Last week's map ended with a family in a quiet room saying yes. This one begins there.
Transplantation is usually taught as somebody else's specialty — a tertiary centre, a long operation, a list of drugs with awkward names. It is not. We meet it at least four times over: at the bedside of the candidate who is becoming too sick to wait; in the seventy-two hours when a graft either takes or does not; on the night a recipient comes back to us with a fever and no white cells with which to raise it; and in the conversation that made any of it possible at all.
How to use a mind map
Do not read it like a chapter. Scan it. Let your eye go where it wants, read three
boxes that catch it, and stop. You are not trying to finish it and you are certainly not trying to
memorise it.
Then come back. Before a shift on which the subject might come up, or after a case that went a
particular way, or in a quiet ten minutes. Thirty seconds at a time, often, beats an hour once.
It works the way a painting in a corridor works. Nobody sits down and studies the painting they walk
past every morning, and yet after a year they could tell you what is in it, where the light falls, and
exactly what is on the left-hand side — and they would notice at once if something had changed.
That noticing is the point. These maps are not built to be recalled on demand; they are built so that
when the thing in front of you does not fit, something quietly objects.
ICU AND YOU · MIND MAP SERIES · No. 30 Transplantation medicine in the ICU BEFORE THE OPERATION The ICU as waiting room BRIDGE TO TRANSPLANT VA-ECMO, Impella, IABP — bridge to decision Durable LVAD as a bridge to candidacy Awake, ambulatory ECMO before lung transplant Albumin dialysis and liver support as a holding pattern ACUTE LIVER FAILURE King's College criteria trigger super-urgent listing Ammonia above 150 µmol/L predicts cerebral oedema ICP care: osmotherapy, sedation, temperature control Transfer early — the window closes faster than you think IS THIS PATIENT A CANDIDATE? MELD 3.0, lung allocation score, cardiac urgency status Frailty and deconditioning weigh as heavily as numbers Active sepsis and uncontrolled malignancy exclude Our question is rarely 'sick enough' — it is 'too sick' CARDIOGENIC SHOCK Fulminant myocarditis can recover — do not list too early SCAI stage guides both escalation and timing Temporary support buys the decision, not the cure Neurological prognostication precedes any listing HOUR ZERO The anastomosis — reperfusion ISCHAEMIA–REPERFUSION INJURY Cold ischaemic time drives early graft dysfunction DCD adds a warm ischaemic insult before retrieval Post-reperfusion syndrome: hypotension, hyperkalaemia, acidosis, arrhythmia — anticipate it, don't react to it PRESERVATION AND PERFUSION Static cold storage is still the default worldwide Machine perfusion: NMP and HOPE for liver, EVLP for lung, OCS for heart — assessment as well as preservation Normothermic regional perfusion in DCD retrieval COAGULOPATHY AND TRANSFUSION Hyperfibrinolysis peaks at reperfusion in liver transplant Viscoelastic testing directs component therapy Over-correction risks hepatic artery thrombosis Vasoplegia: noradrenaline, vasopressin, methylene blue THE HANDOVER THAT MATTERS Ischaemic times, intra-operative events, blood loss Anastomosis sites — and what fails if each one fails Drains, stents and wires: what is each one telling you? Immunosuppression already given, and what is due when DAY 0 TO DAY 7 The graft, organ by organ LUNG Primary graft dysfunction graded 0–3 at 24, 48 and 72 h Lung-protective ventilation; keep them dry Bronchial anastomosis: ischaemia, stenosis, dehiscence Denervated below the carina — no cough, silent aspiration HEART The right ventricle meets the recipient's pulmonary hypertension: inodilators, inhaled nitric oxide, low volume Denervated — atropine will not work; isoprenaline or pace Epicardial wires are a lifeline, not an afterthought LIVER Lactate clearance, glucose and INR are your graft monitors Hepatic artery thrombosis — Doppler now, not tomorrow Primary non-function means relisting, and quickly Small-for-size syndrome in split and living-donor grafts KIDNEY AND PANCREAS Delayed graft function is common after DCD kidneys Separate ATN, rejection, obstruction and CNI toxicity