MARCH 1986, VOL. 43, NO 3 AORN J O U R N A L

Pancreatic Transplantation PERIOPERATIVE NURSING CARE

Patricia Ball, RN

n the United States, more than 10 million people suffer from diabetes mellitus. As a result I of their diabetes, many will experience chronic

pathological changes such as microangiopathy, neuropathy, and retinopathy. Various studies suggest a relationship between high levels of blood glucose and those changes.’

The treatment of diabetes focuses on providing as near normal blood glucose levels as possible in each 24-hour period. That can be achieved by oral hypoglycemia agents, insulin, and/or dietary management. At present, no insulin therapy can achieve a 24-hour glucose level that completely mimics normal glycemic rhythms. Even after 60 years of insulin experiments and treatment, a diabetic’s life expectancy is about two thirds that of nondiabetics because the numerous vascular and neurological complications take their toll. One means of achieving normal or near normal glycemic levels is through a pancreas transplant.

Those suffering from diabetes are divided into Type I and Type 11. Type I1 diabetics produce some insulin and can usually be controlled by diet and/or oral medication. Type I1 diabetes often appears around ages 30 to 60. Although this group may develop vascular disorders as a result of their diabetes, their life expectancy is generally greater than Type I because they have not suffered from diabetes for the majority of their life. Type I1 diabetics are not usually candidates for pancreas transplants because their glucose intolerance is relatively easy to control.

Type I diabetics do not produce any insulin, and are totally dependent on exogenous insulin.

Approximately 10% of the diabetics in the United States are Type I. They are often called “juvenile diabetics” because the disorder usually manifests itself during childhood. In their adult years, Type I diabetics are prone to heart disorders, blindness, neurological dysfunctions, peripheral vascular disorders, and infections. More than half will develop kidney disorders; many will experience renal failure and need dialysis. Patients with severe Type I diabetes that are difficult to control with exogenous insulin and who are showing signs of complications, are candidates for pancreatic transplantation as a means to correct their metabolic imbalances and the diabetes-related complications.

Patient Criteria

ancreas transplant candidates are usually between 20 and 40 years of age. At present, P the graft survival rate for one year is 30%

to 40%; 50% fail in the first six months. The success rate is lower than other organ transplants because a way has not been devised to eliminate the destructive pancreatic enzyme activity. Tissue rejection may play less of a role than inability to control or divert that enzyme activity. Often a concomitant kidney transplant from the same donor will continue to function after the pancreas graft has failed.

As with all transplant recipients, postoperative immunosuppressive therapy used to retard graft rejection increases their infection risk. Recipients must be willing to assume responsibility for their posttransplant follow-up and medication regimen.

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The follow-up may include taking daily vital signs, testing blood glucose levels, having weekly blood work done, reporting signs and symptoms of rejection immediately, and attending the transplant clinic as requested.

If the prospective recipient seems sufficiently motivated, tests are done to determine the patient’s physical suitability for pancreatic transplantation. The tests include glucose tolerance tests, kidney function tests, and neurological examination. Noninvasive peripheral vascular tests or transfem- oral angiograms to assess the iliac vessel and tributaries may be ordered. Once a patient is accepted, tissue typing is performed, and hidher name is added to the waiting list.

When an organ donor becomes available, blood and tissue matching tests are done to determine the best recipient. The recipient has the choice of coming immediately to the hospital for transplantation, or declining the pancreas. Patients who decline may be removed from the transplant list if they express doubts about wanting the surgery. They can get back on the list only after counseling and additional blood work to provide recent serum for tissue typing.

Preoperative Preparation

ow much time is available for patient preparation depends on how quickly the H patient can be reached and admitted after

a donor has been found. Most organ harvesting takes place after the elective surgery schedule has finished, which often places the transplant surgery in the late evening or early morning hours. In Michigan, most blood and tissue typing is done before organ harvesting, which allows more time to prepare the recipient. Even so, the average admission is four to six hours before surgery.

