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Dhar R, Braun P, Kumar A, Patel J, Lee FL, Arshi B. A Recruitment Maneuver After Apnea Testing Improves Oxygenation and Reduces Atelectasis in Organ Donors After Brain Death. Neurocrit Care 2024; 41:576-582. [PMID: 38580801 DOI: 10.1007/s12028-024-01975-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/07/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Hypoxemia is the main modifiable factor preventing lungs from being transplanted from organ donors after brain death. One major contributor to impaired oxygenation in patients with brain injury is atelectasis. Apnea testing, an integral component of brain death declaration, promotes atelectasis and can worsen hypoxemia. In this study, we tested whether performing a recruitment maneuver (RM) after apnea testing could mitigate hypoxemia and atelectasis. METHODS During the study period, an RM (positive end-expiratory pressure of 15 cm H2O for 15 s then 30 cm H2O for 30 s) was performed immediately after apnea testing. We measured partial pressure of oxygen, arterial (PaO2) before and after RM. The primary outcomes were oxygenation (PaO2 to fraction of inspired oxygen [FiO2] ratio) and the severity of radiographic atelectasis (proportion of lung without aeration on computed tomography scans after brain death, quantified using an image analysis algorithm) in those who became organ donors. Outcomes in RM patients were compared with control patients undergoing apnea testing without RM in the previous 2 years. RESULTS Recruitment maneuver was performed in 54 patients after apnea testing, with a median immediate increase in PaO2 of 63 mm Hg (interquartile range 0-109, p = 0.07). Eighteen RM cases resulted in hypotension, but none were life-threatening. Of this cohort, 37 patients became organ donors, compared with 37 donors who had apnea testing without RM. The PaO2:FiO2 ratio was higher in the RM group (355 ± 129 vs. 288 ± 127, p = 0.03), and fewer had hypoxemia (PaO2:FiO2 ratio < 300 mm Hg, 22% vs. 57%; p = 0.04) at the start of donor management. The RM group showed less radiographic atelectasis (median 6% vs. 13%, p = 0.045). Although there was no difference in lungs transplanted (35% vs. 24%, p = 0.44), both better oxygenation and less atelectasis were associated with a higher likelihood of lungs being transplanted. CONCLUSIONS Recruitment maneuver after apnea testing reduces hypoxemia and atelectasis in organ donors after brain death. This effect may translate into more lungs being transplanted.
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Affiliation(s)
- Rajat Dhar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, 63110, USA.
| | - Porche Braun
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, 63110, USA
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, 63110, USA
| | - Jayesh Patel
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, 63110, USA
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Flavia L Lee
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, 63110, USA
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Baback Arshi
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, 63110, USA
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Bai YZ, Yan Y, Chang SH, Yang Z, Delhi A, Farahnak K, Joseph K, Hamilton C, Baumann Walker AA, Hachem RR, Witt CA, Guillamet RV, Byers DE, Marklin GF, Hartwig MG, Brandt WS, Kreisel D, Nava RG, Patterson GA, Kozower BD, Meyers BF, Heiden BT, Puri V. Use of a novel donor lung scoring system as a tool for increasing lung recovery for transplantation. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00781-5. [PMID: 39226995 DOI: 10.1016/j.jtcvs.2024.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 08/10/2024] [Accepted: 08/27/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND There is a critical shortage of donor lungs for transplantation. We previously developed a parsimonious, highly discriminatory 9-variable Lung Donor (LUNDON) acceptability score. Here we assessed the utility of this score as a tool for improving lung recovery rates for transplantation. METHODS We examined all brain-dead donors between 2014 and 2020 from 3 US organ procurement organizations and validated the score's predictive performance. We examined the trajectory of donors with low (<40) and high (>60) initial LUNDON scores, their corresponding lung recovery rates, factors contributing to score improvement using multivariable regression models, and 1-year post-transplant recipient survival. RESULTS Overall lung recovery was 32.4% (1410 of 4351). Validation of the LUNDON score in our cohort revealed a C statistic of 0.904 and required intercept calibration. Low initial LUNDON donors that improved to a high final score had an increase in lung recovery rate from 29.3% (1100 of 3765) to 86.8% (441 of 508), associated with lower body mass index, management in a specialized donor care facility (SDCF), and more bronchoscopies. Donors with high initial and final LUNDON scores had a lung recovery rate of 85.2% (98 of 115), associated with shorter length of hospital stay. One-year survival was similar in recipients of low-to-high versus high-to-high LUNDON score donors (0.89 vs 0.84; P = .2). CONCLUSIONS The LUNDON score performs well as a predictor of lung recovery in a contemporary cohort but may require organ procurement organization-specific calibration. SDCF care, increasing use of bronchoscopy, and decreasing the time from brain death to organ procurement may improve lung utilization. The LUNDON score can be used to guide donor management to expand the donor pool.
