Intestinal Transplantation in Pediatric Patients: A Nursing Challenge Part 2: Intestinal Transplantation and the Immediate Postoperative Period

Abstract

Intestinal transplantation offers new hope to children with intestinal failure and life-threatening complications of parenteral nutrition. As more transplant centers are adding intestinal transplantation to their existing programs, new challenges are presented to nursing professionals. This three-part series will provide information for nursing professionals regarding evaluation for intestinal transplantation, donor preparation, the surgical procedure, immediate postoperative care of the transplant recipient, and long-term care of the intestinal transplant recipient. This article focuses on donor selection and preparation, the surgical procedure for intestinal transplantation, the immediate postoperative course, immunosuppression, rejection, infections, fluid and electrolyte support, and nutrition. The information presented represents the approach taken at University of Nebraska Medical Center/Nebraska Health Systems.

Clinical practice guidelines—Nursing management for pediatric patients with small bowel or multivisceral transplant

“…This is a common complication that occurs in 90% of patients, usually within the first 90 days after transplant, but it can occur at any time. Rejection can recur multiple times in the graft and can be difficult to diagnose, as there are no simple laboratory tests to confirm rejection (Andersen et al., 2000b; Avitzur & Grant, ). The recommended and most definitive diagnostic tool is a biopsy to analyze the bowel mucosa.…”

“…Research is inconclusive on the required frequency of biopsies, but one to two per week during the first month after transplant is common because the risk for rejection is at its highest. There is a gradual reduction in the frequency of biopsies if the graft shows no signs of rejection (Andersen et al., 2000b). Awareness of the possible signs of rejection will allow nurses to notify the transplant team if any of these occur: vomiting, diarrhea, fever, abdominal pain, and changes in ostomy output amount or consistency.…”

Pediatric Intestinal Transplantation—Review of Current Practice

“…IV pain medications are generally discontinued around the second or third postoperative day, and the use of acetaminophen suspension usually provides adequate control of incision discomfort. 46 Infectious complications pose a significant problem postoperatively for any solid organ transplant because of the use of immunosuppressive medications to control rejection. Any fever Ն38.5°C needs to be brought to the attention of the physician.…”

Commentary on “Three Years Clinical Experience With Intestinal Transplantation” and the Nutritional Implications

“…These complications increase resources and the complexity of care, frequently requiring the temporary use of parenteral nutrition and IV fluids as described within this article and elsewhere. 9,10 Today the risk of rejection is less and better controlled than in the early 1990s. Rejection rates among major ITx centers are reported at 66% to 67% subsequent to advances in immunomodulation regimes and preconditioning strategies.…”

“…27,28 Addition of soluble fiber in the form of pectin or fiber enhanced formulas have been used postoperatively to help decrease intestinal transit and thicken stool output. 10,29 There may be a physiologic basis for glutamine enhancement after ITx; however, there is no clinical evidence of its benefit. Prospective, randomized, clinical trials are required to better establish the optimal nutrition support regimens within the ITx patient population.…”