Virginia Commonwealth University (VCU) Health System is an academic medical center in central Virginia that has operated a solid organ transplant program since 1956. The Hume-Lee Transplant Program at VCU consists of outpatient clinics, a 21-bed stepdown and telemetry unit, four beds in the surgical trauma intensive care unit (STICU), a clinical transplant laboratory, and a tissue-typing laboratory. The program uses two nurse practitioners in the inpatient setting, and we collaborate with transplant surgeons, transplant nephrologists and hepatologists in a variety of ways. The figure accompanying this article illustrates the variety in our role.

NP as Provider

In our provider role, we provide medical management of patients with end-stage renal disease and end-stage liver disease, as well as preoperative and postoperative management of patients undergoing fistula creation or graft placement for dialysis access or nephrectomy. We provide medical management for abdominal transplant recipients and patients undergoing surgical diagnosis and treatment for hepatocellular carcinoma (HCC), as well as other general and hepatobiliary surgical procedures.

Postoperative responsibilities include the following:

• prevention of postoperative bleeding and thrombosis

• strict blood pressure management for the first 24 to 48 hours after surgery

• frequent neurovascular assessment of the extremities

• pain management

• tight glycemic and blood pressure control

• monitoring for postoperative complications.

Patients undergoing surgical resection and intraoperative radiofrequency ablation for HCC require liver function monitoring (LFTs), assessment for decompensation, and management of postsurgical issues. Potential complications include acute liver failure, variceal bleeding, ascites, sepsis, hepatic artery damage, encephalopathy and transaminitis.¹

At VCU, liver recipients spend the first few postoperative days in the STICU, usually intubated for the first 24 to 48 hours. We monitor LFTs and synthetic function of the liver closely. A dramatic increase in transaminases is typically the first indication of hepatic complication. We use liver Doppler ultrasound to monitor patency of the hepatic vasculature, any fluid collections or signs of bleeding or hematoma development, ductal dilatation or evidence of anastomotic stricture, and thrombosis. We monitor fluid balance closely with a goal of a low central venous pressure and normotension. This is achieved by a balancing act of diuresis coupled with blood product requirements to correct anemia, thrombocytopenia related to preoperative splenic sequestration, and coagulopathy.

Most kidney and kidney-pancreas transplant recipients at our facility are sent to our stepdown unit immediately after surgery. There, we monitor urine output, laboratory results and kidney ultrasounds to check for resistive indices, patency of vessels, and any evidence of hydronephrosis, fluid collection or hematoma. The most common surgical complications in kidney transplant recipients include wound infection, renal artery or vein thrombosis, and urine leak. Additional goals of management are to ensure an equal fluid balance, adequate urine output and goal central venous pressure. Again, this is a balancing act of diuresis and fluid boluses, as well as aggressive blood pressure control to prevent postoperative complications.

In kidney transplant patients, hypertension can lead to kidney rupture and bleeding. Hypotension compromises blood flow to the kidney. To maintain strict blood pressure control, intravenous vasodilators are administered after surgery, until the patient resumes eating. At that time, oral antihypertensive medications are added to their regimen to ensure normotension. Many kidney recipients have a longstanding history of hypertension. Their postoperative blood pressure may be uncontrolled on previous home regimens, due to the additive hypertensive side effects of calcineurin inhibitors. This means that these patients are typically on maximum doses of triple and quadruple therapy to keep their blood pressure in a normal range.

Kidney transplant patients with a history of diabetes typically require a postoperative insulin drip, along with large doses of subcutaneous insulin. For our kidney-pancreas patients, management is essentially the same as for kidney patients, with one exception: Blood glucose is followed closely, and no insulin is administered. This is due to the possibility of pancreatic thrombosis. The first indication (and a late sign) is sudden hyperglycemia.

Another aspect of our medical management services is the care of living organ donors. Both kidney donors and liver donors recover on our stepdown unit. Because the open live donor nephrectomy is a retroperitoneal surgery, bowel function returns quickly, diet is advanced, and ambulation is encouraged within the first 12 hours of surgery. Most kidney donors are discharged by postoperative day two. Liver donors have a longer postoperative course that is focused on monitoring liver function tests, assessing for return of bowel function, and DVT prophylaxis. Despite the extensive, complicated surgery, the typical liver donor is discharged after 5 to 7 days.