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Affiliation(s)
- Yun Zhu Bai
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo.
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anjana Delhi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Khashayar Farahnak
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Karan Joseph
- Washington University School of Medicine, St. Louis, Mo
| | - Christy Hamilton
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Ana Amelia Baumann Walker
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| | | | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Whitney S Brandt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
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3
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Vail EA, Wang X, Schaubel DE, Reese PP, Cantu E, Martin ND, Abt PL, Olthoff KM, Kerlin MP, Christie JD, Neuman MD. Lung Donation and Transplant Recipient Outcomes at Independent vs Hospital-Based Donor Care Units. JAMA Netw Open 2024; 7:e2417107. [PMID: 38916893 PMCID: PMC11200140 DOI: 10.1001/jamanetworkopen.2024.17107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/26/2024] [Indexed: 06/26/2024] Open
Abstract
Importance Centralizing deceased organ donor management and organ recovery into donor care units (DCUs) may mitigate the critical organ shortage by positively impacting donation and recipient outcomes. Objective To compare donation and lung transplant outcomes between 2 common DCU models: independent (outside of acute-care hospitals) and hospital-based. Design, Setting, and Participants This is a retrospective cohort study of Organ Procurement and Transplantation Network deceased donor registry and lung transplant recipient files from 21 US donor service areas with an operating DCU. Characteristics and lung donation rates among deceased donors cared for in independent vs hospital-based DCUs were compared. Eligible participants included deceased organ donors (aged 16 years and older) after brain death, who underwent organ recovery procedures between April 26, 2017, and June 30, 2022, and patients who received lung transplants from those donors. Data analysis was conducted from May 2023 to March 2024. Exposure Organ recovery in an independent DCU (vs hospital-based DCU). Main Outcome and Measures The primary outcome was duration of transplanted lung survival (through December 31, 2023) among recipients of lung(s) transplanted from cohort donors. A Cox proportional hazards model stratified by transplant year and program, adjusting for donor and recipient characteristics was used to compare graft survival. Results Of 10 856 donors in the starting sample (mean [SD] age, 42.8 [15.2] years; 6625 male [61.0%] and 4231 female [39.0%]), 5149 (primary comparison group) underwent recovery procedures in DCUs including 1466 (28.4%) in 11 hospital-based DCUs and 3683 (71.5%) in 10 independent DCUs. Unadjusted lung donation rates were higher in DCUs than local hospitals, but lower in hospital-based vs independent DCUs (418 donors [28.5%] vs 1233 donors [33.5%]; P < .001). Among 1657 transplant recipients, 1250 (74.5%) received lung(s) from independent DCUs. Median (range) duration of follow-up after transplant was 734 (0-2292) days. Grafts recovered from independent DCUs had shorter restricted mean (SE) survival times than grafts from hospital-based DCUs (1548 [27] days vs 1665 [50] days; P = .04). After adjustment, graft failure remained higher among lungs recovered from independent DCUs than hospital-based DCUs (hazard ratio, 1.85; 95% CI, 1.28-2.65). Conclusions and Relevance In this retrospective analysis of national donor and transplant recipient data, although lung donation rates were higher from deceased organ donors after brain death cared for in independent DCUs, lungs recovered from donors in hospital-based DCUs survived longer. These findings suggest that further work is necessary to understand which factors (eg, donor transfer, management, or lung evaluation and acceptance practices) differ between DCU models and may contribute to these differences.
