附錄 D — 附錄 D. 肺移植病人照護時間表 / Appendix D. Lung Transplant Patient Care Timeline

本附錄整合 UTH Manual 2022 之標準流程與臨床實務經驗，提供肺移植病人從轉介至長期追蹤的完整時間表。

⚠️ 標記 = 需臨床團隊依三總本院流程確認 📋 標記 = 需補充三總本院數據

This appendix integrates the UTH Manual 2022 standard protocols with clinical practice experience, providing a comprehensive timeline from referral through long-term follow-up for lung transplant patients.

⚠️ Marker = Requires clinical team confirmation based on TSGH institutional protocols 📋 Marker = TSGH institutional data to be supplemented

病人照護旅程總覽

D.1 D.1 移植前評估期 / D.1 Pre-Transplant Evaluation Period

D.1.1 D.1.1 轉介與門診初評 / D.1.1 Referral and Initial Outpatient Assessment

階段 內容 時程
轉介收案 由胸腔內科/外科或外院轉介 Day 0
門診初評 mMRC 呼吸困難評估、基本肺功能、6MWT、CXR 第 1 次門診
病史整理 製作 PowerPoint 摘要（含 CXR、CT、心導管等影像）[UTH-Manual-2022] 初評後 1 週內

| Phase | Content | Timeline | |——|——|——| | Referral intake | Referred from pulmonology/thoracic surgery or external hospital | Day 0 | | Initial clinic evaluation | mMRC dyspnea assessment, basic PFT, 6MWT, CXR | First clinic visit | | Medical record summary | Prepare PowerPoint summary (including CXR, CT, cardiac catheterization images) [UTH-Manual-2022] | Within 1 week of initial evaluation |

D.1.2 D.1.2 完整評估（住院 3-5 天） / D.1.2 Comprehensive Evaluation (3-5 Day Admission)

依 UTH Manual 登錄系統，完整評估項目如下 [UTH-Manual-2022]：

Per UTH Manual registry system, comprehensive evaluation items [UTH-Manual-2022]:

第 1 天 - 胸部 X 光、胸部 CT - 肺功能完整檢查（FEV1、FVC、DLCO、TLC） - 動脈血氣體分析（A-aDO2 計算） - 基本血液檢查

Day 1 - Chest X-ray, chest CT - Complete pulmonary function testing (FEV1, FVC, DLCO, TLC) - Arterial blood gas analysis (A-aDO2 calculation) - Basic blood tests

第 2 天 - mMRC 評分 - 6 分鐘步行測試（6MWT） - 心臟超音波 - ⚠️ 右心導管（mPAP > 35 mmHg 時）

Day 2 - mMRC scoring - 6-minute walk test (6MWT) - Echocardiography - ⚠️ Right heart catheterization (if mPAP > 35 mmHg)

第 3 天 - HLA 分型 - PRA（Panel Reactive Antibody）檢測 - CMV/EBV 血清學 - 感染症篩檢（HIV、HTLV-1、HBs、HCV）

Day 3 - HLA typing - PRA (Panel Reactive Antibody) testing - CMV/EBV serology - Infectious disease screening (HIV, HTLV-1, HBs, HCV)

第 4-5 天 - 多專科會診（牙科、精神科、復健科、營養、社工） - 疫苗接種評估與補打（麻疹、德國麻疹、水痘、腮腺炎等）[UTH-Manual-2022] - 必要時：冠狀動脈造影（CAG）

Day 4-5 - Multidisciplinary consultations (dental, psychiatry, rehabilitation, nutrition, social work) - Vaccination assessment and catch-up (measles, rubella, varicella, mumps, etc.) [UTH-Manual-2022] - If needed: coronary angiography (CAG)

D.1.3 D.1.3 適應症審查會議 / D.1.3 Indication Review Meeting

步驟 內容 時程
院內 MDT 討論 胸腔外科、胸腔內科、麻醉科、ICU、感染科 評估完成後 1-2 週
⚠️ 中央適應檢討委員會 提交申請，等待審查結果（適應/不適應/條件適應） 院內通過後
結果通知 書面通知病人與家屬 委員會審查後

| Step | Content | Timeline | |——|——|——| | Institutional MDT discussion | Thoracic surgery, pulmonology, anesthesia, ICU, infectious disease | 1-2 weeks after evaluation completion | | ⚠️ Central Indication Review Committee | Submit application, await review result (approved/not approved/conditional) | After institutional approval | | Result notification | Written notification to patient and family | After committee review |

D.1.4 D.1.4 登錄等候 / D.1.4 Waitlist Registration

項目 說明
JOT 登錄 ⚠️ 日本為 JOT 系統；三總依衛福部器官捐贈移植登錄中心流程
登錄時提交 完整評估資料、HLA 分型、PRA、CMV 狀態、體重/身高（size matching 用）
Status 分級 依病情嚴重度分級（⚠️ 台灣分級制度待確認）

| Item | Description | |——|——| | JOT registration ⚠️ | Japan uses JOT system; TSGH follows MOHW Organ Donation and Transplant Registry Center procedures | | Documents at registration | Complete evaluation data, HLA typing, PRA, CMV status, weight/height (for size matching) | | Status classification | Based on disease severity (⚠️ Taiwan classification system to be confirmed) |

D.2 D.2 等候期管理 / D.2 Waitlist Period Management

D.2.1 D.2.1 定期追蹤時間表 / D.2.1 Periodic Follow-Up Schedule

頻率 項目
每 1-2 個月 門診回診：mMRC、體重、SpO2、氧氣需求變化
每 3 個月 肺功能追蹤（FVC、FEV1 趨勢）
每 6 個月 胸部 CT、完整血液檢查、HLA 抗體追蹤
每年 右心導管（如 PAH 疑慮）、6MWT、疫苗更新

| Frequency | Items | |——|——| | Every 1-2 months | Clinic visit: mMRC, weight, SpO2, oxygen requirement changes | | Every 3 months | PFT follow-up (FVC, FEV1 trends) | | Every 6 months | Chest CT, complete blood work, HLA antibody tracking | | Annually | Right heart catheterization (if PAH concern), 6MWT, vaccine update |

D.2.2 D.2.2 等候期臨床重點 / D.2.2 Waitlist Clinical Key Points

根據臨床實務觀察 [UTH-Manual-2022]：

Based on clinical practice observations [UTH-Manual-2022]:

  • 體重監測：等候期體重下降為常見問題，需密切追蹤營養狀態
  • 氧氣需求變化追蹤：記錄安靜時/活動時氧氣流量變化趨勢
  • ADL 評估：步行距離、自理能力、是否需輪椅
  • Status 升級評估：病情惡化時需重新評估，向登錄中心申請 Status 變更

- Weight monitoring: Weight loss during waitlist period is common; close nutritional status tracking required - Oxygen requirement trending: Record resting and exertional oxygen flow rate changes - ADL assessment: Walking distance, self-care ability, wheelchair dependency - Status upgrade evaluation: When condition worsens, reassess and apply for status change with registry center

D.2.3 D.2.3 移植協調師訪視 / D.2.3 Transplant Coordinator Visits

根據臨床實務，協調師定期訪視內容包含 [UTH-Manual-2022]：

Per clinical practice, coordinator periodic visit content includes [UTH-Manual-2022]:

項目 內容
病情追蹤 呼吸症狀、氧氣使用、體重變化、ADL
JOT 採血更新 定期更新登錄中心所需血液檢體
心理評估 等候焦慮、end-of-life 意願確認
家屬狀況 照顧者支持、住宿安排、經濟狀況
衛教 手術準備、術後預期、復健期展望
Prehabilitation 確認復健運動執行狀況（步行、呼吸訓練）

| Item | Content | |——|——| | Disease tracking | Respiratory symptoms, oxygen use, weight changes, ADL | | Registry blood sample update | Periodically update blood specimens required by registry center | | Psychological assessment | Waitlist anxiety, end-of-life wishes confirmation | | Family situation | Caregiver support, housing arrangements, financial status | | Education | Surgical preparation, postoperative expectations, rehabilitation outlook | | Prehabilitation | Confirm rehabilitation exercise compliance (walking, breathing exercises) |

