View
460
Download
3
Category
Preview:
Citation preview
The Alfred Intensive Care Unit, Melbourne, Australia
General & post-operative managementfor the general Intensivist
Lung Transplantation
David PilcherIntensive Care Specialist, The Alfred
The Alfred Intensive Care Unit, Melbourne, Australia
Summary
Background – donors & recipients
Post-operative management
Complications:
Primary Graft Failure
Dynamic Hyper-inflation
Outcomes
The Future
The Alfred Intensive Care Unit, Melbourne, Australia
116
14 149
27
11
11
22
10
9
7
9
9
5
8
2
0
2
1
0
10
20
30
40
50
60
1-4 5-9 10-19 20-29 30-39 40-49 50+
Nu
mb
er
of
Ce
nte
rs
Average number of lung transplants per year
Other
North America
Europe
Adult and Pediatric Lung TransplantsAverage Center Volume by Location
(January 2009 – June 2015)
The Alfred Intensive Care Unit, Melbourne, Australia
Adult Lung Transplants - major Indications
0
500
1,000
1,500
2,000
2,500
3,000
3,500
Nu
mb
er
of
Tra
ns
pla
nts
Year
COPD A1ATD CF IIP ILD-not IIP Retransplant
The Alfred Intensive Care Unit, Melbourne, Australia
0
12
24
36
48
60
72
0%
20%
40%
60%
80%
100%
Me
dia
n r
ecip
ien
t a
ge
(ye
ars
) (b
lue
lin
e)
% o
f T
ran
sp
lan
ts
Year
0-10 11-17 18-34 35-49 50-59 60-65 66+ Median age
Adult and Pediatric Lung Transplants Recipient Age by Year (Transplants: 1987 – 2015)
The Alfred Intensive Care Unit, Melbourne, Australia
DONOR SELECTION
The Alfred Intensive Care Unit, Melbourne, Australia
Call
The Alfred Intensive Care Unit, Melbourne, Australia
RECIPIENT SELECTION
The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung diseaseEmphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung diseaseEmphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
SINGLE LUNG?
The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung diseaseEmphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
DOUBLE LUNG
The Alfred Intensive Care Unit, Melbourne, Australia
SURGERY &
POST-OPERATIVE CARE
The Alfred Intensive Care Unit, Melbourne, Australia
The Alfred Intensive Care Unit, Melbourne, Australia
Thoracotomy Clamshell
Bronchial anastomosis
Bypass only rarely (Pulm hypertension)
The Alfred Intensive Care Unit, Melbourne, Australia
Bilateral Sequential Lung Transplant
The Alfred Intensive Care Unit, Melbourne, Australia
Transplant - physiology
Infection
Denervation
No bronchial blood supply
No lymphatics
“Leaky” lungs
Lungs
The Alfred Intensive Care Unit, Melbourne, Australia
RespiratoryICC drainage
Chest X-ray
Bronchoscopy(when practical)
Poor gas exchange
Primary Graft Dysfunction – “leaky” lungs
ABG at 6 – 12 hours predicts outcome
Post-op management
The Alfred Intensive Care Unit, Melbourne, Australia
Cardiovascular
Hypotension - epidural
ECG changes
Low filling pressures
CVP less than 7 mmHg = better outcomes
Manage by CVS-Resp guideline
Post-op management
The Alfred Intensive Care Unit, Melbourne, Australia
Neurological
Pain
Anxiety
Psychosis & confusion
Management
Paracetamol
Epidural
No NSAIDS or Tramadol
Post-op management
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Haemodynamic Guideline
Target blood pressure
Target cardiac index
Vasoconstrictor
CVP 7 mmHg
iv fluids / diuretics
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Respiratory Guideline
Manage as per PaO2/FiO2 ratio
Wean mechanical ventilation
Check list
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Analgesia &
ImmunosuppressionEpidural & pain team
Immunosuppression “sticker”
The Alfred Intensive Care Unit, Melbourne, Australia
Post-operative Complications
S**t happens
The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft FailureDynamic HyperinflationRejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs
The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft FailureDynamic HyperinflationRejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs
The Alfred Intensive Care Unit, Melbourne, Australia
Primary Graft Dysfunction
Risk Factors:
Poor gas exchange in donor
Pulmonary thrombo-embolism
Intra-operative colloid
Very long ischaemic time
Causes:
Lymphatics disruption
Inadequate preservation
Surgical trauma
Inflammatory mediators
TreatmentSupportiveDiureticAvoid excess iv fluidPulmonary vasodilator
Consider alternative diagnosis
Pulmonary Venous AnastomosisRejection
The Alfred Intensive Care Unit, Melbourne, Australia
Dynamic Hyperinflation
Causes:
Hyperinflated Native Lung
Transplant Graft Dysfunction
Proportion needing ILV
TLC % Predicted < 150% 7%
TLC % Predicted > 150% 26%
TLC % Predicted > 175% 44%
TreatmentIndependent lung ventilation
Native LungLow RRNormal tidal volume No PEEP
Transplanted lungHigh RRSmall tidal volumeHigh PEEP
The Alfred Intensive Care Unit, Melbourne, Australia
Other Post-op Management
ImmunosuppressionSteroids
Mycophenolate
Tacrolimus or Cyclosporin
(Basiliximab – IL2R antagonist)
Infection ProphylaxisCMV prophylaxis (for all except Neg. donor /Neg. recipient)
PCP prophylaxis (starts at 3 weeks post op)
The Alfred Intensive Care Unit, Melbourne, Australia
Are things getting better?
New organ preservation techniquesPerfadex
New surgical techniquesRetrograde flush
Bilateral thoracotomy
No more aprotonin
New anaesthetic techniquesCrystalloids & epidurals
New ICU managementProtocolised care
Recognition of potential complications
The Alfred Intensive Care Unit, Melbourne, Australia
OUTCOMES
The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality
ICU length of stay
Duration of ventilation
Hospital length of stay
The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality 4%
ICU length of stay
Duration of ventilation
Hospital length of stay
The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality 4%
ICU length of stay 4.1 days (3.3 – 7.6)
Duration of ventilation 24 hours (13 – 73)
Hospital length of stay 23 days (17 – 35)
The Alfred Intensive Care Unit, Melbourne, Australia
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Su
rviv
al
(%)
Years
1990-1998 (N=9,794) 1999-2008 (N=21,666) 2009-6/2014 (N=20,067)
Adult Lung TransplantsSurvival by Era
(1990 – 2014)
The Alfred
The Alfred Intensive Care Unit, Melbourne, Australia
THE FUTURE
The Alfred Intensive Care Unit, Melbourne, Australia
The Future
DCD lungs
Elderly donors
Ex-vivo perfusion/preservation
ECMO - bridge to transplant
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
Australian DCD vs BD v the World0
25
50
75
100
0 1 2 3 4
Su
rviv
al
(%)
Years
Aus DCD
Aus Brain
Dead Donors
World
The Future……….is now
The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….will always be the future
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
Thank you
Any more questions?
Recommended