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Affiliation(s)
- Emily A. Vail
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Transplant Institute, Philadelphia, Pennsylvania
| | - Edward Cantu
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Niels D. Martin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Peter L. Abt
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Kim M. Olthoff
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Meeta P. Kerlin
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Jason D. Christie
- Penn Transplant Institute, Philadelphia, Pennsylvania
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Mark D. Neuman
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
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4
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Gunst J, Souter MJ. Management of the brain-dead donor in the intensive care unit. Intensive Care Med 2024; 50:964-967. [PMID: 38598128 DOI: 10.1007/s00134-024-07409-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/23/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Michael J Souter
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
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5
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Frick AE, Schiefer J, Maleczek M, Schwarz S, Benazzo A, Rath A, Kulu A, Hritcu R, Faybik P, Schaden E, Jaksch P, Tschernko E, Frommlet F, Markstaller K, Hoetzenecker K. The Effect of Prone Positioning After Lung Transplantation. Ann Thorac Surg 2024; 117:1045-1051. [PMID: 37150273 PMCID: PMC10162468 DOI: 10.1016/j.athoracsur.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 03/19/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Prone positioning has become a standard therapy in acute respiratory distress syndrome to improve oxygenation and decrease mortality. However, little is known about prone positioning in lung transplant recipients. This large, singe-center analysis investigated whether prone positioning improves gas exchange after lung transplantation. METHODS Clinical data of 583 patients were analyzed. Prone position was considered in case of impaired gas exchange Pao2/fraction of oxygen in inhaled air (<250), signs of edema after lung transplantation, and/or evidence of reperfusion injury. Patients with hemodynamic instability or active bleeding were not proned. Impact of prone positioning (n = 165) on gas exchange, early outcome and survival were determined and compared with patients in supine positioning (n = 418). RESULTS Patients in prone position were younger, more likely to have interstitial lung disease, and had a higher lung allocation score. Patients were proned for a median of 19 hours (interquartile range,15-26) hours). They had significantly lower Pao2/fraction of oxygen in inhaled air (227 ± 96 vs 303 ± 127 mm Hg, P = .004), and lower lung compliance (24.8 ± 9.1 mL/mbar vs 29.8 ± 9.7 mL/mbar, P < .001) immediately after lung transplantation. Both values significantly improved after prone positioning for 24 hours (Pao2/fraction of oxygen ratio: 331 ± 91 mm Hg; lung compliance: 31.7 ± 20.2 mL/mbar). Survival at 90 days was similar between the 2 groups (93% vs 96%, P = .105). CONCLUSIONS Prone positioning led to a significant improvement in lung compliance and oxygenation after lung transplantation. Prospective studies are needed to confirm the benefit of prone positioning in lung transplantation.
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Affiliation(s)
| | - Judith Schiefer
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Mathias Maleczek
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alberto Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Rath
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Askin Kulu
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Richard Hritcu
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Faybik
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Edda Tschernko
- Division of Cardiothoracic and Vascular Anesthesia, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Klaus Markstaller
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
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6
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Terada Y, Takahashi T, Hachem RR, Liu J, Witt CA, Byers DE, Guillamet RV, Kulkarni HS, Nava RG, Kozower BD, Meyers BF, Pasque MK, Patterson GA, Marklin GF, Eghtesady P, Kreisel D, Puri V. Characteristics of donor lungs declined on site and impact of lung allocation policy change. J Thorac Cardiovasc Surg 2023; 166:1347-1358.e11. [PMID: 36990425 PMCID: PMC10533747 DOI: 10.1016/j.jtcvs.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 02/25/2023] [Accepted: 03/08/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE National and institutional data suggest an increase in organ discard rate (donor lungs procured but not implanted) after a new lung allocation policy was introduced in 2017. However, this measure does not include on-site decline rate (donor lungs declined intraoperatively). The objective of this study is to examine the impact of the allocation policy change on on-site decline. METHODS We used a Washington University (WU) and our local organ procurement organization (Mid-America Transplant [MTS]) database to abstract data on all accepted lung offers from 2014 to 2021. An on-site decline was defined as an event in which the procuring team declined the organs intraoperatively, and the lungs were not procured. Logistic regression models were used to investigate potentially modifiable reasons for decline. RESULTS The overall study cohort comprised 876 accepted lung offers, of which 471 donors were at MTS with WU or others as the accepting center and 405 at other organ procurement organizations with WU as the accepting center. At MTS, the on-site decline rate increased from 4.6% to 10.8% (P = .01) after the policy change. Given the greater likelihood of non-local organ placement and longer travel distance after policy change, the estimated cost of each on-site decline increased from $5727 to $9700. In the overall group, latest partial pressure of oxygen (odds ratio [OR], 0.993; 95% confidence interval [CI], 0.989-0.997), chest trauma (OR, 2.474; CI, 1.018-6.010), chest radiograph abnormality (OR, 2.902; CI, 1.289-6.532), and bronchoscopy abnormality (OR, 3.654; CI, 1.813-7.365) were associated with on-site decline, although lung allocation policy era was unassociated (P = .22). CONCLUSIONS We found that nearly 8% of accepted lungs are declined on site. Several donor factors were associated with on-site decline, although lung allocation policy change did not have a consistent impact on on-site decline.