D.2.4 D.2.4 Prehabilitation 方案 / D.2.4 Prehabilitation Protocol

項目 建議內容
有氧運動 每日步行（依耐受度調整）或使用步行機 30 分鐘/天
肌力訓練 下肢肌力（深蹲等）、呼吸肌訓練
營養支持 高蛋白高熱量飲食、⚠️ 營養補充品（如 PulmoCare）
訪問復健 週 1-2 次訪問復健師（呼吸復健 + 床上肌力訓練）

| Item | Recommended Content | |——|———-| | Aerobic exercise | Daily walking (adjusted per tolerance) or walking machine 30 min/day | | Strength training | Lower extremity strength (squats, etc.), respiratory muscle training | | Nutritional support | High-protein, high-calorie diet; ⚠️ nutritional supplements (e.g., PulmoCare) | | Visiting rehabilitation | 1-2x/week visiting rehabilitation therapist (pulmonary rehab + bed-level strength training) |

D.3 D.3 收到器官通知 → 入院 / D.3 Organ Offer Notification to Admission

D.3.1 D.3.1 通知流程（逐時） / D.3.1 Notification Process (Hourly)

Hour 0     器官捐贈中心通知 → 移植協調師接獲通知
           ├─ 確認供體資訊（ABO、size match、CMV 狀態、HLA）
           ├─ 評估 size matching（VCD/VCR ±30% 成人；±12% 兒童）[UTH-Manual-2022]
           └─ 通知主刀醫師，決定是否接受

> *```*
> *Hour 0     Organ donation center notification → Transplant coordinator receives notification*
> *           ├─ Confirm donor information (ABO, size match, CMV status, HLA)*
> *           ├─ Evaluate size matching (VCD/VCR ±30% adult; ±12% pediatric) [UTH-Manual-2022]*
> *           └─ Notify lead surgeon, decide whether to accept*

Hour 0-1   通知受者入院
           ├─ 協調師聯繫病人/家屬
           ├─ 確認交通方式與預計到院時間
           └─ 啟動手術團隊 call-in

> *Hour 0-1   Notify recipient for admission*
> *           ├─ Coordinator contacts patient/family*
> *           ├─ Confirm transportation method and estimated arrival time*
> *           └─ Activate surgical team call-in*

Hour 1-3   受者到院
           ├─ 急診或直接入住病房
           ├─ 術前採血（CBC、生化、凝血、Type & Screen、ABG）
           ├─ 胸部 X 光
           ├─ COVID-19 PCR ⚠️
           ├─ Crossmatch 檢體送出
           └─ 麻醉科術前評估

> *Hour 1-3   Recipient arrives at hospital*
> *           ├─ Emergency department or direct ward admission*
> *           ├─ Pre-op blood work (CBC, chemistry, coagulation, Type & Screen, ABG)*
> *           ├─ Chest X-ray*
> *           ├─ COVID-19 PCR ⚠️*
> *           ├─ Crossmatch specimen sent*
> *           └─ Anesthesia pre-op evaluation*

Hour 2-4   術前準備
           ├─ 手術同意書簽署
           ├─ 麻醉同意書簽署
           ├─ ⚠️ 術前免疫抑制劑給予：
           │   ├─ MMF (CellCept) 500 mg PO [UTH-Manual-2022]
           │   └─ Methylprednisolone (Solu-Medrol) 500 mg IV
           ├─ 術前抗生素（PIP/TAZ 4.5g）
           └─ 轉送手術室

Hour 2-4 Pre-op preparation * ├─ Surgical consent signing ├─ Anesthesia consent signing ├─ ⚠️ Pre-op immunosuppressant administration: │ ├─ MMF (CellCept) 500 mg PO [UTH-Manual-2022] │ └─ Methylprednisolone (Solu-Medrol) 500 mg IV ├─ Pre-op antibiotics (PIP/TAZ 4.5g) └─ Transfer to operating room ```*

D.3.2 D.3.2 家屬安排 / D.3.2 Family Arrangements

項目 說明
家屬等候室 安排家屬至手術等候區
聯絡窗口 協調師或護理師定期更新手術進度
住宿安排 如遠道家屬，協助安排院內或附近住宿 ⚠️

| Item | Description | |——|——| | Family waiting area | Arrange family in surgical waiting area | | Contact person | Coordinator or nurse provides periodic surgical progress updates | | Accommodation | Assist with in-hospital or nearby accommodation for families traveling from afar ⚠️ |

D.4 D.4 手術日（Day 0） / D.4 Surgery Day (Day 0)

D.4.1 D.4.1 麻醉準備序列 / D.4.1 Anesthesia Preparation Sequence

根據 UTH Manual 及臨床實務 [UTH-Manual-2022]：

Per UTH Manual and clinical practice [UTH-Manual-2022]:

時序 步驟
T-60 min 病人入手術室，確認身分、手術部位
T-45 min 動脈導管（A-line）建立
T-30 min 全身麻醉誘導（Propofol、Fentanyl、肌肉鬆弛劑）
T-20 min 雙腔氣管內管或支氣管阻斷器插管
T-15 min 中央靜脈導管（CV line）— 右內頸靜脈
T-10 min Swan-Ganz 肺動脈導管置入
T-5 min 經食道超音波（TEE）置入
T-0 消毒鋪單完成，準備開刀

| Sequence | Step | |——|——| | T-60 min | Patient enters OR, identity and surgical site verification | | T-45 min | Arterial line (A-line) placement | | T-30 min | General anesthesia induction (Propofol, Fentanyl, muscle relaxant) | | T-20 min | Double-lumen endotracheal tube or bronchial blocker insertion | | T-15 min | Central venous catheter (CV line) — right internal jugular vein | | T-10 min | Swan-Ganz pulmonary artery catheter insertion | | T-5 min | Transesophageal echocardiography (TEE) placement | | T-0 | Prep and drape complete, ready to operate |

D.4.2 D.4.2 手術步驟與時間估算 / D.4.2 Surgical Steps and Time Estimates

典型 BLTx（雙肺移植）手術流程，依臨床實務資料：

Typical BLTx (bilateral lung transplant) surgical workflow, per clinical practice data:

≈ Hour 0        Clamshell incision（第 4 肋間雙側開胸）
                 心包逆 T 字切開

> *```*
> *≈ Hour 0        Clamshell incision (4th intercostal bilateral thoracotomy)*
> *                 Pericardial inverted-T incision*

≈ Hour 0.5      Central ECMO cannulation
                 ├─ SVC：脫血管（如 20Fr）
                 ├─ IVC：脫血管（如 20Fr）
                 └─ 升主動脈：送血管（如 15Fr）
                 確認 full flow

> *≈ Hour 0.5      Central ECMO cannulation*
> *                 ├─ SVC: drainage cannula (e.g., 20Fr)*
> *                 ├─ IVC: drainage cannula (e.g., 20Fr)*
> *                 └─ Ascending aorta: return cannula (e.g., 15Fr)*
> *                 Confirm full flow*

≈ Hour 1-2      第一側肺（通常右肺）全摘
                 ├─ 肺門剝離
                 ├─ 肺動脈 stapling
                 ├─ 肺靜脈 stapling
                 └─ 支氣管 stapling

> *≈ Hour 1-2      First side pneumonectomy (usually right lung)*
> *                 ├─ Hilum dissection*
> *                 ├─ Pulmonary artery stapling*
> *                 ├─ Pulmonary vein stapling*
> *                 └─ Bronchus stapling*

≈ Hour 2-3      第一側移植肺吻合
                 ├─ 支氣管吻合（4-0 PDS）
                 ├─ 肺動脈吻合（5-0 Pronova）
                 └─ 左房吻合（4-0 Pronova）
                 → 再灌流（reperfusion）

> *≈ Hour 2-3      First side donor lung implantation*
> *                 ├─ Bronchial anastomosis (4-0 PDS)*
> *                 ├─ Pulmonary artery anastomosis (5-0 Pronova)*
> *                 └─ Left atrial anastomosis (4-0 Pronova)*
> *                 → Reperfusion*