The perioperative care of a pancreatic transplant patient follows a nursing care plan similar to an insulin-dependent diabetic patient arriving for emergency surgery. Because patients tolerate surgery and anesthesia best with near normal blood glucose levels that have been controlled before admission, the nurse obtains a current blood glucose level and assesses the patient’s diabetic status three to four days before admission. Recent

vomiting, fatigue, blurred vision, marked glyco- suria, or ketonuria would indicate how controlled the patient’s glucose has been.

Preoperative insulin therapy is directed at maintaining a blood glucose level under 300 mg/ 100 mL. A higher circulating level may interfere with the body’s immunity system.

To assist in maintaining a blood glucose level between 200 and 300 mg/100 mL, the patient can be connected by intravenous (IV) line to a monitor that provides a constant digital readout of the blood glucose values. The equipment withdraws only 2 mL/h of blood. A module can be added that automatically infuses insulin or glucose to maintain a preset blood glucose level.

If this equipment is not available, the nurse must measure blood glucose levels every four hours before surgery, and every two hours during surgery If the patient is receiving IV insulin, the blood glucose level is measured every 30 minutes to one hour. A slightly higher than normal blood glucose level (200 to 300 mg/100 mL) is maintained to challenge the transplanted pancreas to produce insulin.

Administering insulin by a route other than IV is not recommended because insulin uptake from subcutaneous tissues cannot be controlled or predicted. An IV of 0.9% normal saline or lactated

Patricia Ball, lW, MA, CNOR, is an OR nurse educator at Mt Carmel Mercy Hospital, Detroit. She earned both her master’s degree in education and her bachelor’s degree in humanities from the University of Detroit. Her nursing diploma was earned at the Mercy School (9 Nursing Detroit.

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Preoperative studies include urine, throat, sputum, and blood specimens for viral culture, and

urine for bacterial culture and sensitivity.

Ringer’s solution is started before surgery. Generally, IVs containing glucose are not infused because they may cause hyperglycemia. If the patient is hypoglycemic, a 5% to 10% glucose and lactated Ringer’s solution can be started as a secondary IV until the blood glucose level reaches 150 mg/100 mL.

If the blood glucose level is over 250 mg/100 mL, regular insulin, 15 U/loOO mL of normal saline, is “piggybacked” in the primary IV. It is important to run approximately 60 mL of insulin solution through the IV tubing before attaching the infusion to the patient. That will fill any insulin- binding potential of the plastic tubing. Other insulin/glucose protocols may be used according to anesthesiologist preference and hospital practice to control intraoperative blood glucose.

If the patient has renal insufficiency, all IVs are regulated to provide 30 mL/h. With an elevated blood glucose level, limiting the fluid intake may require a greater concentration of insulin in a smaller amount of fluid to control hyperglycemia.

Attention must also be paid to the preoperative electrolyte balance. The diabetic with functioning kidneys is often potassium depleted, while the person with renal insufficiency may be hyperka- lemic. During hyperglycemia, there can be an increase loss of urine phosphorus resulting in a decreased oxygenation of tissue. Therefore, serum chemistries are tested and supplemental electro- lytes given as needed. As with any vascular surgery, a type and cross matching is done. However, blood transfusions are usually not required unless the preoperative hemoglobin is low.

Because pancreatic transplant patients risk postoperative infection, their preoperative laboratory studies must include urine, throat, sputum, and blood specimens for viral culture, and urine for bacterial culture and sensitivity. A broad spectrum antibiotic, such as cefoxitin sodium (Me foxin), may be given prophylactically

in three 1 g dosages intravenously at an hour preoperatively, at the time of incision, and an hour into the surgery. Also, the patient will be asked to take a shower with an iodophor detergent.