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Affiliation(s)
- Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University, Saint Louis, Mo
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Mo
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Gary F Marklin
- Mid-America Transplant, Washington University, Saint Louis, Mo
| | - Pirooz Eghtesady
- Department of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo; Department of Pathology & Immunology, Washington University, Saint Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, Saint Louis, Mo.
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7
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Tommasino N, Koolhaas A, Mizraji R, Zamit O, Lacuesta G. Ultrasound Scanning in Lung Procurement. Protocol for Decision-Making With the Purpose of Increasing Transplant Eligible Lungs. Transplant Proc 2023; 55:1463-1465. [PMID: 36973147 DOI: 10.1016/j.transproceed.2023.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/08/2023] [Accepted: 02/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The main obstacle to obtaining lungs for transplantation is the shortage of donors. Once potential donors have been offered to transplant programs, the acceptance rate is highly variable, ranging from 5% to 20%. Minimizing donor leakage by converting potential lung donors into real donors is one of the key elements to improve results, and it is essential to have tools that facilitate decision-making in this scenario. The selection and rejection of transplantation-eligible lungs are usually made with chest x-rays; however, lung ultrasound scanning has shown better sensitivity and specificity for diagnosing pulmonary pathologies. Lung ultrasound scanning allows us to identify the reversible causes of low PaO2/fraction of inspired oxygen (FIO2) ratio, thus enabling the establishment of specific interventions, which, if proved successful, could turn lungs into transplant-eligible lungs. The available literature on its use in managing brain death donors and lung procurement is extremely scarce. METHODS A simple protocol aimed at identifying and treating the main reversible causes of low PaO2/FIO2 ratio to aid in decision-making is presented in this paper. CONCLUSION Lung ultrasound is a powerful, useful, and cheap technique available at the donor's bedside. It is conspicuously underused, despite being potentially helpful in decision-making by minimizing the discarding of donors, thus probably increasing the number of lungs sui for transplantation.
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Affiliation(s)
- Nicolas Tommasino
- National Lung Transplant Program, National Resources Fund, Montevideo, Uruguay; Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay.
| | - Andrea Koolhaas
- Critical Care Department, Evangelic Hospital, Montevideo, Uruguay
| | - Raul Mizraji
- Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay
| | - Olga Zamit
- Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay
| | - Gonzalo Lacuesta
- Procurement Department, National Institute for Donation and Transplantation, Montevideo, Uruguay
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8
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Heiden BT, Yang Z, Bai YZ, Yan Y, Chang SH, Park Y, Colditz GA, Dart H, Hachem RR, Witt CA, Vazquez Guillamet R, Byers DE, Marklin GF, Pasque MK, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Development and validation of the lung donor (LUNDON) acceptability score for pulmonary transplantation. Am J Transplant 2023; 23:540-548. [PMID: 36764887 PMCID: PMC10234600 DOI: 10.1016/j.ajt.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
There is a chronic shortage of donor lungs for pulmonary transplantation due, in part, to low lung utilization rates in the United States. We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients database (2006-2019) and developed the lung donor (LUNDON) acceptability score. A total of 83 219 brain-dead donors were included and were randomly divided into derivation (n = 58 314, 70%) and validation (n = 24 905, 30%) cohorts. The overall lung acceptance was 27.3% (n = 22 767). Donor factors associated with the lung acceptance were age, maximum creatinine, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, mechanism of death by asphyxiation or drowning, history of cigarette use (≥20 pack-years), history of myocardial infarction, chest x-ray appearance, bloodstream infection, and the occurrence of cardiac arrest after brain death. The prediction model had high discriminatory power (C statistic, 0.891; 95% confidence interval, 0.886-0.895) in the validation cohort. We developed a web-based, user-friendly tool (available at https://sites.wustl.edu/lundon) that provides the predicted probability of donor lung acceptance. LUNDON score was also associated with recipient survival in patients with high lung allocation scores. In conclusion, the multivariable LUNDON score uses readily available donor characteristics to reliably predict lung acceptability. Widespread adoption of this model may standardize lung donor evaluation and improve lung utilization rates.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yun Zhu Bai