In liver recipients, we check immunosuppressive drug levels daily to make dosage adjustments to achieve therapeutic drug levels. Levels that are too high lead to side effects; low drug levels may lead to rejection of the graft.

Infection is always a concern with transplant recipients, due to initial high-dose and long-term immunosuppression. Beginning postoperatively and continuing for the first 3 to 12 months, our organ transplant recipients receive antibiotic prophylaxis. We also provide patient education about basic infection control measures.

ecause we have been specially trained in the acute care transplant setting, we are able to provide expert and timely care. We have experience within the hospital system and use those resources effectively. In most cases, we have followed the patient preoperatively (initiating and updating the preoperative plan of care, performing the history and physical, and obtaining consent for surgery). We have knowledge of operating room procedures and events. Postoperatively, we design, implement and evaluate the care of the patient. Studies show that such focus by NPs "provides an additional dimension beyond medical diagnosis and management."²

NP as Facilitator

A facilitator enables groups and organizations to work more effectively. We maintain a professional relationship with ancillary and consult services and often are the point of contact for the transplant surgery service. By functioning in this role, we make our service more effective. On a daily basis, we interact with a wide range of disciplines, including but not limited to radiology, pathology, hepatology, nephrology, cardiology and other medical and surgical services, to ensure that immediate patient needs are met and the warranted evaluations are done at the appropriate level of urgency. We also follow up on these consults and procedure results, disseminate the information and initiate further work-up, when indicated. If consults or diagnostic procedures are not being completed in a timely fashion, we escalate the process.

NP as Collaborator

Our role features collaborative practice as well as independent practice. Our collaboration role focuses on improved communication among all disciplines. An integral part of our regular work day involves a multidisciplinary team meeting. One of us leads this meeting, which addresses all aspects of patient care. In attendance are nursing staff members, clinical coordinators, inpatient transplant coordinators, the transplant pharmacist, the transplant dietitian, the hospital care coordinator, the transplant social worker, physical and occupational therapists, and at least one resident physician.

Each patient in our service is discussed, and all aspects of patient care are addressed. We disseminate the information while communicating and implementing treatment plans to attending physicians, residents and consult services. This collaborative working relationship ensures quality patient care.³

NP as Liaison

liaison is a channel for communication between groups. Our transplant service consists of five attending surgeons, one transplant fellow, three residents and one intern. The entire team maintains close collaboration with two transplant nephrologists and five hepatologists. We mainly work with staff nurses in the STICU and stepdown-telemetry floor, but occasionally we interact with nurses on other units.

e encourage communication about patient care, and our approachability and availability optimize care.⁴The residents use our knowledge and expertise in the care of these patients; we are the constant in the ever-changing environment of an academic medical center.

We have assisted in the development of protocols and can assist both the nursing staff and residents. We are the throughput of patient information, and we disseminate and coordinate that information so that the output of care is in the best interest of the patients and their families. We are the offense and defense for the patient, because we receive pertinent data from a variety of sources and disseminate this information to the appropriate people. We may consult with other subspecialty services. We involve and are involved in many areas of the hospital and with hospital personnel, functioning as a liaison for disseminating information to achieve excellent outcomes.⁵

Putting It Into Practice

The nurse practitioner role in the transplant setting is a dichotomy of surgical and medical management. Since the inception of this position within our large medical center, we have been described as "the keepers of the flame"- a constant presence in a world of flux. This is perhaps one of our most critical roles, because it is directly related to continuity of care.

References

1. Pietrosi G, et al. Arterial chemoembolization/embolization and early complications after hepatocellular carcinoma treatment: a safe standardized protocol in selected patients with Child class A and B cirrhosis. J Vasc Interv Radiol. 2009;20(7):896-902.

2. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medicine service. Am J Critical Care. 2002;11(5):448-458.

3. MacDonald C. Nurse autonomy as relational. Nurs Ethics. 2002;9(2):194-201.

4. O'Brien JL, et al.. A phenomenological perspective on advanced practice nurse-physician collaboration within an interdisciplinary healthcare team. J Am Acad Nurse Pract. 2009;21(8):444-453.

5. Ballard KA, et al. Nursing: Scope and Standard of Practice. Silver Spring, Md.: American Nurses Association; 2004.

Leslie Gallagher is an adult nurse practitioner who practices in the solid organ transplant program at Virginia Commonwealth University Health Systems in Richmond, Va. ?Kathryn Kane is a family nurse practitioner who also practices in the solid organ transplant program.