Immunosuppression treatment begins before surgery. It may include oral azathioprine (Imuran), parenteral prednisolone, and intravenous cyclo- sporine A. A Foley catheter is inserted before surgery, either in the holding area or the OR, and intake and output recording is begun.

Because the pancreas is usually implanted through a rectus incision before the patient enters the OR, the nurse removes the pubic hair on the upper thighs and abdomen, preferably with clippers to avoid skin abrasions that could contribute to postoperative infection.

Nurses also assess the peripheral vascular system of the patient’s feet and legs. A decrease in skin temperature, discoloration of skin, ulceration, and paresthesia can signal peripheral vascular abnormalities.

An ankle/brachial (A/B) Doppler pressure index can provide an evaluation of the lower peripheral circulation, a baseline for monitoring the postoperative circulation, and a method to detect problems arising from use of the external iliac artery. The A/B index is a simple, noninvasive test that compares the Doppler pressure in each ankle to an arm (brachial) Doppler pressure by dividing the brachial pressure into the ankle pressure. A normal A/B index is one or more. An index less than one indicates a peripheral circulatory problem in the legs. Use of the iliac artery on that side may be contraindicated. The nurse should compare ankle pressure with the same arm before and after surgery for consistency.

Intraoperative Care

hirty to 40 minutes before surgery, the circulating nurse primes the slush-making T unit with cold refrigerant. The colder the

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Most pancreatic transplant patients are put in a supine position with their heels and elbows

padded to avoid developing pressure points.

unit the quicker the sterile ice/slush is made. If the slush unit equipment does not have a temperature regulator, the organ cannot be placed in it. “Freezer burn” could occur if the organ touches the side of the super-cold metal pan, or the pancreas could freeze. To avoid that, the nurse puts the slush in a small basin before putting in the pancreas, which had been preserved in a sterile bag inside an ice chest, or in a refrigerator at 4 OC (39.2 OF).

Tissue trimmed from the pancreas before transplantation is placed in a sterile container and sent for culture and sensitivity studies as a precautionary measure. If a positive culture is obtained, specific antibiotic therapy can be initiated.

Most pancreatic transplant patients are put in a supine position with their heels and elbows padded to avoid developing pressure points. A warming blanket may be used but extreme care must be taken to maintain a blanket temperature close to normal.

Induction of anesthesia is usually with thiopental sodium and a relaxant such as succinylcholine chloride. The level of anesthesia is maintained using a balanced technique of narcotic/tranquilizer/relaxant along with con- trolled ventilation. Some inhalational anesthetics, such as halothane, may have some hyperglycemic effects, but are of little danger to the diabetic patient.* Spinal anesthesia may also be used.

Pancreatic transplantation techniques are still evolving. They differ mainly in the treatment of the pancreatic enzymes. Which technique used is the personal preference of the surgeon. When transplanting, the surgeon may remove the entire pancreas, the posterior segment, or the pancreas plus a portion of the duodenum.

Transplanting the pancreas distal segment is a simpler surgical procedure. However, it requires management of the exocrine pancreatic juice. One method is to occlude the pancreatic ductal system

with a polymer. To set up for that procedure, a nurse can take the radiolucent extension from an OR table and fit it on a Mayo stand making the top of the stand radiolucent with the exception of the metal bar down the middle. It is covered with a sterile plastic Mayo drape. The polymer, which contains a radiopaque substance, is injected into the ductal system under image intensification using a C-arm to assure complete filling of the ducts. Occlusion of the ductal system is associated with fibrosis and possible atrophy of the transplanted organ, but it is a necessary risk.

The duct of the segmental pancreas can be anastornosed to a Roux en Y loop of bowel, implanted into the urinary bladder, or allowed to drain into the peritoneum. However, drainage into the peritoneum risks ascites and possible infection.