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hank Dart
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | | | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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9
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Marklin GF, Brockmeier D, Spector K. The 20-year paradigm shift toward organ recovery centers: 2500 donors at Mid-America Transplant and broader adoption across the United States. Am J Transplant 2023:S1600-6135(23)00232-0. [PMID: 36720312 DOI: 10.1016/j.ajt.2023.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/24/2023] [Indexed: 01/30/2023]
Abstract
On March 1, 2001, Mid-America Transplant, the organ procurement organization (OPO) located in St Louis, Missouri, performed the first organ recovery of a brain-dead donor in a hospital-independent, free-standing, organ recovery center (ORC), with successful transplantation of a liver. This was the inception of a paradigm shift in donor management and organ procurement, moving away from the traditional method of using the donor hospital. In the last 20 years, many advances have occurred in the ORC. Brain-dead donors are moved within hours of authorization to fully equipped intensive care units. Some ORCs are equipped with computed tomography scanners, portable radiography, laboratory facilities, bronchoscopy, and a cardiac catheterization laboratory. ORCs have dedicated surgical suites, and operating time is frequently during the day and is rarely delayed. Donor management in an ORC is more consistent, efficient, and effective than that in a donor hospital, and studies have demonstrated increased organ yield. Multiple studies have demonstrated a cost benefit of an ORC as well as providing an ideal environment for donor research studies. Currently, there are 24 of 57 OPOs that are using an independent or hospital-based ORC to manage their donors. We review the history and describe the current state of ORCs.
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10
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Jiang H, Han Y, Zheng X, Fang Q. Roles of electrical impedance tomography in lung transplantation. Front Physiol 2022; 13:986422. [PMID: 36407002 PMCID: PMC9669435 DOI: 10.3389/fphys.2022.986422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
Lung transplantation is the preferred treatment method for patients with end-stage pulmonary disease. However, several factors hinder the progress of lung transplantation, including donor shortages, candidate selection, and various postoperative complications. Electrical impedance tomography (EIT) is a functional imaging tool that can be used to evaluate pulmonary ventilation and perfusion at the bedside. Among patients after lung transplantation, monitoring the graft’s pulmonary function is one of the most concerning issues. The feasible application of EIT in lung transplantation has been reported over the past few years, and this technique has gained increasing interest from multidisciplinary researchers. Nevertheless, physicians still lack knowledge concerning the potential applications of EIT in lung transplantation. We present an updated review of EIT in lung transplantation donors and recipients over the past few years, and discuss the potential use of ventilation- and perfusion-monitoring-based EIT in lung transplantation.
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Affiliation(s)
| | | | - Xia Zheng
- *Correspondence: Xia Zheng, ; Qiang Fang,
| | - Qiang Fang
- *Correspondence: Xia Zheng, ; Qiang Fang,
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11
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Yeo HJ. Allocation of Donor Lungs in Korea. J Chest Surg 2022; 55:274-276. [PMID: 35924532 PMCID: PMC9358154 DOI: 10.5090/jcs.22.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022] Open
Abstract
The expansion of indications for lung transplantation, the growth of the waiting list, and donor shortages are increasing the waiting list mortality rate in Korea. The current lung allocation system in Korea is based mainly on urgency, but outcomes should also be considered to avoid futile transplantation. This review describes the current status of, and issues with, the lung allocation system in Korea including donors, the waiting list, and transplant outcomes in the context of an aging society, in which the frequency of end-stage pulmonary disease is increasing.