≈ Hour 3-5      第二側肺全摘 + 移植肺吻合（同上步驟）
                 → 再灌流

> *≈ Hour 3-5      Second side pneumonectomy + donor lung implantation (same steps)*
> *                 → Reperfusion*

≈ Hour 5-6      ECMO weaning
                 ├─ 逐步降低 ECMO flow
                 ├─ 監測 mPAP、血壓、SpO2
                 ├─ 必要時啟動 iNO（10-20 ppm）[UTH-Manual-2022]
                 ├─ 氣管支鏡抽痰
                 └─ 確認血行動力學穩定後 ECMO 離脱

> *≈ Hour 5-6      ECMO weaning*
> *                 ├─ Gradual ECMO flow reduction*
> *                 ├─ Monitor mPAP, BP, SpO2*
> *                 ├─ Initiate iNO (10-20 ppm) if needed [UTH-Manual-2022]*
> *                 ├─ Bronchoscopic suctioning*
> *                 └─ Confirm hemodynamic stability before ECMO decannulation*

≈ Hour 6-7      關胸
                 ├─ 置入胸腔引流管（4 條）
                 ├─ 心膜重建（Gore-Tex sheet）
                 ├─ 胸骨鋼絲固定
                 └─ 逐層閉合

> *≈ Hour 6-7      Chest closure*
> *                 ├─ Place chest drains (4 tubes)*
> *                 ├─ Pericardial reconstruction (Gore-Tex sheet)*
> *                 ├─ Sternal wire fixation*
> *                 └─ Layered closure*

≈ Hour 7-8      術後氣管支鏡檢查
                 確認吻合口通暢、無再灌流障礙

> *≈ Hour 7-8      Post-operative bronchoscopy*
> *                 Confirm anastomotic patency, no reperfusion injury*

≈ Hour 8+       轉送 ICU

≈ Hour 8+ Transfer to ICU ```

典型時間參數 [根據臨床實務]：

Typical Time Parameters [per clinical practice]:

參數 典型值
總手術時間 8-10 小時
Cold ischemic time (CIT) 第一肺 4-6 hr；第二肺 6-8 hr
Warm ischemic time (WIT) 45-70 min/側
Total ischemic time 6-8 hr（第一肺）；7-9 hr（第二肺）

| Parameter | Typical Value | |——|——–| | Total surgical time | 8-10 hours | | Cold ischemic time (CIT) | First lung 4-6 hr; second lung 6-8 hr | | Warm ischemic time (WIT) | 45-70 min/side | | Total ischemic time | 6-8 hr (first lung); 7-9 hr (second lung) |

D.4.3 D.4.3 術中免疫抑制劑 / D.4.3 Intraoperative Immunosuppression

時間點 藥物 劑量
術前（麻醉誘導前） MMF (CellCept) 500 mg PO
術中（再灌流前） Solu-Medrol 500 mg IV（部分中心用 500-1000 mg）

| Timing | Drug | Dose | |——–|——|——| | Pre-op (before anesthesia induction) | MMF (CellCept) | 500 mg PO | | Intraoperative (before reperfusion) | Solu-Medrol | 500 mg IV (some centers use 500-1000 mg) |

D.4.4 D.4.4 術中 ECMO 管理要點 [UTH-Manual-2022] / D.4.4 Intraoperative ECMO Management Points [UTH-Manual-2022]

  • Central V-A ECMO 為標準配置
  • iPAH 病人：術後需 ICU 維持 ECMO 2-3 天後再嘗試脫離
  • ECMO weaning 失敗時：回復 flow，排除原因（PH、出血、氣道分泌物）後再試
  • iNO 20 ppm 可輔助 ECMO 脫離

- Central V-A ECMO is the standard configuration - iPAH patients: Post-op ICU ECMO maintenance for 2-3 days before weaning attempt - ECMO weaning failure: Restore flow, troubleshoot cause (PH, bleeding, airway secretions) before re-attempting - iNO 20 ppm can assist ECMO weaning

D.5 D.5 ICU 照護時間表（POD 0-14） / D.5 ICU Care Timeline (POD 0-14)

D.5.1 D.5.1 POD 0（手術當日，ICU 入室） / D.5.1 POD 0 (Surgery Day, ICU Admission)

項目 內容
呼吸器設定 Lung protective：Vt 6-8 mL/kg, PEEP 5 cmH2O, plateau < 30 cmH2O [UTH-Manual-2022]
iNO 如術中使用，維持 10-20 ppm，12-24 小時後逐漸 weaning [UTH-Manual-2022]
血行動力學 Swan-Ganz 監測 mPAP、CVP、CO/CI、SvO2
輸液 限制性輸液策略，30-40 mL/kg/day [UTH-Manual-2022]
目標 SvO2 ≥ 60%、CI ≥ 2.5
藥物啟動 Tacrolimus IV 持續輸注（見 D.6）
抗生素 PIP/TAZ 4.5g q8h [UTH-Manual-2022]
抗黴菌 Micafungin 100 mg/day IV（ECMO 中 200 mg）[UTH-Manual-2022]
抗病毒 Ganciclovir 5 mg/kg/day IV [UTH-Manual-2022]
ABG 入室後立即，此後 q4-6h
CXR 入室後立即（baseline）
Labs CBC、生化、凝血（入室時）

| Item | Content | |——|——| | Ventilator settings | Lung protective: Vt 6-8 mL/kg, PEEP 5 cmH2O, plateau < 30 cmH2O [UTH-Manual-2022] | | iNO | If used intraoperatively, maintain 10-20 ppm, gradually wean after 12-24 hours [UTH-Manual-2022] | | Hemodynamics | Swan-Ganz monitoring mPAP, CVP, CO/CI, SvO2 | | Fluids | Restrictive fluid strategy, 30-40 mL/kg/day [UTH-Manual-2022] | | Targets | SvO2 ≥ 60%, CI ≥ 2.5 | | Drug initiation | Tacrolimus IV continuous infusion (see D.6) | | Antibiotics | PIP/TAZ 4.5g q8h [UTH-Manual-2022] | | Antifungal | Micafungin 100 mg/day IV (200 mg on ECMO) [UTH-Manual-2022] | | Antiviral | Ganciclovir 5 mg/kg/day IV [UTH-Manual-2022] | | ABG | Immediately upon admission, then q4-6h | | CXR | Immediately upon admission (baseline) | | Labs | CBC, chemistry, coagulation (on admission) |

D.5.2 D.5.2 POD 1 / D.5.2 POD 1

項目 內容
免疫抑制 mPSL 250 mg IV × 1 [UTH-Manual-2022]
Tacrolimus 監測 第 1 次 trough level（啟動後 6 小時）[UTH-Manual-2022]
第 2 次 Tac level 啟動後 16 小時
Basiliximab POD 1 給予 Simulect 20 mg + NS 50 mL（30 分鐘滴注）（如使用）[UTH-Manual-2022]
IVIg POD 1-2 Venoglobulin 7.5 g（如使用）[UTH-Manual-2022]
CellCept 開始 PO/NG：BW < 50 kg → 500 mg/day；BW ≥ 50 kg → 1000 mg/day（分 2 次）[UTH-Manual-2022]
CXR 每日
氣管支鏡 視情況進行（確認吻合口、抽痰）

| Item | Content | |——|——| | Immunosuppression | mPSL 250 mg IV x 1 [UTH-Manual-2022] | | Tacrolimus monitoring | 1st trough level (6 hours after initiation) [UTH-Manual-2022] | | 2nd Tac level | 16 hours after initiation | | Basiliximab | POD 1: Simulect 20 mg + NS 50 mL (30-minute infusion) (if used) [UTH-Manual-2022] | | IVIg | POD 1-2: Venoglobulin 7.5 g (if used) [UTH-Manual-2022] | | CellCept | Start PO/NG: BW < 50 kg → 500 mg/day; BW ≥ 50 kg → 1000 mg/day (divided BID) [UTH-Manual-2022] | | CXR | Daily | | Bronchoscopy | As needed (check anastomosis, suction) |

