Management of Pediatric Transplant Patients in the Emergency Department (Pharmacology CME) -

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Publication Date: October 2021 (Volume 18, Number 10)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 10/01/2024.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5  Pharmacology CME credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Transplant patients are at risk for illnesses and complications days, months, or years after transplantation, and they can present complex challenges for emergency clinicians. This review discusses the general approach to the management of pediatric transplant patients in the emergency department, with a focus on general complications and organ-specific complications after solid organ transplantation. Hematopoietic stem cell transplantation and its common complications will also be discussed. A key step in the management of all transplant patients includes consultation with the patient’s transplant team to ensure appropriate testing, treatment, and disposition for these patients.

Case Presentations

An 11-year-old boy who received a heart transplant 8 months ago presents to the ED for evaluation of fever…

• He has had a mild cough and rhinorrhea for the past 2 days and developed a fever to 38°C this morning. He received his heart transplant for hypoplastic left heart syndrome and has been doing well on his maintenance immunosuppression medications. He sees his transplant physician every 2 months and has had no complications. There are no sick contacts at home, but the child does attend school.
• Given the boy’s history of transplantation, he was triaged as a high-acuity case. His vital signs are: temperature, 38.6°C; heart rate, 185 beats/min; respiratory rate, 25 breaths/min; blood pressure, 105/82 mm Hg; oxygen saturation, 95% on room air. On physical examination, you note crackles at the lung bases bilaterally.
• Knowing this patient is immunocompromised, you are worried about a lower respiratory tract infection, but you are also concerned this could be an episode of acute rejection manifesting as early congestive heart failure. As you consider the possible diagnoses, you think about your next steps. Which laboratory tests would be most helpful? Which antibiotics does he need? Should corticosteroids be started to treat possible rejection?

A 3-year-old girl with a history of acute lymphoblastic leukemia who underwent a hematopoietic stem cell transplant 3 months ago presents to the ED for evaluation of fever...

• The girl’s parents say she has had a runny nose and mild cough over the last 2 days. Today, she has been fussier than usual. They took her temperature at home, noted a fever of 39.7°C, and called their transplant physician, who advised them to go to the nearest ED.
• When the girl arrived to the ED, she was alert and fussy, but consolable. Given her history, despite her mild symptoms, she was triaged as a high-acuity patient. Her vital signs are: temperature, 39.4°C; heart rate, 190 beats/min; respiratory rate, 30 breaths/min; blood pressure, 85/66 mm Hg; oxygen saturation, 98% on room air. Her physical examination is notable for rhinorrhea and referred upper airway congestion. She has a subcutaneous port over her right chest, with no overlying erythema or warmth.
• While you are obtaining the history from the parents, they mention that the girl was diagnosed with acute graft-versus-host disease 1 week ago and was started on some new medications to treat it. You are not at the patient’s transplant center and do not have access to their records. You wonder whether the girl’s symptoms are from the acute graft-versus-host disease or a new infection? Which antibiotics are most appropriate in this situation? How will the history of new medications change your management of this patient?