Protect perfusion; avoid NSAIDs, contrast, hypovolaemia Pancreas grafts fail by thrombosis and graft pancreatitis FROM DAY ONE, FOR LIFE Immunosuppression THE REGIMEN Induction: basiliximab, anti-thymocyte globulin, alemtuzumab Maintenance triad: calcineurin inhibitor, antimetabolite, corticosteroid — mTOR inhibitors substituted in later Sirolimus impairs wound and bronchial healing: not early WHERE THE ICU GETS IT WRONG Azoles raise tacrolimus sharply; rifampicin collapses it Levels daily, and again after every interacting drug CNI toxicity: AKI, tremor, seizures, PRES, microangiopathy Never stop, halve or hold without the transplant unit ANY TIME, BUT RARELY QUIETLY Rejection THE FOUR PATTERNS Hyperacute — preformed antibody, minutes, graft lost Acute cellular — days to weeks, usually steroid-responsive Antibody-mediated — donor-specific antibodies, harder Chronic — CLAD and BOS, cardiac allograft vasculopathy, interstitial fibrosis, the vanishing bile duct RECOGNISE AND TREAT Biopsy remains the arbiter; bloods and imaging only suggest Donor-derived cell-free DNA is emerging, not yet definitive Pulse methylprednisolone first for cellular rejection Plasma exchange, IVIG, rituximab for antibody-mediated Rejection and infection can, and do, coexist THE FIRST YEAR Infection is a timeline, not a list MONTH 0 TO 1 Nosocomial and technical: line, wound, chest, urine Clostridioides difficile and resistant colonisers Donor-derived infection — think of it, then ask about it Candidaemia, particularly after abdominal transplant MONTH 1 TO 6, AND BEYOND Opportunistic: CMV, Pneumocystis, Aspergillus, Nocardia BK virus, tuberculosis, toxoplasma, listeria After six months the community pathogens return EBV-driven post-transplant lymphoproliferative disease THE BLUNTED SIGNAL Fever may be absent, the white cell count misleading, the CRP unhelpful and the chest film clear. Image earlier and sample invasively sooner than instinct suggests. Then check that prophylaxis — valganciclovir, cotrimoxazole, antifungal — is actually being given, and not merely prescribed. YEARS LATER The recipient who comes back A DIFFERENT PATIENT ENTIRELY Sepsis in the immunosuppressed: muted onset, fast course Infection, rejection and drug toxicity are all on the list Chronic kidney disease, vascular disease, skin malignancy Adrenal suppression — stress dosing is not optional YOUR FIRST THREE PHONE CALLS The transplant unit — before you change anything at all The microbiologist — before the third-line antibiotic The pharmacist — with the whole drug chart in front of you The graft is a shared patient. Behave accordingly. THE LONG VIEW Outcomes, equity, and the thread back One-year survival now sits near 95% for kidney, around 90% for liver, 85–90% for heart and about 85% for lung — and each of those percentages is a life measured in decades rather than days. The hard questions are elsewhere: allocation and justice, retransplantation, futility, and the widening distance between the waiting list and the donor pool. Machine perfusion and, eventually, xenotransplantation may narrow that gap. Consent is what fills it. Last week we sat with the donor. Here, with the recipient. It is one continuous piece of intensive care.
On a phone: turn it sideways, or scroll the map across. Pinch to zoom on any section.
Challenge for you
One sentence, back to me: what is the single most important way a transplant recipient in your ICU should be managed differently from any other patient? Clinical, cultural or systems — anything counts, and there is no wrong answer.
And if you want to go further, an optional reflection: have you ever found out what happened to a recipient? We do the donation work at this end and almost never learn the ending. If you know one, tell me — I would like to hear it, and so would everyone else.
Themes, and the best of your answers, go into a coming newsletter.
Send your response
The button opens a reply straight to me with the headings already in it. If your device blocks it, write to icuandyou@icloud.com instead.
First published July 2026
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← All of ICU AND YOU Views my own, not those of NSW Health or any other organisation. No identifiable patients — scenarios are constructed or combined for teaching. More .