*3.4.2 Postoperative immunosuppression*



**109**

allergy history.

transplant patients.

*Perioperative Care for Lung Transplant Recipients: A Multidisciplinary Approach*

*3.4.3 Maintenance and monitoring of immunosuppressant levels*

throughout the first six (6) months posttransplantation.

manner as described above for tacrolimus levels.

with a history of prior *Clostridium difficile* infection.

**3.5 Perioperative antibiotic therapy**

*3.5.2 Immediate postoperative phase*

*3.5.1 Intraoperative phase*

Daily tacrolimus level measurements are taken. The target tacrolimus level is 10–15 ng/dl with a goal level of 12. In general, once the tacrolimus level is within this range, trough levels will be measured every Monday, Wednesday, and Friday or prior to the administration of the fourth dose. The target level is maintained

1. Tacrolimus (Prograf) 0.5 mg orally or sublingual Q 12 h (target 10–12): IV route is to be avoided. Begin when patient is hemodynamically stable and aggressive diuresis is not required. For split doses, the higher

2. MMF (Cellcept) 250 mg orally or feeding tube Q 12 h: dose if lymphocyte count greater than or equal to 10 and/or platelet count greater than or equal to 40 K (oral dose = IV dose). Reevaluate daily for titration to goal

Prograf dose on the day of discharge from initial transplant admission is required to be greater than or

Cyclosporine is maintained at a target level of 350–400 ng/ml. When the patient is able to take medications orally, the parenteral cyclosporine medication is changed to Neoral given every 12 h. The target level is maintained throughout the first 6 months posttransplantation. Cyclosporine trough levels are monitored in the same

In the immediate postoperative period, daily monitoring of complete blood count, platelet count, liver function data, electrolytes, magnesium, calcium, phosphorus, and creatinine is performed. Frequency of blood draws is modified based on the patient's clinical condition. A baseline immune cell function level is obtained

Antibiotics are given in the operating room 1 h or less before incision and include

vancomycin l g IV and cefepime 2 g IV (if allergic to penicillin, substitute ciprofloxacin 400 mg IV). Metronidazole (Flagyl) 500 mg IV is used only for patients

Postoperatively, the patient is given vancomycin 15 mg/kg IV every 12 h for 3 days (patients with a creatinine clearance of less than 50 will require renal dosing of vancomycin) and cefepime 2 g IV every 12 h for 3 days to begin 12 h after the dose given in the operating room. Ciprofloxacin 400 mg IV every 8 h for 3 days is substituted for patients with a penicillin allergy. Metronidazole (Flagyl) 500 mg IV is used only for patients with history of prior *Clostridium difficile* infection. Antibiotic therapy is adjusted by the team based on donor culture/gram stains and

The Transplant Infectious Disease physician is consulted on all postoperative

Tacrolimus may be switched to cyclosporine if clinically warranted.

preoperatively, 1 week postoperatively, and prior to lung biopsies.

*DOI: http://dx.doi.org/10.5772/intechopen.85277*

dose is scheduled for the evening

*Postoperative immunosuppression: all patients.*

POD#1

of 750 mg Q 12 h

equal to 6

**Table 3.**

### **Table 2.**

*Induction therapy: Basiliximab (Simulect).*

#### POD#1

*Perioperative Care for Organ Transplant Recipient*

*3.4.2 Postoperative immunosuppression*

are found in **Tables 1**–**3**.

tion to goal of 750 mg Q12 h.

B. Postoperative immunosuppression (Simulect)

POD #4 Basiliximab (Simulect) 20 mg IV

*Induction therapy: Basiliximab (Simulect).*

procedure

1. POD #1 Steroid taper

anesthesiologist. Exceptions to the standard therapy are documented in the patient's medical record. Alemtuzumab (Campath) is the first-line induction therapy (**Table 1**). Basiliximab (Simulect) is given to patients with cytomegalovirus (CMV) mismatch, Hepatitis B virus (HBV)/HCV/HIV infection, and/or a history of malignancy (**Table 2**).

i.Postoperative immunosuppression is a combination therapy including a calcineurin-inhibitor therapy (CIT), steroids, and antimetabolite therapy. The postoperative immunosuppression administration and dosing guidelines

ii.Tacrolimus is the first-line CIT and is initiated on the first postoperative day (POD) #1 via the sublingual route of administration. Initiation of tacrolimus may be held at the discretion of the lung transplant surgeon and/or transplant pulmonologist if the patient is not hemodynamically stable, aggressive diuresis is required, or there is evidence of renal complications. Oral medication will be administered when the patient has been cleared for oral intake.

iii.Postoperative steroid therapy begins on POD #1 and the dosing is based on

iv.Mycophenolate mofetil (Cellcept) is the first-line antimetabolite and begins on POD #1 if the platelet count is greater than 40,000 and rising and the lymphocyte count is greater than 10. The dose is reevaluated daily for titra-

v.For patients receiving basiliximab (Simulect) based induction, an additional

A. Induction (intraoperative): begin induction when final decision is made by the surgeons to accept the lungs 1.Basiliximab (Simulect) 20 mg IV and methylprednisolone (Solu-Medrol) 1 g IV at the start of the