D.5.3 D.5.3 POD 1-3：mPSL 高劑量期 / D.5.3 POD 1-3: High-Dose mPSL Phase

日 Methylprednisolone 其他重點
POD 1 250 mg IV × 1 第一次 Tac level，CellCept 開始
POD 2 250 mg IV × 1 持續呼吸器管理，開始評估拔管可能
POD 3 250 mg IV × 1 胸腔引流量評估，開始腸道營養評估

| Day | Methylprednisolone | Other Key Points | |—-|——————-|———-| | POD 1 | 250 mg IV x 1 | First Tac level, CellCept started | | POD 2 | 250 mg IV x 1 | Continue ventilator management, begin extubation readiness assessment | | POD 3 | 250 mg IV x 1 | Chest drain output evaluation, begin enteral nutrition assessment |

D.5.4 D.5.4 POD 4-6：mPSL 減量期 / D.5.4 POD 4-6: mPSL Taper Phase

日 Methylprednisolone 其他重點
POD 4 125 mg IV × 1 Basiliximab 第 2 劑（POD 4）[UTH-Manual-2022]
POD 5 125 mg IV × 1 評估拔管（目標 72 小時內拔管）
POD 6 125 mg IV × 1 拔管後開始口服藥物轉換準備

| Day | Methylprednisolone | Other Key Points | |—-|——————-|———-| | POD 4 | 125 mg IV x 1 | Basiliximab 2nd dose (POD 4) [UTH-Manual-2022] | | POD 5 | 125 mg IV x 1 | Extubation assessment (target within 72 hours) | | POD 6 | 125 mg IV x 1 | Post-extubation oral medication transition preparation |

D.5.5 D.5.5 POD 7-9：mPSL 最終減量 / D.5.5 POD 7-9: Final mPSL Taper

日 Methylprednisolone 其他重點
POD 7 62.5 mg IV × 1 開始 Tacrolimus IV → oral 轉換 [UTH-Manual-2022]
POD 8 62.5 mg IV × 1 追蹤 Tac oral trough level
POD 9 62.5 mg IV × 1 抗黴菌轉 ITCZ oral（20 mL suspension）

| Day | Methylprednisolone | Other Key Points | |—-|——————-|———-| | POD 7 | 62.5 mg IV x 1 | Begin Tacrolimus IV → oral conversion [UTH-Manual-2022] | | POD 8 | 62.5 mg IV x 1 | Track Tac oral trough level | | POD 9 | 62.5 mg IV x 1 | Switch antifungal to ITCZ oral (20 mL suspension) |

D.5.6 D.5.6 POD 10-14：穩定期 / D.5.6 POD 10-14: Stabilization Phase

日 重點
POD 10 Prednisolone 30 mg PO 開始（取代 IV mPSL）[UTH-Manual-2022]
POD 10 Tacrolimus 完成 IV → oral 轉換
POD 10-14 PSL 每週減量 2.5 mg → 目標 5 mg/day 維持 [UTH-Manual-2022]
POD 10-14 Valganciclovir 900 mg/day PO 取代 GCV IV [UTH-Manual-2022]
POD 14 Baktar (TMP-SMX) 開始（1 錠 × 1/day，週一三五）[UTH-Manual-2022]

| Day | Key Points | |—-|——| | POD 10 | Prednisolone 30 mg PO begins (replaces IV mPSL) [UTH-Manual-2022] | | POD 10 | Tacrolimus IV → oral conversion complete | | POD 10-14 | PSL taper 2.5 mg/week → target 5 mg/day maintenance [UTH-Manual-2022] | | POD 10-14 | Valganciclovir 900 mg/day PO replaces GCV IV [UTH-Manual-2022] | | POD 14 | Baktar (TMP-SMX) starts (1 tab x 1/day, Mon-Wed-Fri) [UTH-Manual-2022] |

D.5.7 D.5.7 呼吸器脫離與拔管時程 / D.5.7 Ventilator Weaning and Extubation Timeline

目標時程 內容
POD 1-2 開始 weaning trial（降 PEEP、降 PS）
POD 2-3（目標 72 小時） 拔管 [UTH-Manual-2022]
拔管後 HFNC 或 NIV 過渡
拔管延遲 > 7-14 天 評估氣管切開 [UTH-Manual-2022]

| Target Timeline | Content | |———-|——| | POD 1-2 | Begin weaning trial (reduce PEEP, reduce PS) | | POD 2-3 (target 72 hours) | Extubation [UTH-Manual-2022] | | Post-extubation | HFNC or NIV transition | | Extubation delay > 7-14 days | Evaluate tracheostomy [UTH-Manual-2022] |

D.5.8 D.5.8 營養支持時程 [UTH-Manual-2022] / D.5.8 Nutritional Support Timeline [UTH-Manual-2022]

時間 內容
POD 0 TPN 開始（Elneopa 等）
POD 1-2 管灌營養開始：50 mL/hr Glutamine F，逐步增量
POD 2-3 轉 PulmoCare 管灌
拔管後 口服飲食開始（流質 → 軟食 → 普通飲食）
目標 Harris-Benedict BEE × 1.2-1.8；蛋白質 1.2-2.0 g/kg/day

| Timeline | Content | |——|——| | POD 0 | TPN initiated (Elneopa, etc.) | | POD 1-2 | Tube feeding starts: 50 mL/hr Glutamine F, gradually increase | | POD 2-3 | Switch to PulmoCare tube feeding | | Post-extubation | Oral diet begins (liquids → soft → regular diet) | | Target | Harris-Benedict BEE x 1.2-1.8; protein 1.2-2.0 g/kg/day |

D.5.9 D.5.9 復健啟動時程 / D.5.9 Rehabilitation Initiation Timeline

時間 內容
POD 1-2 床上被動運動、關節活動度
POD 2-3 床邊坐起
POD 3-5 輪椅移位（即使有多條管路）
拔管後 站立、步行訓練
POD 7-14 每日步行距離逐增

| Timeline | Content | |——|——| | POD 1-2 | Bed-level passive exercises, ROM | | POD 2-3 | Bedside sitting | | POD 3-5 | Wheelchair transfer (even with multiple lines) | | Post-extubation | Standing, walking training | | POD 7-14 | Progressive daily walking distance increase |

D.5.10 D.5.10 氣管支鏡檢查時程 / D.5.10 Bronchoscopy Schedule

時間 目的
術後即刻（OR 內） 確認吻合口通暢、有無再灌流障礙
POD 1-3 抽痰、評估吻合口癒合
POD 7（第 1 週） protocol biopsy + BAL
POD 14（第 2 週） 追蹤吻合口、排斥評估
⚠️ 之後依各中心 protocol 每 1-2 週至出院

| Timeline | Purpose | |——|——| | Immediately post-op (in OR) | Confirm anastomotic patency, assess reperfusion injury | | POD 1-3 | Suctioning, anastomotic healing assessment | | POD 7 (Week 1) | Protocol biopsy + BAL | | POD 14 (Week 2) | Anastomosis follow-up, rejection assessment | | ⚠️ Thereafter per center protocol | Every 1-2 weeks until discharge |

D.6 D.6 免疫抑制劑時間表 / D.6 Immunosuppression Timeline

D.6.1 D.6.1 總覽流程圖 / D.6.1 Overview Flowchart

術前 ─────────── 術中 ──── POD 0 ── POD 1 ── POD 4 ── POD 7-10 ── POD 10 ── 出院後

> *```*
> *Pre-op ─────────── Intra-op ──── POD 0 ── POD 1 ── POD 4 ── POD 7-10 ── POD 10 ── Post-discharge*

MMF 500mg PO ──────────── → CellCept 500-1500mg/day PO 持續 ──────────→

> *MMF 500mg PO ──────────── → CellCept 500-1500mg/day PO continuous ──────────→*

Solu-Medrol ──── 500mg IV
                          mPSL 250mg×3d → 125mg×3d → 62.5mg×3d
                                                          PSL 30mg PO → 減量至 5mg

> *Solu-Medrol ──── 500mg IV*
> *                          mPSL 250mg×3d → 125mg×3d → 62.5mg×3d*
> *                                                          PSL 30mg PO → taper to 5mg*

                          Tac IV 0.03mL/kg/hr ──────────→ Tac oral
                                                          (×1.5-2 IV rate)

> *                          Tac IV 0.03mL/kg/hr ──────────→ Tac oral*
> *                                                          (×1.5-2 IV rate)*

