1. Dickinson, Sharon MSN, RN, CNS-BC ANP, CCRN
  2. Issue Editor
  3. Reames, Christina MSN, RN, CNS-BC
  4. Issue Editor
  5. Shever, Leah L. PhD, RN
  6. Issue Editor

Article Content

Since the publication of Critical Care Nursing Quarterly's transplantation update in 2008, much has changed but much has remained the same. In 2008, there was hope that advances in medical care would reduce the need for solid-organ transplants. Although advances have been made, the current need for organ transplantation far exceeds the supply. In this issue, we hope to elucidate many of the recent improvements and highlight best practices for solid-organ transplants.


For a more in-depth study, this issue focuses on heart and liver transplants and even follows some posttransplant children to summer camp. Scheuher starts the issue by giving an overview of solid-organ transplant describing the process for organ allocation and reviewing the United Network of Organ Sharing (UNOS) steps that a patient must go through to be considered for placement on the transplant list. Freeman and coworkers describe the advances in cardiac transplantation. Since 2008, there have been advances in the medical management of heart failure as well as marked advances in long-term mechanical support of cardiac function with ventricular assist devices. Their second article highlights the postoperative care of the cardiac transplant recipient.


Jasiak and Park go on to give an in-depth review of the immunosuppressant medications used to prevent rejection of solid-organ transplants. This includes mechanisms of action, dosing, important drug-drug interactions, and side effects. They also describe some newer techniques to evaluate the minimization of these potent drugs to prevent overimmunosuppression.


Due to the fact that large numbers of patients with end-stage liver disease develop renal failure (hepatorenal syndrome), Wonnacott, Josephs, and Jamieson describe the use of continuous renal replacement therapy (CRRT) in liver failure and transplant. Renal failure is an ominous diagnosis in cirrhotic patients. Of particular concern for the intensive care unit (ICU) nurse performing CRRT is the need to anticoagulate the circuit in a patient with poor intrinsic clotting. They outline the rationale and management of patients on CRRT with citrate anticoagulation.


Cosica, Saxton, and Dickinson's article on liver transplant noted that there have been advances in the prevention and treatment of chronic viral liver disease (hepatitis B and C) that have reduced the need for transplant. However, other liver diseases, such as nonalcoholic fatty liver disease, have filled the void. They also describe an innovative way to track patients arriving in the ICU from the operating room based on their expected needs. This method allows for a more efficient utilization of available ICU resources including nursing staff.


A review by Tischer and Miller complements Cosica and colleagues' article by outlining strategies to prevent a major complication of liver transplant-bleeding. They describe the anticipated hemostatic changes associated with chronic liver disease and cirrhosis that result in bleeding. In addition, the article discusses how the use of the protease inhibitors, aprotinin and tranexamic acid, which decrease fibrinolysis and improve clot formation, thus can reduce bleeding. Since the liver is responsible for the production of all the blood coagulation factors except for factor VIII, patients with cirrhosis are at increased risk of intractable bleeding. Thus, they also describe recent advances in blood product administration including factor VII. The findings in this review can be applied to bleeding in other nontransplant populations.


Bilhartz and Shieck describe the unique concerns for pediatric liver transplant. Although there is significant overlap in the concepts and care pathways of pediatric and adult liver transplant, there are also significant differences. One important item is the fact that most children suffer from cholestatic liver disease, whereas most adults have hepatocellular disease. Bilhartz, Drayton, and Shieck have contributed an important and inspiring article on transplant summer camps. We included this article for several reasons. First, the experience of most ICU nurses to transplant is often focused on the acute medical care needs. A larger picture of how patients spend their lives after transplant can be understandably overlooked. Second, patients who spend the most time in the ICU are often associated with the poorest outcomes, and this can skew the view of solid-organ transplant for the critical care nurse. Finally, we have found that having the critical care nurses (both pediatric and adult) attend the camps is therapeutic for the patients but perhaps even more so for the involved staff. This is a model that could also be applied to other patient populations.


The issue concludes with Scheuher's short work about efforts to increase organ donation on a global basis. With a widening gap between urgent needs and availability of suitable organs for transplant, more must be done to educate the public and to increase awareness of the social responsibility for considering organ donation.


-Sharon Dickinson, MSN, RN, CNS-BC ANP, CCRN


Christina Reames, MSN, RN, CNS-BC


Leah L. Shever, PhD, RN


Issue Editors