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Affiliation(s)
- Hye Ju Yeo
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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12
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Bery A, Ali A, Cypel M, Kreisel D. Centralized Organ Recovery and Reconditioning Centers. Thorac Surg Clin 2022; 32:167-174. [PMID: 35512935 DOI: 10.1016/j.thorsurg.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An increased focus on improving efficiency and decreasing costs has resulted in alternative models of donor management and organ recovery. The specialized donor care facility model provides highly efficient and cost-effective donor care at a free-standing facility, resulting in improved organ yield, shorter ischemic times, decreased travel, and fewer nighttime operations. Ex vivo lung perfusion (EVLP) improves utilization of extended criteria donor lungs, and centralized EVLP facilities have the potential to increase transplant volumes for smaller transplant programs in specified geographic regions. These alternative models are increasingly being used in the United States to improve waitlist mortality and combat the ongoing donor organ shortage.
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Affiliation(s)
- Amit Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, St Louis, MO 63110, USA.
| | - Aadil Ali
- Toronto Lung Transplant Program, Division of Thoracic Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 9N969, Toronto, Ontario M5G 2C4, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Division of Thoracic Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 9N969, Toronto, Ontario M5G 2C4, Canada
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Campus Box 8234, 660 South Euclid Avenue, St Louis, MO 63110, USA; Department of Pathology & Immunology, Washington University School of Medicine, Campus Box 8234, 660 South Euclid Avenue, St Louis, MO 63110, USA
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13
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Heiden BT, Tetteh E, Robbins KJ, Tabak RG, Nava RG, Marklin GF, Kreisel D, Meyers BF, Kozower BD, McKay VR, Puri V. Dissemination and Implementation Science in Cardiothoracic Surgery: A Review and Case Study. Ann Thorac Surg 2021; 114:373-382. [PMID: 34499861 PMCID: PMC9112075 DOI: 10.1016/j.athoracsur.2021.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/06/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
Dissemination and implementation (D&I) science is the practice of taking evidence-based interventions (EBI) and sustainably incorporating them in routine clinical practice. As a relatively young field, D&I techniques are underutilized in cardiothoracic surgery. This review offers an overview of D&I science from the context of the cardiothoracic surgeon. First, we provide a general introduction to D&I science and basic terminology that is used in the field. Second, to illustrate D&I techniques in a real-world example, we discuss a case study for implementing lung protective management (LPM) strategies for lung donor optimization nationally. Finally, we discuss challenges to successful implementation that are unique to cardiothoracic surgery and give several examples of EBIs that have been poorly implemented into surgical practice. We also provide examples of successful D&I interventions - including de-implementation strategies - from other surgical subspecialties. We hope that this review offers additional tools for cardiothoracic surgeons to explore when introducing EBIs into routine practice.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Emmanuel Tetteh
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO
| | - Keenan J Robbins
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rachel G Tabak
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO; Institute for Implementation Science, Washington University in St. Louis, St. Louis, MO
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Gary F Marklin
- Institute for Implementation Science, Washington University in St. Louis, St. Louis, MO
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Virginia R McKay
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
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14
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Son E, Jang J, Cho WH, Kim D, Yeo HJ. Successful lung transplantation after prone positioning in an ineligible donor: a case report. Gen Thorac Cardiovasc Surg 2021; 69:1352-1355. [PMID: 34159516 PMCID: PMC8218964 DOI: 10.1007/s11748-021-01676-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/18/2021] [Indexed: 11/25/2022]
Abstract
Atelectasis is a reversible factor in hypoxemia among brain-dead donors. In ineligible donors, prone positioning reverses atelectasis and improves oxygenation. We present a successful lung transplantation after salvaging a previously unviable lung. A 37-year-old woman presented with acute pontine hemorrhage that progressed to brain death. The initial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio of the donor’s lung was 342 mmHg. The PaO2/FiO2 ratio dropped to 49 mmHg due to atelectasis. There was no improvement despite recruitment maneuvers, bronchoscopy, and chest percussion. After placing the donor in the prone position for four hours, electrical impedance tomography showed improved atelectasis. The donor did not experience hemodynamic instability. The lung was transplanted into a patient with Kartagener’s syndrome with situs inversus. The surgical procedure was uneventful. He was successfully weaned from the mechanical ventilator on the second-day post-transplantation and was discharged from the hospital after 4 weeks.
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Affiliation(s)
- Eunjeong Son
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jinook Jang
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Woo Hyun Cho
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Dohyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hye Ju Yeo
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea. .,Department of Pulmonology and Critical Care Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan, Gyeongsangnam, 626-770, Republic of Korea.
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