                          Basiliximab ── D1 ──── D4
  •                      Basiliximab ── D1 ──── D4*
    ```

D.6.2 D.6.2 Tacrolimus 詳細時程 [UTH-Manual-2022] / D.6.2 Tacrolimus Detailed Timeline [UTH-Manual-2022]

階段 給法 劑量/目標
POD 0（ICU 入室） Prograf 1A (2mg/0.4mL) + NS 50mL IV drip 0.03 mL/kg/hr
BW 30kg → 0.9 mL/hr
BW 50kg → 1.5 mL/hr
BW 70kg → 2.1 mL/hr
POD 1（6hr） 第 1 次 trough level 抽血 目標 15-20 ng/mL
POD 1（16hr） 第 2 次 trough level 抽血
此後 每日 trough level（ICU: A-line 抽取）
POD 7-10 IV → Oral 轉換 口服劑量 = IV rate × 1.5-2 倍
例：IV 0.8 mL/hr → oral 1.2-1.6 mg q12h
⚠️ 併用 ITCZ 或 VRCZ 時 口服劑量 = IV rate × 1.0 倍

| Phase | Route | Dose/Target | |——|——|———–| | POD 0 (ICU admission) | Prograf 1A (2mg/0.4mL) + NS 50mL IV drip | 0.03 mL/kg/hr | | | | BW 30kg → 0.9 mL/hr | | | | BW 50kg → 1.5 mL/hr | | | | BW 70kg → 2.1 mL/hr | | POD 1 (6hr) | 1st trough level blood draw | Target 15-20 ng/mL | | POD 1 (16hr) | 2nd trough level blood draw | | | Thereafter | Daily trough level (ICU: draw from A-line) | | | POD 7-10 | IV → Oral conversion | Oral dose = IV rate x 1.5-2 | | | | Example: IV 0.8 mL/hr → oral 1.2-1.6 mg q12h | | | ⚠️ With concurrent ITCZ or VRCZ | Oral dose = IV rate x 1.0 |

Tacrolimus 目標濃度 [UTH-Manual-2022]：

Tacrolimus Target Levels [UTH-Manual-2022]:

時期 目標 trough (ng/mL)
0-3 個月 14-17
3-6 個月 10-15
> 6 個月 8-12

| Period | Target Trough (ng/mL) | |——|———————| | 0-3 months | 14-17 | | 3-6 months | 10-15 | | > 6 months | 8-12 |

D.6.3 D.6.3 Corticosteroid 詳細時程 [UTH-Manual-2022] / D.6.3 Corticosteroid Detailed Timeline [UTH-Manual-2022]

時間 藥物 劑量 給法
術中（再灌流前） Solu-Medrol 500 mg IV bolus
POD 1-3 mPSL 250 mg/day IV × 1/day
POD 4-6 mPSL 125 mg/day IV × 1/day
POD 7-9 mPSL 62.5 mg/day IV × 1/day
⚠️ 替代方案 mPSL 62.5 → 40 → 30 mg（逐步） 部分中心 3 天一減
POD 10 Prednisolone (PSL) 30 mg PO
POD 10 起 PSL 減量 每週減 2.5 mg PO
維持劑量 PSL 5 mg/day PO，長期

| Timing | Drug | Dose | Route | |——|——|——|——| | Intraoperative (before reperfusion) | Solu-Medrol | 500 mg | IV bolus | | POD 1-3 | mPSL | 250 mg/day | IV x 1/day | | POD 4-6 | mPSL | 125 mg/day | IV x 1/day | | POD 7-9 | mPSL | 62.5 mg/day | IV x 1/day | | ⚠️ Alternative | mPSL | 62.5 → 40 → 30 mg (stepwise) | Some centers use 3-day steps | | POD 10 | Prednisolone (PSL) | 30 mg | PO | | From POD 10 | PSL taper | 2.5 mg/week reduction | PO | | Maintenance dose | PSL | 5 mg/day | PO, long-term |

體重別 Prednisone 參考劑量 [UTH-Manual-2022]：

Weight-Based Prednisone Reference Dosing [UTH-Manual-2022]:

時期 劑量公式 60 kg 40 kg
3 個月 0.25 mg/kg/day 15 mg 10 mg
6 個月 0.15 mg/kg/day 9 mg 6 mg
9 個月 0.08-0.1 mg/kg/day 5-6 mg 3-4 mg

| Period | Dose Formula | 60 kg | 40 kg | |——|———-|——-|——-| | 3 months | 0.25 mg/kg/day | 15 mg | 10 mg | | 6 months | 0.15 mg/kg/day | 9 mg | 6 mg | | 9 months | 0.08-0.1 mg/kg/day | 5-6 mg | 3-4 mg |

D.6.4 D.6.4 Basiliximab (Simulect) [UTH-Manual-2022] / D.6.4 Basiliximab (Simulect) [UTH-Manual-2022]

  • 適應：Tacrolimus 啟動延遲或腎功能不佳時使用
  • POD 1：Simulect 20 mg + NS 50 mL，30 分鐘以上滴注
  • POD 4：Simulect 20 mg + NS 50 mL，30 分鐘以上滴注

- Indication: When Tacrolimus initiation is delayed or renal function is poor - POD 1: Simulect 20 mg + NS 50 mL, infuse over 30 minutes or more - POD 4: Simulect 20 mg + NS 50 mL, infuse over 30 minutes or more

D.6.5 D.6.5 MMF (CellCept) [UTH-Manual-2022] / D.6.5 MMF (CellCept) [UTH-Manual-2022]

時間 劑量 備註
術前 500 mg PO 術前 9 小時前（第一劑）
術前 — 術前 7 小時前（已由前晚給予）
POD 0（21:00） CellCept 500 mg NG/PO
POD 1 起 BW < 50 kg：500 mg/day；BW ≥ 50 kg：1000 mg/day 分 2 次（7:00、19:00）
排斥時 可增至 3000 mg/day（ACR）或 1500 mg/day 以上
副作用監測 WBC < 1500/μL 時減量或暫停

| Timing | Dose | Notes | |——|——|——| | Pre-op | 500 mg PO | 9 hours before surgery (first dose) | | POD 0 (21:00) | CellCept 500 mg | NG/PO | | POD 1 onward | BW < 50 kg: 500 mg/day; BW ≥ 50 kg: 1000 mg/day | Divided BID (7:00, 19:00) | | During rejection | May increase to 3000 mg/day (ACR) or ≥ 1500 mg/day | | | Side effect monitoring | Reduce or hold when WBC < 1500/uL | |

D.6.6 D.6.6 替代方案：Cyclosporine (Neoral) [UTH-Manual-2022] / D.6.6 Alternative: Cyclosporine (Neoral) [UTH-Manual-2022]

項目 內容
適應 Tacrolimus 無法耐受時
起始劑量 5 mg/kg PO 分 2 次
Trough 目標 0-3 月：250-350；3-6 月：200-300；>6 月：150-250 ng/mL

| Item | Content | |——|——| | Indication | When Tacrolimus is not tolerated | | Starting dose | 5 mg/kg PO divided BID | | Trough target | 0-3m: 250-350; 3-6m: 200-300; >6m: 150-250 ng/mL |

D.7 D.7 感染預防時間表 / D.7 Infection Prevention Timeline

D.7.1 D.7.1 周術期抗生素 [UTH-Manual-2022] / D.7.1 Perioperative Antibiotics [UTH-Manual-2022]

時間 藥物 劑量 備註
術前 PIP/TAZ 4.5g IV 切皮前 30 分鐘
POD 0 起 PIP/TAZ 4.5g q8h IV 持續至少 7-14 天
依供體培養結果調整
供體有 MRSA 加 Vancomycin 1g q12h
供體有 Pseudomonas 改 Ceftazidime 或 Meropenem
ESBL 陽性 Meropenem 1g q8h

| Timing | Drug | Dose | Notes | |——|——|——|——| | Pre-op | PIP/TAZ | 4.5g IV | 30 minutes before incision | | POD 0 onward | PIP/TAZ | 4.5g q8h IV | Continue at least 7-14 days; adjust per donor culture results | | Donor MRSA | Add Vancomycin | 1g q12h | | | Donor Pseudomonas | Switch to Ceftazidime or Meropenem | | | | ESBL positive | Meropenem | 1g q8h | |

