E9

Table E9.2. Signs and symptoms of adrenal insufficiency

Refractory hypotension Hyperkalemia Hyponatremia General malaise Severe fatigue wound healing, and the risk of infection represent important technical challenges. It is therefore advisable to keep the operative incision as small as is practical, and meticulous wound care is similarly important. Recognition of complicating underlying systemic illness in the context of the required immunosuppressive medications represent important considerations when estimating relative operative risk. When faced with particularly high risk patients, we have occasionally used the percutaneous tracheostomy technique with success.

Additionally, head and neck malignancies have been particularly challenging after transplantation. These are usually squamous cell cancers, and an aggressive approach including early biopsy to establish a specific tissue diagnosis is recommended. When the initial procedure can be performed under local anesthesia, no specific preparation is required. However, when general anesthesia is necessary for adequate examination (e.g., endoscopy) and biopsy, or when a mass threatens airway maintenance, the usual dose of oral immunosuppressive medications should be given preoperatively to avoid missed doses. Additionally when a more complex procedure is required, antibiotic prophylaxis covering oropharyngeal flora is recommended.

When the diagnosis of malignancy is established, a reduction in the immunosuppressive regimen should be considered in developing the treatment plan. A specific discussion with the patient, covering practical and theoretical issues concerning ongoing immunosuppressive management should allow ample opportunity for informed decision making. A well informed kidney or pancreas recipient might elect to discontinue immunosuppression, accepting the risk of rejection or even graft loss, to maximize the anti-neoplastic strategies. Alternatively, s/he may elect to continue maintenance immunosuppression, except perhaps for a brief time during chemo- or radiation therapy. Although anecdotal, our experience has suggested that most patients elect reduced immunosuppression, but only occasional individuals have concluded that permanent discontinuation of immunosuppression is desirable. If the patient and/or family are unable to participate knowledgeably, our preference is to use a reduced level of immunosuppression. We have concluded that the negative impact of acute graft loss detracts sufficiently from the quality of life that most patients are most comfortable with this approach. Additionally, avoiding acute rejection due to rapid reduction or cessation of immunosuppression seems logical when developing a therapeutic plan for patients with malignant disease. The stakes are even higher for orthotopic allograft recipients (heart, lung, liver) where certain death will result if the transplanted organ undergoes acute rejection and fails. Here too, we have usually been successful using lower doses of Cy or Tcl plus low dose prednisone.

Major head and neck resections also have important therapeutic implications for transplant recipients. Here, the route of immunosuppressant administration becomes an important consideration, because oral intake will be disrupted. Whenever possible, we advocate intra-operative placement of a nasogastric or nasoesophageal tube to allow early enteral medications. When early oral alimentation is impractical, placement of a gastrostomy or jejeunostomy should be

0 0

Post a comment