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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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Ventilation in the prone position improves oxygenation and results in more lungs being transplanted from organ donors with hypoxemia and atelectasis. J Heart Lung Transplant 2020; 40:120-127. [PMID: 33339675 DOI: 10.1016/j.healun.2020.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/05/2020] [Accepted: 11/30/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hypoxemia is the most common barrier to lungs being transplanted from eligible organ donors who are brain dead (BD). Atelectasis is the principal reversible contributing factor to hypoxemia after brain death. We evaluated prospectively whether ventilation in the prone position in donors who are BD would reverse atelectasis, improve oxygenation, and result in more lungs being transplanted. METHODS Organ donors managed at the recovery center of 1 organ procurement organization over a 2-year period who exhibited hypoxemia (partial pressure of arterial oxygen [PaO2]/fraction of inspired oxygen of <300 mm Hg) and had evidence of atelectasis were ventilated in the prone position for 12 hours or longer during donor management. A subset underwent computed tomography (CT) imaging to quantify the degree of atelectasis before and after prone positioning. Outcomes were compared with those of a control group with hypoxemia and atelectasis managed similarly but in the supine position in the previous 2 years. RESULTS A total of 40 lung-eligible donors who were BD with hypoxemia and atelectasis were managed in a prone position and compared with 79 donors in supine position. Baseline PaO2 was similar between the prone and the supine groups (194 ± 78 vs 177 ± 77 mm Hg, p = 0.26) but increased more in the prone group at 4 hours (by 113 vs 54 mm Hg, p = 0.001) and remained 74-mm Hg higher at 12 hours (340 vs 266 mm Hg, p = 0.0006). CT-graded atelectasis was significantly reduced after ventilation in the prone position but persisted in the supine group (p = 0.001). Final PaO2 was not significantly higher (344 vs 306, p = 0.12), but lungs were more often transplanted in the prone group (45% vs 24%, p = 0.03). CONCLUSIONS Ventilation in the prone position reverses atelectasis and rapidly and sustainably improves oxygenation in organ donors who are BD with hypoxemia. This effect appears to translate into more lungs being transplanted.
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Teijeiro-Paradis R, Cypel M, Del Sorbo L. Protective Mechanical Ventilation in Organ Donors: A Lifesaving Maneuver. Am J Respir Crit Care Med 2020; 202:167-169. [PMID: 32433890 PMCID: PMC7365355 DOI: 10.1164/rccm.202005-1559ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canadaand
| | - Marcelo Cypel
- Division of Thoracic SurgeryUniversity of TorontoToronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canadaand
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Healey A, Watanabe Y, Mills C, Stoncius M, Lavery S, Johnson K, Sanderson R, Humar A, Yeung J, Donahoe L, Pierre A, de Perrot M, Yasufuku K, Waddell TK, Keshavjee S, Cypel M. Initial lung transplantation experience with uncontrolled donation after cardiac death in North America. Am J Transplant 2020; 20:1574-1581. [PMID: 31995660 DOI: 10.1111/ajt.15795] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/12/2019] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
Uncontrolled donation after cardiac death (uDCD) has the potential to ameliorate the shortage of suitable lungs for transplant. To date, no lung transplant data from these donors are available from North America. We describe the successful use of these donors using a simple method of in situ lung inflation so that the organ can be protected from warm ischemic injury. Forty-four potential donors were approached, and family consent was obtained in 30 cases (68%). Of these, the lung transplant team evaluated 16 uDCDs on site, and 14 were considered for transplant pending ex vivo lung perfusion assessment. Five lungs were ultimately used for transplant (16.7% use rate from consented donors). The mean warm ischemic time was 2.8 hours. No primary graft dysfunction grade 3 was observed at 24, 48, or 72 hours after transplant. Median intensive care unit stay was 5 days (range: 2-78 days), and median hospital stay was 17 days (range: 8-100 days). The 30-day mortality was 0%. Four of 5 patients are alive at a median of 651 days (range: 121-1254 days) with preserved lung function. This study demonstrates the proof of concept and the potential for uDCD lung donation using a simple donor intervention.
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Affiliation(s)
- Andrew Healey
- Trillium Gift of Life Network, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Critical Care, Department of Medicine, William Osler Health System, Brampton, Ontario, Canada
| | - Yui Watanabe
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Caitlin Mills
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | | | - Susan Lavery
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | - Karen Johnson
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | | | - Atul Humar
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Yeung
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laura Donahoe
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Pierre
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Parent B, Caplan A, Angel L, Kon Z, Dubler N, Goldfrank L, Lindner J, Wall SP. The unique moral permissibility of uncontrolled lung donation after circulatory death. Am J Transplant 2020; 20:382-388. [PMID: 31550420 PMCID: PMC6984986 DOI: 10.1111/ajt.15603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/28/2019] [Accepted: 09/12/2019] [Indexed: 01/25/2023]
Abstract
Implementing uncontrolled donation after circulatory determination of death (uDCDD) in the United States could markedly improve supply of donor lungs for patients in need of transplants. Evidence from US pilot programs suggests families support uDCDD, but only if they are asked permission for using invasive organ preservation procedures prior to initiation. However, non-invasive strategies that confine oxygenation to lungs may be applicable to the overwhelming majority of potential uDCDD donors that have airway devices in place as part of standard resuscitation. We propose an ethical framework for lung uDCDD by: (a) initiating post mortem preservation without requiring prior permission to protect the opportunity for donation until an authorized party can be found; (b) using non-invasive strategies that confine oxygenation to lungs; and (c) maintaining strict separation between the healthcare team and the organ preservation team. Attempting uDCDD in this way has great potential to obtain more transplantable lungs while respecting donor autonomy and family wishes, securing public support, and enabling authorized persons to affirm or cease preservation decisions without requiring evidence of prior organ donation intent. It ensures prioritization of life-saving, the opportunity to allow willing donors to donate, and respect for bodily integrity while adhering to current ethical norms.
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Affiliation(s)
- Brendan Parent
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Arthur Caplan
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Luis Angel
- NYU Langone Transplant Institute, New York, NY USA
| | - Zachary Kon
- NYU Langone Transplant Institute, New York, NY USA
| | - Nancy Dubler
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Lewis Goldfrank
- NYU Langone Health, Ronald O. Perelman Department of
Emergency Medicine, New York, NY USA
| | - Jacob Lindner
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA,University of Pennsylvania, History and Sociology of
Science Department, Philadelphia, PA USA
| | - Stephen P. Wall
- NYU Langone Health, Ronald O. Perelman Department of
Emergency Medicine, New York, NY USA,NYU Langone Health, Department of Population Health,
Division of Health and Behavior, New York, NY USA
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