D.7.2 D.7.2 抗黴菌預防 [UTH-Manual-2022] / D.7.2 Antifungal Prophylaxis [UTH-Manual-2022]

階段 藥物 劑量 期間
ICU（POD 1 起） Micafungin (MCFG) 100 mg/day IV（ECMO 中 200 mg） 至脫離 ECMO + ICU
口服轉換後 Itraconazole (ITCZ) suspension 20 mL/day 至少 7 天後可轉膠囊
維持期 ITCZ capsule 50-200 mg/day 至少 3-6 個月
吸入 Amphotericin B (Fungizone) 霧化 ICU 期間開始，⚠️ 視中心 protocol

| Phase | Drug | Dose | Duration | |——|——|——|——| | ICU (from POD 1) | Micafungin (MCFG) | 100 mg/day IV (200 mg on ECMO) | Until ECMO decannulation + ICU discharge | | Oral transition | Itraconazole (ITCZ) suspension | 20 mL/day | May switch to capsules after 7 days or more | | Maintenance | ITCZ capsule | 50-200 mg/day | At least 3-6 months | | Inhaled | Amphotericin B (Fungizone) nebulized | | Starting in ICU, ⚠️ per center protocol |

D.7.3 D.7.3 CMV 預防 [UTH-Manual-2022] / D.7.3 CMV Prevention [UTH-Manual-2022]

D/R 狀態 預防策略 藥物 劑量 期間
D+/R-（最高風險） Prophylaxis GCV IV 5 mg/kg/day → VGC PO 900 mg/day 術後立即開始 ≥ 12 個月（0-6 月 900 mg → 6-12 月 450-900 mg）
D+/R+ 或 D-/R+ Prophylaxis VGC PO 900 mg/day 口服可能後開始 6 個月
D-/R- 低風險 Acyclovir PO 400 mg × 2/day 6 個月

| D/R Status | Strategy | Drug | Dose | Duration | |———–|———-|——|——|——| | D+/R- (highest risk) | Prophylaxis | GCV IV 5 mg/kg/day → VGC PO 900 mg/day | Start immediately post-op | 12 months or more (0-6m: 900 mg → 6-12m: 450-900 mg) | | D+/R+ or D-/R+ | Prophylaxis | VGC PO 900 mg/day | Start when oral intake possible | 6 months | | D-/R- | Low risk | Acyclovir PO 400 mg x 2/day | | 6 months |

CMV 監測時程： - ICU 期間：C7-HRP 或 CMV-PCR 每週 1-2 次 - 出院後 3 個月內：每 1-2 週 - 3-12 個月：每月 - Preemptive therapy 閾值：C7-HRP ≥ 10/50,000；CMV-PCR ≥ 1500 IU/mL（R+）或 ≥ 500 IU/mL（R-）[UTH-Manual-2022]

CMV Monitoring Schedule: - ICU period: C7-HRP or CMV-PCR 1-2x/week - First 3 months post-discharge: Every 1-2 weeks - 3-12 months: Monthly - Preemptive therapy threshold: C7-HRP ≥ 10/50,000; CMV-PCR ≥ 1500 IU/mL (R+) or ≥ 500 IU/mL (R-) [UTH-Manual-2022]

D.7.4 D.7.4 PCP 預防 [UTH-Manual-2022] / D.7.4 PCP Prevention [UTH-Manual-2022]

藥物 劑量 起始 期間
TMP-SMX (Baktar/Bactrim) 1 錠/day，週一三五 POD 14（或口服可能後） 終生
替代（TMP-SMX 過敏） Atovaquone (Samitrel) 1500 mg/day 終生

| Drug | Dose | Start | Duration | |——|——|——|——| | TMP-SMX (Baktar/Bactrim) | 1 tab/day, Mon-Wed-Fri | POD 14 (or when oral intake possible) | Lifelong | | Alternative (TMP-SMX allergy) | Atovaquone (Samitrel) 1500 mg/day | | Lifelong |

D.7.5 D.7.5 吸入藥物時程 [UTH-Manual-2022] / D.7.5 Inhaled Medication Schedule [UTH-Manual-2022]

藥物 頻率 起始 備註
Meptin（Procaterol）霧化 q4h → PRN ICU 入室即開始 支氣管擴張
Atrovent（Ipratropium）霧化 q4h ICU 入室
QVAR（Beclomethasone）吸入 2 puffs BID-QID 口服可能後 局部抗炎
Tobramycin 霧化 PRN Pseudomonas 培養陽性時 180-270 mg
Amphotericin B 霧化 PRN Aspergillus 風險時 25 mg

| Drug | Frequency | Start | Notes | |——|——|——|——| | Meptin (Procaterol) nebulized | q4h → PRN | Start immediately upon ICU admission | Bronchodilator | | Atrovent (Ipratropium) nebulized | q4h | ICU admission | | | QVAR (Beclomethasone) inhaled | 2 puffs BID-QID | When oral intake possible | Local anti-inflammatory | | Tobramycin nebulized | PRN | When Pseudomonas culture positive | 180-270 mg | | Amphotericin B nebulized | PRN | When Aspergillus risk present | 25 mg |

D.8 D.8 出院準備與出院標準 / D.8 Discharge Preparation and Criteria

D.8.1 D.8.1 出院標準檢核表 / D.8.1 Discharge Criteria Checklist

項目 標準
☐ 呼吸 脫離呼吸器、室內空氣或低流量 O2 穩定
☐ 肺功能 FEV1 穩定或改善中
☐ CXR 穩定，無新浸潤
☐ 免疫抑制 口服三聯療法穩定（Tac + MMF + PSL），Tac level 達標
☐ 感染 無活動性感染
☐ 營養 口服攝入足夠
☐ 活動 可獨立步行或輕度協助
☐ 傷口 癒合良好
☐ 排斥 氣管支鏡 biopsy 無顯著排斥（≤ A1）
☐ 教育 完成衛教（見下表）

| Item | Criteria | |——|——| | Respiratory | Weaned from ventilator, stable on room air or low-flow O2 | | Pulmonary function | FEV1 stable or improving | | CXR | Stable, no new infiltrates | | Immunosuppression | Stable oral triple therapy (Tac + MMF + PSL), Tac level on target | | Infection | No active infection | | Nutrition | Adequate oral intake | | Mobility | Independent walking or minimal assistance | | Wound | Healing well | | Rejection | Bronchoscopy biopsy with no significant rejection (≤ A1) | | Education | Completed education (see below) |

D.8.2 D.8.2 出院衛教項目 / D.8.2 Discharge Education Items

項目 內容
藥物指導 三聯免疫抑制劑服藥時間（早 8:30 服 Prograf/CellCept/Prednisone）[UTH-Manual-2022]
抗感染藥物（ITCZ、Baktar、VGC）
GI 保護藥物（PPI、Metoclopramide 等）
自我監測 每日體溫、體重、SpO2
居家肺量計（HiChek 等）使用 [UTH-Manual-2022]
感染預防 手部衛生、口腔衛生（每餐後刷牙）
避免人群密集處、戴口罩
食物安全（避免生食）
回診預約 告知追蹤頻率（見 D.9）
緊急聯絡 提供 24 小時聯絡電話、何時需緊急就醫

| Item | Content | |——|——| | Medication guidance | Triple IS timing (morning 8:30 take Prograf/CellCept/Prednisone) [UTH-Manual-2022] | | | Anti-infective drugs (ITCZ, Baktar, VGC) | | | GI protective drugs (PPI, Metoclopramide, etc.) | | Self-monitoring | Daily temperature, weight, SpO2 | | | Home spirometer (HiChek, etc.) use [UTH-Manual-2022] | | Infection prevention | Hand hygiene, oral hygiene (brush after every meal) | | | Avoid crowded places, wear mask | | | Food safety (avoid raw foods) | | Follow-up | Inform follow-up frequency (see D.9) | | Emergency contacts | Provide 24-hour contact number, when to seek emergency care |

