepsis, HIV, Hepatitis C, active malignancy, drug abuse, carbon monoxide poisioning
◦ No injury to heart or concussion to heart.

◦ Selection of recipient -
◦ No pulmonary artery hypertension
◦ No infection - HIV, Hepatitis, Pneumonia, Sepsis
◦ No pulmonary infarction
◦ Age below 60 years
◦ No renal failure
◦ No malignancy for 5 years

§ Technique of transplantation-
 ◦ Assisted circulation and Mechanical hearts -
◦ It consists of a pump which is implanted in the abdominal wall and connected to the left
ventricle of the heart.
◦ It assists weak ventricles to draw blood into it and circulate throughout the body.
◦ The surgeon connects the VAD to the bottom of the heart and an aorta
◦ Blood then flows into the heart and out the aorta by mean of small electrically driven
motor placed in VAD.
◦ The VAD is also consists of battery and controller that place beneath skin thus is easier
to carry.
◦ It bridges the time until a donor heart become available.

§ Post operative monitoring-

◦ Bleeding
◦ Rejection
◦ Hypovolemia
◦ Arrhythmias
◦ Pulmonary HTN

References:

◦ Black Joycee, Hawks Jane, Medical Surgical Nursing - Clinical Management For
Positive Outcome, Volume- 2, 7th Edition, Elsevier Publication.
◦ www.googleimage.com
◦ www.wikipedia.com
◦ www.pubmed.com