The pancreaticoduodenal transplantation may be intraperitoneal with the duodenal portion anastornosed to a loop of bowel. It could also be extraperitoneal with the duodenum anasto- mosed to the urinary bladder or inserted through the peritoneum for drainage into the peritoneal cavity. Pancreaticoduodenal transplantation is associated with a high incidence of pancreatic fistulas. In a worldwide study, approximately 60% of all pancreas transplant patients have a nephropathy that will require kidney transplantion before, at the same time as, or after pancreas transplantation.3

Instrumentation for pancreatic transplantation is much the same as that for a herniorrhaphy, with the addition of some deep retractors and vascular clamps, tissue forceps, and needle holders.

The surgeon starts the procedure by exposing the retroperitoneum through an oblique incision in the iliac fossa. If the graft is to be placed in the peritoneum, the retroperitoneum is incised. Sharp dissection is used to expose the external iliac vessels and vessel loops are used for identification and traction. A retroperitoneal

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pouch is made by blunt dissection for extraper- itoneal placement. Cardiovascular sutures, such as 5-0 or 6-0 polypropylene, are used for an end- to-side anastomoses of the splenic vein of the pancreas to the external iliac vein, and the splenic artery to the external iliac artery. Care must be taken to avoid trauma to the pancreatic tissue during the anastamoses.

The spleen may be transplanted with the pancreas. By implanting both organs, the surgeon avoids ligating the splenic vessels, which can cause a regurgitation of flow through the artery and an increased tendency for thrombosis because of the shared vessels.

Postoperative Care

he patient is usually extubated before leaving the OR or shortly after arrival in T the recovery room. Hypoglycemia is

common in diabetic surgical patients during the immediate postoperative phase if they received insulin during surgery. In addition, the stress and trauma of surgery may cause a resistance to insulin metabolism during the operative phase, resulting in high insulin levels after surgery. Immediately after transplantation, the patient’s blood glucose level should be maintained between 200 and 250 mg/100 mL. The best indicator of graft function is a drop in the blood glucose concentration.

If the patient is not on a glucose monitor, the nurse takes blood glucose levels in the recovery room and every four hours to six hours after the patient leaves the recovery room. Normal glycemia (80- 120 mg/l 00 mL) may be seen within 12 hours or may be delayed one to two weeks. Because pancreatitis is not unusual, serum amylase is monitored daily.

Patients usually begin ambulation within 24 hours of surgery. As soon as they are able to maintain adequate hydration by oral intake of fluids, IV therapy is discontinued. Insulin therapy is administered as needed to maintain a slightly elevated blood glucose level for three to four days posttransplant or until the graft begins insulin production. The nurse measures blood glucose levels every six hours to avoid hypoglycemia or hypergl ycemia.

After four days, or once the graft is functioning, the blood glucose level is measured each morning and evening. Pancreas transplant patients may have cardiovascular and/or renal disorders that affect their postoperative course. Watching for problems with circulation at the graft site and/ or distal to the graft by compromising peripheral arteries during the postoperative period is important. Using a base A/B index, the nurse can monitor ankle pressure every two to four hours after surgery for the first 12 hours, and twice a day thereafter. Any deterioration in the A/B index signals a problem developing in the peripheral arterial circulation. A Doppler pressure change will be seen before any clinical symptoms appear.

Because the graft site is susceptible to infection, nurses must keep the wound clean and dry. They must also make sure the patients practice deep breathing and coughing, which is essential because patients on immunosuppressive therapy are susceptible to upper respiratory infections. Broad spectrum antibiotics are usually continued for several days postoperatively.

Rejection in a functioning graft is detected by a rise in blood glucose, especially in a postprandial measurement. Measurements of serum insulin during the first month are usually meaningless because of circulating insulin antibodies. Those antibodies disappear in a month with a functioning graft.

The day after transplantation, the patient starts to assume responsibility for his medication. The nurse instructs the patient concerning medication habits to use when discharged. An instruction sheet is reviewed and left with the patient. During the next few days, the nurse reviews the medications with the patient, the dosages, and possible side effects.

