Early Donor Management Increases the Retrieval Rate of Lungs for Transplantation
ABSTRACT Lung transplantation activity is frustrated by donor lung availability. We sought to examine the effect of active donor management and hormone administration on pulmonary function and yield in cadaveric heart-beating potential lung donors.
We studied 182 potential lung donors (arterial oxygen tension [PaO2]/fractional inspired oxygen [FIO2] ratio > or = 230). From this group, 60 patients (120 lungs) were allocated, within a randomized trial, to receive methylprednisolone (1 g), triiodothyronine (0.8 microg/kg bolus and 0.113 microg/kg/h infusion), both methylprednisolone and triiodothyronine, or placebo as soon as feasible after consent and initial assessment. Trial donors underwent protocol-guided optimization of ventilation and hemodynamics, lung water assessment, and bronchoscopy. Function was assessed by PaO2/FIO2 ratio, extravascular lung water index (EVLWI), and pulmonary vascular resistance (PVR). A nontrial group of 122 donors (244 lungs) received similar management without bronchoscopy, pulmonary artery flotation catheter monitoring, or lung water assessment.
Within the trial, management commenced within a median of 2 hours (interquartile range, 0.5 to 3.5 hours) of consent and continued for an average of 6.9 +/- 1.2 hours. The PaO2/FIO2 ratio deteriorated (p = 0.028) from 397 +/- 78 (95% CL, 376 to 417) to 359 +/- 126 (95% CL, 328 to 390) and EVLWI from 9.7 +/- 4.5 mL/kg (95% CL, 8.6 to 10.9 mL/kg) to 10.8 +/- 5.2 mL/kg (95% CL, 9.4 to 12.2 mL/kg; p = 0.009). PVR remained unchanged (p = 0.28). At end management, 48 of 120 trial lungs (40%) were transplanted versus 66 of 244 nontrial lungs (27%; p = 0.016). Neither methylprednisolone and triiodothyronine nor T3 increased lung yield or affected PaO2/FIO2 or EVLWI; however, methylprednisolone attenuated the increase in EVLWI (p = 0.009).
Early active management of lung donors increases yield. Steroid administration reduces progressive lung water accumulation.
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ABSTRACT: The concept of brain death developed with the advent of mechanical ventilation, and guidelines for determining brain death have been refined over time. Organ donation after brain death is a common source of transplant organs in Western countries. Early identification and notification of organ procurement organizations are essential. Management of potential organ donors must take into consideration specific pathophysiologic changes for medical optimization. Future aims in intensive and neurocritical care medicine must include reducing practice variability in the operational guidelines for brain death determination, as well as improving communication with families about the process of determining brain death.Critical Care Clinics 10/2014; 30(4):813–831. DOI:10.1016/j.ccc.2014.06.010 · 2.50 Impact Factor
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ABSTRACT: Background The purpose of this study was to assess treatment patterns and examine organ utilization in the setting of single lung transplantation (SLT). Methods The United Network for Organ Sharing database was queried for all SLTs performed from 1987-2011. Trends in utilization of the second donor lung were assessed, both from recipient and donor perspectives. Donors were stratified into two groups: those donating both lungs and those donating only one. Independent predictors of utilizing only one donor lung were identified using multivariable logistic regression. Results 10,361 SLTs were identified, originating from 7,232 unique donors. Of these donors, only 3,129 (43.3%) had both lungs utilized, resulting in over 200 second donor lungs going unused annually since 2005, with no significant increase in utilization over time (p=.95). Following adjustment, donor characteristics predicting the second donor lung going unused included B/AB blood groups (adjusted odds ratio [AOR]: 1.69 and 2.62, respectively, p<.001), lower body surface area (AOR 1.30, p=.02), lower donor pO2 (AOR 0.90 per 50 mmHg increase, p<.001), pulmonary infection (AOR 1.15, p=.04), extended criteria donor status (AOR 1.66, p<.001), and head trauma or anoxia cause of death (AOR 1.57 and 1.53, p<.001 and p=.001, respectively). Conclusions Among donors for SLT, less than half of all cases led to use of the second donor lung. While anatomic, infectious, or other pathophysiologic issues prohibit 100% utilization, more aggressive donor matching efforts may be a simple method of increasing the utilization of this scarce resource, particularly for less common blood types.The Journal of Heart and Lung Transplantation 08/2014; DOI:10.1016/j.healun.2014.08.018 · 5.61 Impact Factor
The Journal of Heart and Lung Transplantation 10/2014; 33(10). DOI:10.1016/j.healun.2014.08.001 · 5.61 Impact Factor