transplant Irish physiotherapy

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The first Irish heart and double lung transplant - Petra Grehan

Ireland's first heart and double lung transplant - A case study and discussion from Petra Grehan

I began working with the Mater Misericordaie University Hospital (MMUH) Heart and Lung transplant team in early 2015. Since then I have been involved in the pre-operative and post-operative journeys of hundreds of heart and lung transplant service patients. Nothing gives me greater pleasure then walking with a patient for the first time post-transplant and they realise that they are not fighting and struggling for every breath anymore – they realise they have their life back. Being part of that moment is something truly special. For some heart and lung transplant patients their post-transplant course appears seamless and they can be sitting at home in their favourite chair 10 days post-surgery.

But then there are the other more complex and challenging patients where their post-operative course is fraught with complications which have a detrimental effect on their post-operative physical capabilities and their ability to partake in the required rehabilitation which is so important following transplant surgery.

In 2015 the first Irish heart and double lung transplant took place in MMUH. Unfortunately from the start there were complications. She suffered a ventricular fibrillation arrest requiring a resternotomy, Extracorpeal Life Support (ECLS) for worsening cardiac function, continuous venous veno haemodialysis filtration (CVVHDF) for renal impairment and a further resternotomy and thoracotomy for the removal of clots. She also suffered from Grade 4 pressure areas, multiple infections and a tracheostomy insertion to manage respiratory status and facilitate weaning. Due to the management and treatment of these issues the patient’s required antigravity rehabilitation was chronically delayed and she suffered from severe critical care myopathy, global joint pain and loss of range of motion despite passive and active assisted range of motion exercises, resting splints and positioning. During this time the patient also suffered from thoracic issues including chyle leak, increasing secretion retention and issues with ischemia of the tracheal anastomosis.

Eventually the patient’s status began to stabilise and she became rehabilitation appropriate. This started with sitting up, sitting at the edge of the bed with assistance of 4-5 people and hoist to chair – building up time spent in the chair as able on a daily basis. One of the most difficult things I recall from this time was a team of physiotherapists and nurses being sweaty and red faced in gloves and gown in a warm, sun drenched ICU cubicle using all our muscle strength to assist this severely impaired patient in her rehabilitation. We became experts in contorting our bodies to manage and keep safe all the wires and tubes coming from seemingly every inch of the patient throughout the treatment. While this was happening we had one eye on the monitor and the ventilator machine to see how the patient was reacting physiologically to the session while the other eye was on the patient providing words of encouragement, motivation and calm to the patient and the various nervous looking colleagues assisting at the same time. After these sessions we would be exhausted but happy knowing that as difficult and time consuming as this rehabilitation effort was, it going to count towards improving the patient’s strength and conditioning.

Over time her respiratory status stabilised progressing to cuff deflation and the use of the speaking valve as her strength slowly began to improve. The transplant physiotherapy team continued rehabilitation on a daily basis using a combination of bed and chair based exercises, the bed based bicycle (LETTO) and eventually progressing to using the ARJO walking frame and sling and assistance of many skilled hands to start standing the patient. This was a momentous mile stone as when we first sat the patient up she had no trunk or head control and now she was standing controlling her trunk and head simultaneously. We all collectively breathed a sigh of relief…we may have had a long way to go but we were on the right track. This inspired us all to push on and push harder than before. The patient was discharged from the ICU to the Cardiothoracic High Dependency Unit after 5 months. During this time physiotherapy strengthening, stretching and endurance exercises progressed but were stilted by investigations for joint pain and a brief transfer back to the Intensive Care Unit. For the next few months we were all on a mission – patient and therapist combined - rehab, rehab and more rehab! Every movement was treated as an exercise and a means to getting back her independence. During this time the patient was receiving intermittent haemodynamic dialysis therapy four times a week which slowed progress but none the less she progressed from walking with an ARJO to a gutter frame to a 4 wheeled walker and progressing distance covered on a flat surface from day to day.

Eventually it became time to tackle the stairs. This took many weeks to master due to the continuous decreased muscle strength and endurance but master it she did and finally, a year post transplant she was discharged home to her husband and four year old daughter.
This patient journey was particularly challenging because of her numerous medical issues and severe myopathy but through a constant and consistent effort by the patient, her family and her health care workers we were able to reunite this young family with the hope of improved quality of life.

Petra Grehan