Approximately four days after the transplant, the nurse gives the patient a medication card and reviews it each time the patient receives medication. By the fifth or sixth day, the patient has a box containing all the medications. Each morning, the nurse helps the patient fill out the medication card and set up the medications. If changes are made in dosage and/or medication, the nurse helps the patient change the medication card.

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Table 1 Signs of Pancreatic Rejection

Elevated body temperature Pain over the transplant site is more of a gnawing,

burning pain than pain associated with an incision-this symptom can appear months after transplant

Decreased urine output (if the kidney was also transplanted), can also be a sign of cyclosporine toxicity; a drop of 25% is significant

Blood glucose level of 150- 175 mg/ 100 mL An increase in creatinine (if the kidney was

An increase in size of the transplant (swelling), transplanted)

this can be assessed by echogram

As part of the program, the patient’s education booklet is reviewed. The booklet contains information from the pharmacy department concerning medications and their interactions, information on antilymphocyte globulin that might be used to treat a rejection episode, the signs and symptoms of rejection (Table I), and a glossary of terms. It reviews the tests to be done each day at home including blood sugar, weight, temperature, pulse, and blood pressure. It also lists the 24-hour transplant ofice telephone number, the surgeon’s number, and the paging number at the hospital.

During the postoperative period, patients start maintaining records they will continue at home. Length of stay in the hospital depends on the type of pancreatic transplant performed, but it is generally three to four weeks. After discharge, each time a patient reports to the clinic he/she brings the medicine card and outpatient record sheet. After the laboratory work is done, the results are added to the record. Thus, the patient is not only aware of the graft’s status, but takes an active part in the posttransplant follow-up.

Transplants that do succeed, even for short periods of time, have given freedom and new life to the insulin-dependent diabetic, and ameliorated the diabetic complications present at trans- plantation. Although diabetic retinopathy is not reversed, it is stabilized. Neuropathy may improve. Patients have often remarked that after transplan-

tation they realized they had not actually felt good for years. Even those who experienced compli- cations considered it worthwhile for a short period of normal glycemia. They encourage other diabetics to seek a transplant.

Pancreas transplantation has the potential of preventing or delaying chronic complications and even reversing some early lesions of diabetes. 0

Notes 1. A Rossini, “Why control blood glucose levels?”

Archives of Surgery 1 1 1 (March 1976) 229-233. 2. K George, M M Alberti et al, “Insulin delivery

during surgery in the diabetic patient,” Diabetes Care 5 (May-June 1982) 65-67.

3. Louis Toledo-Pereyra, The Pancreas Principles of Medical and Surgical Practice (New York: John Wiley and Sons, 1985) 459.

Suggested reading Biddle, C J; Hernandez, S. “Perioperative control of

diabetes mellitus-revisited.” Journal of the American Association of Nurse Anesthetkts 51 (April 1983) 138-140.

Goosen, H G et al. “The effect of duct obliteration on the histology and endocrine function of the canine pancreas.” Transplantation 38 (July 1984) 13-1 7.

Hilton, Ann. “Does diabetic control really make a difference?” The Canadian Nurse 78 (October 1982)

Lynch, J A. “Preoperative and intraoperative insulin needs in diabetic patients.” Journal of the American Association of Nurse Anesthetists 52 (June 1984)

Molitch, M E; Reichlin, S. “The care of the diabetic patient during emergency surgery and postopera- tively.” Orthopedic Clinics of North America 9 (July

Nemchik, Rita. “Diabetes today. A Startling new body of knowledge.” RN45 (October 1982) 31-36.

Rossini, A A. “Why control blood glucose levels?“ Archives of Surgery 11 1 (March 1976) 229-223.

Schwartz, S S et al. “Use of a glucose controlled insulin infusion system (artificial beta-cell) to control diabetes during surgery.” Diabetologia 16 (1979)

49-52.

275-279.

1978) 811-824.

157-164.

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