2.Methylprednisolone (Solu-Medrol): additional dose of 250 mg IV prior to reperfusion of each lung

15 15 daily 12 daily Taper dose to 0.1 mg/kg/

day by 3 months

Begin with methylprednisolone (Solu-Medrol) IV and switch to prednisone when tolerating PO POD Prednisone (mg) Methylprednisolone (mg)

 50 daily 20 Q 12 h 40 daily 32 daily 30 daily 24 daily 4–14 20 daily 16 daily

2. Standard tacrolimus (Prograf) and MMF (Cellcept) schedule

The intravenous route of administration is not preferred.

dose of basiliximab (Simulect) is administered on POD #4.

Protocol for patients with CMV mismatch HBV/HCV/HIV infection, or history of malignancy

the specified induction therapy for the patient.

**108**

**Table 2.**

1. Tacrolimus (Prograf) 0.5 mg orally or sublingual Q 12 h (target 10–12): IV route is to be avoided. Begin when patient is hemodynamically stable and aggressive diuresis is not required. For split doses, the higher dose is scheduled for the evening

2. MMF (Cellcept) 250 mg orally or feeding tube Q 12 h: dose if lymphocyte count greater than or equal to 10 and/or platelet count greater than or equal to 40 K (oral dose = IV dose). Reevaluate daily for titration to goal of 750 mg Q 12 h

Prograf dose on the day of discharge from initial transplant admission is required to be greater than or equal to 6

#### **Table 3.**

*Postoperative immunosuppression: all patients.*

#### *3.4.3 Maintenance and monitoring of immunosuppressant levels*

Daily tacrolimus level measurements are taken. The target tacrolimus level is 10–15 ng/dl with a goal level of 12. In general, once the tacrolimus level is within this range, trough levels will be measured every Monday, Wednesday, and Friday or prior to the administration of the fourth dose. The target level is maintained throughout the first six (6) months posttransplantation.

Tacrolimus may be switched to cyclosporine if clinically warranted. Cyclosporine is maintained at a target level of 350–400 ng/ml. When the patient is able to take medications orally, the parenteral cyclosporine medication is changed to Neoral given every 12 h. The target level is maintained throughout the first 6 months posttransplantation. Cyclosporine trough levels are monitored in the same manner as described above for tacrolimus levels.

In the immediate postoperative period, daily monitoring of complete blood count, platelet count, liver function data, electrolytes, magnesium, calcium, phosphorus, and creatinine is performed. Frequency of blood draws is modified based on the patient's clinical condition. A baseline immune cell function level is obtained preoperatively, 1 week postoperatively, and prior to lung biopsies.

#### **3.5 Perioperative antibiotic therapy**

#### *3.5.1 Intraoperative phase*

Antibiotics are given in the operating room 1 h or less before incision and include vancomycin l g IV and cefepime 2 g IV (if allergic to penicillin, substitute ciprofloxacin 400 mg IV). Metronidazole (Flagyl) 500 mg IV is used only for patients with a history of prior *Clostridium difficile* infection.

#### *3.5.2 Immediate postoperative phase*

Postoperatively, the patient is given vancomycin 15 mg/kg IV every 12 h for 3 days (patients with a creatinine clearance of less than 50 will require renal dosing of vancomycin) and cefepime 2 g IV every 12 h for 3 days to begin 12 h after the dose given in the operating room. Ciprofloxacin 400 mg IV every 8 h for 3 days is substituted for patients with a penicillin allergy. Metronidazole (Flagyl) 500 mg IV is used only for patients with history of prior *Clostridium difficile* infection. Antibiotic therapy is adjusted by the team based on donor culture/gram stains and allergy history.

The Transplant Infectious Disease physician is consulted on all postoperative transplant patients.

## **3.6 Antimicrobial prophylaxis**

### *3.6.1 Antifungal prophylaxis*

Patients are ordered antifungal prophylaxis on admission to the ICU. Voriconazole (Vfend) is the first-line agent. Amphotericin B lipid complex (Abelcet) will be ordered for patients with intolerance to voriconazole (Vfend).

### *3.6.2 PCP prophylaxis*

The patient is ordered Bactrim DS one (I) tab Monday, Wednesday, and Friday when the patient is discharged following transplant. Atovaquone (Mepron) 750 mg every 12 h is substituted or monthly inhaled pentamidine for patients with a sulfa allergy. PCP prophylaxis is given throughout the patient's posttransplant course.

#### *3.6.3 CMV prophylaxis*

Cytomegalovirus (CMV) prophylaxis is initiated on the POD# 1 based on the donor and recipient CMV status. CMV infection following the completion of the prophylaxis is treated at the induction dose for 3 weeks then decreased to the maintenance dose. Duration of therapy is determined in consultation with the Transplant Infectious Disease physician.