D.8.3 D.8.3 出院藥物清單範例 [UTH-Manual-2022] / D.8.3 Sample Discharge Medication List [UTH-Manual-2022]

類別 藥物 劑量
免疫抑制 Tacrolimus (Prograf) 依 trough 調整
MMF (CellCept) 500-1500 mg/day 分 2 次
Prednisolone 減量中（目標 5 mg/day）
抗黴菌 ITCZ suspension/capsule 20 mL/day 或 50-200 mg
抗病毒 Valganciclovir (Valixa) 依 CMV 風險 450-900 mg
PCP 預防 TMP-SMX (Baktar) 1 錠 週一三五
吸入劑 QVAR + Procaterol BID-QID
腸胃 Metoclopramide 15 mg、Pantoprazole
Lubiprostone (Amitiza) 48 μg 或 Senokot 便秘預防
益生菌 Miyairi-BM 或 Biofermin-R 1 g
助眠 Ramelteon (Rozerem) 8 mg PRN
骨質 Alendronate 35 mg 週一、Vit D3 見 D.10

| Category | Drug | Dose | |——|——|——| | Immunosuppression | Tacrolimus (Prograf) | Per trough adjustment | | | MMF (CellCept) | 500-1500 mg/day divided BID | | | Prednisolone | Tapering (target 5 mg/day) | | Antifungal | ITCZ suspension/capsule | 20 mL/day or 50-200 mg | | Antiviral | Valganciclovir (Valixa) | Per CMV risk 450-900 mg | | PCP prevention | TMP-SMX (Baktar) | 1 tab Mon-Wed-Fri | | Inhaled | QVAR + Procaterol | BID-QID | | GI | Metoclopramide 15 mg, Pantoprazole | | | | Lubiprostone (Amitiza) 48 ug or Senokot | Constipation prevention | | Probiotic | Miyairi-BM or Biofermin-R | 1 g | | Sleep aid | Ramelteon (Rozerem) 8 mg | PRN | | Bone health | Alendronate 35 mg Monday, Vit D3 | See D.10 |

D.9 D.9 出院後追蹤時間表 / D.9 Post-Discharge Follow-Up Schedule

D.9.1 D.9.1 門診回診頻率 [UTH-Manual-2022] / D.9.1 Clinic Visit Frequency [UTH-Manual-2022]

時期 頻率 內容
出院後第 1-4 週 每週 1-2 次 基本 Labs + Tac level + CXR
第 1-3 個月 每 1-2 週 Labs + Tac level + 肺功能 + CXR
第 3-6 個月 每 2 週至每月 Labs + Tac level + 肺功能
第 6-12 個月 每月 Labs + Tac level + CT（每 3-6 月）
> 12 個月 每 2-3 個月 年度全套檢查

| Period | Frequency | Content | |——|——|——| | Post-discharge weeks 1-4 | 1-2 times/week | Basic labs + Tac level + CXR | | Months 1-3 | Every 1-2 weeks | Labs + Tac level + PFT + CXR | | Months 3-6 | Every 2 weeks to monthly | Labs + Tac level + PFT | | Months 6-12 | Monthly | Labs + Tac level + CT (every 3-6 months) | | > 12 months | Every 2-3 months | Annual comprehensive workup |

D.9.2 D.9.2 每次回診檢查項目 [UTH-Manual-2022] / D.9.2 Tests at Each Visit [UTH-Manual-2022]

基本項目（每次）： - CBC、生化（肝腎功能） - Tacrolimus (或 CsA) trough level - CXR - 居家肺量計數據回顧

Basic items (every visit): - CBC, chemistry (liver/renal function) - Tacrolimus (or CsA) trough level - CXR - Home spirometer data review

定期追加項目：

Periodic additional items:

頻率 項目
每 1-2 週（前 3 月） CMV (C7-HRP)、EBV-DNA、Aspergillus antigen
每月（3-12 月） CMV 監測、IgG/IgA/IgM
每 3-6 個月 胸部 CT、HLA 抗體（DSA）追蹤
每次 Aspergillus antigen、Candida antigen、β-D-glucan

| Frequency | Items | |——|——| | Every 1-2 weeks (first 3 months) | CMV (C7-HRP), EBV-DNA, Aspergillus antigen | | Monthly (3-12 months) | CMV monitoring, IgG/IgA/IgM | | Every 3-6 months | Chest CT, HLA antibody (DSA) tracking | | Every visit | Aspergillus antigen, Candida antigen, beta-D-glucan |

D.9.3 D.9.3 protocol 氣管支鏡時程 / D.9.3 Protocol Bronchoscopy Schedule

時間點 內容
POD 7 第 1 次 protocol biopsy + BAL
POD 14 第 2 次 biopsy
1 個月 Surveillance biopsy
3 個月 Surveillance biopsy
6 個月 Surveillance biopsy
12 個月 Surveillance biopsy
⚠️ 之後 依臨床需求（FEV1 下降 > 10% 時需加做）

| Time Point | Content | |——–|——| | POD 7 | 1st protocol biopsy + BAL | | POD 14 | 2nd biopsy | | 1 month | Surveillance biopsy | | 3 months | Surveillance biopsy | | 6 months | Surveillance biopsy | | 12 months | Surveillance biopsy | | ⚠️ Thereafter | Per clinical need (add when FEV1 decline > 10%) |

每次 BAL 送檢： - 細菌培養（含 Aspergillus、Cryptococcus、Mucor、Nocardia） - 抗酸菌染色/培養（TB/NTM） - CMV PCR - 細胞學

Each BAL submission: - Bacterial culture (including Aspergillus, Cryptococcus, Mucor, Nocardia) - Acid-fast stain/culture (TB/NTM) - CMV PCR - Cytology

D.10 D.10 長期里程碑 / D.10 Long-Term Milestones

D.10.1 D.10.1 時間軸總覽 / D.10.1 Timeline Overview

時間點 里程碑事件
3 個月 Tac level 目標調降至 10-15 ng/mL
mPSL 減量目標：0.25 mg/kg/day
首次骨密度檢查（DEXA）[UTH-Manual-2022]
評估是否需 mTOR inhibitor
考慮疫苗（滅活疫苗）
6 個月 Tac level 目標調降至 8-12 ng/mL
mPSL 減量目標：0.15 mg/kg/day
首次年度實驗室全套
CMV 預防藥物評估（D+/R+ 或 D-/R+ 可考慮停藥）
抗黴菌藥物評估（可考慮停 ITCZ）
9 個月 mPSL 目標：0.08-0.1 mg/kg/day (5-6 mg)
12 個月 年度全面體檢
胸部 CT
完整肺功能
6MWT
HLA 抗體（DSA）
骨密度追蹤
血脂、血糖、HbA1c
癌症篩檢（皮膚科、子宮頸抹片等）
CMV/EBV 監測
每年（> 1 年後） 年度全套檢查（同上）
DEXA
疫苗評估更新
CLAD 篩檢（FEV1 趨勢分析）
PTLD 監測（EBV-DNA）
皮膚癌篩檢

| Time Point | Milestone Event | |——–|———–| | 3 months | Tac level target lowered to 10-15 ng/mL | | | mPSL taper target: 0.25 mg/kg/day | | | First bone density scan (DEXA) [UTH-Manual-2022] | | | Evaluate need for mTOR inhibitor | | | Consider vaccination (inactivated vaccines) | | 6 months | Tac level target lowered to 8-12 ng/mL | | | mPSL taper target: 0.15 mg/kg/day | | | First annual comprehensive laboratory panel | | | CMV prophylaxis evaluation (D+/R+ or D-/R+ may consider discontinuation) | | | Antifungal evaluation (may consider stopping ITCZ) | | 9 months | mPSL target: 0.08-0.1 mg/kg/day (5-6 mg) | | 12 months | Annual comprehensive examination | | | Chest CT, complete PFT, 6MWT | | | HLA antibody (DSA), bone density follow-up | | | Lipids, glucose, HbA1c | | | Cancer screening (dermatology, cervical smear, etc.) | | | CMV/EBV monitoring | | Annually (> 1 year) | Annual comprehensive workup (same as above) | | | DEXA, vaccine assessment update | | | CLAD screening (FEV1 trend analysis) | | | PTLD monitoring (EBV-DNA), skin cancer screening |

