A. Cardiac transplant patients are similar to nontransplant cardiac surgery patients in many regards, but there are several key differences that are due in part to the denervation of the transplanted heart.

1. Autonomic interventions are often futile.

a. Atropine.

b. Maneuvers.

i. Carotid sinus massage.

ii. Valsalva.

2. Intrinsic SA node will pace between 90 and 110 bpm. Changes in HR are mediated via circulating catecholamines (epinephrine) rather than nervous innervation, so the response is slower.

3. Pain: Patients may not experience cardiac chest pain.

B. Posttransplant monitoring is similar to that in nontransplant cardiac surgery patients.

1. Hemodynamics: arterial line, central venous line, pulse oximetry: these lines aid in determining cardiac output, need for IV fluids/inotropic support, treatment of pulmonary hypertension, and need for further interventions.

2. Epicardial pacing wires (placed intraoperatively, backup rate = 60 bpm). Cardiac rhythm support, used in the treatment of posttransplant bradycardia.

3. Mediastinal and pleural chest tubes are placed to −20 cm H₂O suction.

a. To monitor for postoperative intrathoracic hemorrhage.

b. Prevention of cardiac tamponade.

4. Foley catheter.

a. To monitor urine output.

b. To assess core body temperature.

A. Immediately posttransplant, the focus is on achieving and maintaining hemodynamic stability.

B. Volume status: IV fluids (crystalloids or colloids) to maintain adequate systemic perfusion as evidenced by the following.

1. Palpable distal pulses, upper extremities.

2. Urine output >0.5 mL/kg/h (without diuretics).

3. Acid-base balance.

4. Cardiac index >2.0 L/min/m2.

5. CVP of 8 to 12 cm H₂O and/or pulmonary capillary wedge pressure of 15 to 20 mm Hg.

C. Hemodynamics.

1. Inotropic support (required when above criteria are not met; β-adrenergic agents should be used in the presence of adequate preload).

2. Afterload management goals: mean arterial pressure (MAP) 65 to 80 mm Hg and/or a calculated systemic vascular resistance 1,000 to 1,400 dynes/s/cm⁵. MAPs > 80 mm Hg should be treated in order to avoid excessive ventricular wall stress.

a. IV sodium nitroprusside.

b. IV nitroglycerin (associated with less intrapulmonary shunting than sodium nitroprusside due to relative preservation of the pulmonary hypoxic vasoconstrictor reflex).

D. Respiratory management: follows the same principles as after routine cardiac surgery.

E. Electrolyte balance and renal function: follows the same principles as after routine cardiac surgery.

1. Serum electrolytes are closely monitored. Maintaining normal K⁺, Mg²⁺, and Ca²⁺ levels is particularly important in reducing the frequency of arrhythmias.

2. On initiation of immunosuppressant therapies, particularly cyclosporine, serum creatinine is followed closely to monitor for early nephrotoxicity.

3. Diuresis with furosemide is usually initiated 24 to 48 hours postoperatively and continued to achieve euvolemia.

F. Perioperative infection prophylaxis.

1. General prophylaxis: First-generation cephalosporins (vancomycin for patients with β-lactam allergy) are administered 30 minutes prior to induction of anesthesia and continued for 48 hours postoperatively.

2. Prophylaxis for Pneumocystis jirovecii pneumonia, Toxoplasma gondii, Listeria, Legionella, and Nocardia: Trimethoprim-sulfamethoxazole (TMP-SMX) (or aerosolized pentamidine if TMP-SMX is not tolerated).

3. Prophylaxis for prevention of mucocutaneous candidiasis.

a. Nystatin or clotrimazole.

b. Fluconazole is indicated for patients with a history of candidiasis refractory to these topical antifungal agents or involving the esophagus.

4. Prophylaxis for herpes simplex and varicella zoster viruses: low-dose acyclovir.

5. Latent tuberculosis infection: recipients with a positive purified protein derivative skin test should be considered for prophylaxis with isoniazid or rifampin.

6.

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