D.10.2 D.10.2 骨質疏鬆預防與治療 [UTH-Manual-2022] / D.10.2 Osteoporosis Prevention and Treatment [UTH-Manual-2022]

項目 內容
篩檢 YAM < 80% 或 T-score ≤ -2.5 SD 即需治療
一線治療 Alendronate 35 mg PO 每週一次
Vitamin D Eldecalcitol 0.75 μg/day 或 Alfacalcidol 1.0 μg/day
二線 Denosumab (Pralia) 60 mg SC 每 6 個月
追蹤 DEXA 每年；骨折風險評估

| Item | Content | |——|——| | Screening | Treat when YAM < 80% or T-score ≤ -2.5 SD | | First-line | Alendronate 35 mg PO weekly | | Vitamin D | Eldecalcitol 0.75 ug/day or Alfacalcidol 1.0 ug/day | | Second-line | Denosumab (Pralia) 60 mg SC every 6 months | | Follow-up | DEXA annually; fracture risk assessment |

D.10.3 D.10.3 代謝症候群管理 [UTH-Manual-2022] / D.10.3 Metabolic Syndrome Management [UTH-Manual-2022]

高血壓（目標 < 130/80 mmHg）： 1. ARB 為首選（Candesartan 4-8 mg、Telmisartan 20-40 mg） 2. CCB：避免 Diltiazem、Verapamil（↑CNI 濃度）；可用 Amlodipine（↑CNI 約 25%） 3. ⚠️ 禁用 Aliskiren（與 Cyclosporine 交互作用）

Hypertension (target < 130/80 mmHg): 1. ARB first-line (Candesartan 4-8 mg, Telmisartan 20-40 mg) 2. CCB: Avoid Diltiazem, Verapamil (increase CNI levels); may use Amlodipine (increases CNI ~25%) 3. ⚠️ Aliskiren contraindicated (interaction with Cyclosporine)

高血脂（目標 LDL < 120-140 mg/dL）： 1. Statin：選用 Pitavastatin 或 Rosuvastatin（低 CYP3A4 交互作用） 2. 避免 Atorvastatin、Simvastatin（高 CYP3A4 交互作用）

Hyperlipidemia (target LDL < 120-140 mg/dL): 1. Statin: Choose Pitavastatin or Rosuvastatin (low CYP3A4 interaction) 2. Avoid Atorvastatin, Simvastatin (high CYP3A4 interaction)

糖尿病（目標 HbA1c < 7.0%）： 1. 首選 DPP-4 inhibitor（Sitagliptin、Linagliptin — 不需腎劑量調整） 2. 避免 Metformin（移植後腎功能波動） 3. ⚠️ α-glucosidase inhibitor 與 MMF/AZA 有交互作用

Diabetes (target HbA1c < 7.0%): 1. First-line: DPP-4 inhibitor (Sitagliptin, Linagliptin — no renal dose adjustment needed) 2. Avoid Metformin (post-transplant renal function fluctuations) 3. ⚠️ Alpha-glucosidase inhibitors interact with MMF/AZA

D.10.4 D.10.4 CLAD 監測 [UTH-Manual-2022] / D.10.4 CLAD Monitoring [UTH-Manual-2022]

指標 警示值 處置
FEV1 下降 > 10% Possible CLAD 追蹤確認
FEV1 下降 > 20% 持續 3 週以上 Probable → Definite CLAD 氣管支鏡 + CT + HLA 抗體
TLC 下降 > 10% 疑 RAS 加做 CT 鑑別 BOS vs RAS

| Indicator | Alert Value | Action | |——|——–|——| | FEV1 decline > 10% | Possible CLAD | Follow-up confirmation | | FEV1 decline > 20% sustained > 3 weeks | Probable → Definite CLAD | Bronchoscopy + CT + HLA antibodies | | TLC decline > 10% | Suspect RAS | Add CT to differentiate BOS vs RAS |

CLAD 治療選項 [UTH-Manual-2022]： 1. Azithromycin 250 mg QOD 2. Montelukast 10 mg/day 3. Pulse steroid（mPSL 500 → 250 → 125 mg × 3 天） 4. Thymoglobulin 1.5 mg/kg（嚴重時）

CLAD Treatment Options [UTH-Manual-2022]: 1. Azithromycin 250 mg QOD 2. Montelukast 10 mg/day 3. Pulse steroid (mPSL 500 → 250 → 125 mg x 3 days) 4. Thymoglobulin 1.5 mg/kg (severe cases)

D.11 D.11 特殊族群注意事項 / D.11 Special Population Considerations

D.11.1 D.11.1 iPAH（特發性肺動脈高壓）患者 [UTH-Manual-2022] / D.11.1 iPAH (Idiopathic Pulmonary Arterial Hypertension) Patients [UTH-Manual-2022]

  • 術後 ECMO 維持 2-3 天，不急於脫離
  • PEEP 管理需更保守
  • 升壓藥優先序：Catecholamine → Milrinone → Prostacyclin (PGE1 0.01-0.02 μg/kg/min)
  • 可能需 OnO/Octanoate 1-2 μg/kg/min

- Post-op ECMO maintenance for 2-3 days, do not rush to wean - PEEP management requires more conservative approach - Vasopressor priority: Catecholamine → Milrinone → Prostacyclin (PGE1 0.01-0.02 ug/kg/min) - May require OnO/Octanoate 1-2 ug/kg/min

D.11.2 D.11.2 小兒患者 / D.11.2 Pediatric Patients

  • Size matching 標準：predicted VC 差異 ±12%（兒童專用公式）[UTH-Manual-2022]
  • Central ECMO cannulation 技術細節需調整（較小管徑）
  • 營養支持：考慮兒童專用配方
  • 心理支持：多職種團隊（兒童生活輔導員、心理師、社工）
  • 家屬住宿與照顧安排

- Size matching criteria: predicted VC difference ±12% (pediatric-specific formula) [UTH-Manual-2022] - Central ECMO cannulation technical details require adjustment (smaller caliber) - Nutritional support: Consider pediatric-specific formulas - Psychological support: Multidisciplinary team (child life specialist, psychologist, social worker) - Family accommodation and care arrangements

D.11.3 D.11.3 再移植患者 [UTH-Manual-2022] / D.11.3 Retransplantation Patients [UTH-Manual-2022]

  • 手術難度高（嚴重沾黏）
  • CLAD 為最常見適應症
  • 術後出血風險高
  • 免疫抑制可能需調整（已致敏化）

- Higher surgical difficulty (severe adhesions) - CLAD is the most common indication - Higher postoperative bleeding risk - Immunosuppression may require adjustment (already sensitized)

D.12 D.12 緊急情況時間表 / D.12 Emergency Situation Timeline

D.12.1 D.12.1 何時緊急就醫 / D.12.1 When to Seek Emergency Care

症狀 可能原因 建議
發燒 > 38°C 感染、排斥 立即就醫
SpO2 下降 > 3-5% baseline PGD、排斥、感染 立即就醫
FEV1 下降 > 10% 排斥、CLAD、感染 24 小時內就醫
呼吸困難急性加重 多種原因 立即就醫
咳血 吻合口問題、感染 立即就醫

| Symptom | Possible Cause | Recommendation | |——|———-|——| | Fever > 38 degrees C | Infection, rejection | Seek immediate care | | SpO2 decline > 3-5% from baseline | PGD, rejection, infection | Seek immediate care | | FEV1 decline > 10% | Rejection, CLAD, infection | Seek care within 24 hours | | Acute worsening dyspnea | Multiple causes | Seek immediate care | | Hemoptysis | Anastomotic problems, infection | Seek immediate care |

參考文獻 [UTH-Manual-2022] 東京大學醫學部附屬病院 呼吸器外科，肺移植手冊 2022 年版（繁體中文翻譯版 2024）。 📋 三總本院 protocol 待補充對照。

References [UTH-Manual-2022] University of Tokyo Hospital Department of Thoracic Surgery, Lung Transplant Handbook 2022 Edition (Traditional Chinese Translation 2024). 📋 TSGH institutional protocol to be supplemented for comparison.