Mitigating the risk of inflammatory type primary graft dysfunction by applying an integrated approach to assess, modify and match risk factors in lung transplantation.

Long-term outcome following lung transplantation remains one of the poorest of all solid organ transplants with a 1- and 5-year survival of 85% and 59% respectively for adult lung transplant recipients and with 50% of patients developing chronic lung allograft dysfunction (CLAD) in the first 5 years following transplant. Reducing the risk of inflammatory type primary graft dysfunction (PGD) is vital for improving both short-term survival following lung transplantation and long-term outcome due to the association of early inflammatory-mediated damage to the allograft and the risk of CLAD. PGD has a multifactorial aetiology and high-grade inflammatory-type PGD is the result of cumulative insults that may be incurred in one or more of the three variables of the transplantation continuum: the donor lungs, the recipient and intraoperative process. We set out a conceptual framework which uses a fully integrated approach to this transplant continuum to attempt to identify and, where possible, modify specific donor, recipient and intraoperative PGD risk with the goal of reducing inflammatory-type PGD risk for an individual recipient. We also consider the concept and risk-benefit of matching lung allografts and recipients on the basis of donor and recipient PGD-risk compatibility. The use of ex vivo lung perfusion (EVLP) and the extended preservation of lung allografts on EVLP will be explored as safe, non-injurious EVLP may enable extensive inflammatory testing of specific donor lungs and has the potential to provide a platform for targeted therapeutic interventions on lung allografts.

Ventilation during ex vivo lung perfusion, a review.

Evidence suggests that ventilation during ex vivo lung perfusion (EVLP) with a 'one-size-fits-all' strategy has the potential to cause lung injury which may only become clinically relevant in marginal lung allografts. EVLP induced- or accelerated lung injury is a dynamic and cumulative process reflecting the interplay of a number of factors. Stress and strain in lung tissue caused by positive pressure ventilation may be exacerbated by the altered properties of lung tissue in an EVLP setting. Any pre-existing injury may alter the ability of lung allografts to accommodate set ventilation and perfusion techniques on EVLP leading to further injury. This review will examine the effects of ventilation on donor lungs in the setting of EVLP. A framework for developing a protective ventilation technique will be proposed.

Hypoxemia during procedural sedation in adult patients: a retrospective observational study.

PURPOSE: Since 2010, new guidelines for procedural sedation and the Helsinki Declaration on Patient Safety have increased patient safety, comfort, and acceptance considerably. Nevertheless, the administration of sedatives and opioids during sedation procedures may put the patient at risk of hypoxemia. However, data on hypoxemia during procedural sedation are scarce. Here, we studied the incidence and severity of hypoxemia during procedural sedations in our hospital. METHODS: A historical, single-centre cohort study was performed at the University Medical Centre Utrecht (UMCU), a tertiary centre in the Netherlands. Data from procedural sedation in our hospital between 1 January 2011 and 31 December 2018 (3,459 males and 2,534 females; total, 5,993) were extracted from our Anesthesia Information Management System. Hypoxemia was defined as peripheral oxygen saturation < 90% lasting at least two consecutive minutes. The severity of hypoxemia was calculated as area under the curve. The relationship between the severity of hypoxemia and body mass index (BMI), American Society of Anesthesiologists (ASA) Physical Status classification, and duration of the procedure was investigated. The primary outcome was the incidence of hypoxemia. RESULTS: Twenty-nine percent of moderately to deeply sedated patients developed hypoxemia. A high incidence of hypoxemia was found in patients undergoing procedures in the heart catheterization room (54%) and in patients undergoing bronchoscopy procedures (56%). Hypoxemia primarily occurred in longer lasting procedures (> 120 min) and especially in the latter phases of the procedures. There was no relationship between severity of hypoxemia and BMI or ASA Physical Status. CONCLUSIONS: This study showed that a considerable number of patients are at risk of hypoxemia during procedural sedation with a positive correlation shown with increasing duration of medical procedures. Additional prospective research is needed to investigate the clinical consequences of this cumulative hypoxemia.

RéSUMé: OBJECTIF: Depuis 2010, les nouvelles lignes directrices pour la sédation procédurale et la Déclaration d'Helsinki concernant la sécurité des patients ont considérablement augmenté la sécurité, le confort et l'acceptation des patients. L'administration de sédatifs et d'opioïdes pendant les interventions sous sédation peut toutefois mettre le patient à risque d'hypoxémie. Cependant, les données concernant l'hypoxémie pendant une sédation procédurale sont rares. Ici, nous avons étudié l'incidence et la sévérité de l'hypoxémie pendant la sédation procédurale dans notre hôpital. MéTHODE: Une étude de cohorte historique monocentrique a été réalisée au Centre médical universitaire d'Utrecht (UMCU), un centre tertiaire aux Pays-Bas. Les données des sédations procédurales réalisées dans notre hôpital entre le 1er janvier 2011 et le 31 décembre 2018 (3459 hommes et 2534 femmes; au total, 5993 patients) ont été extraites de notre système de gestion de l'information en anesthésie. L'hypoxémie a été définie comme une saturation périphérique en oxygène < 90 % durant au moins deux minutes consécutives. La sévérité de l'hypoxémie a été calculée en tant que surface sous la courbe. Les relations entre la sévérité de l'hypoxémie et l'indice de masse corporelle (IMC), la classification du statut physique selon l'American Society of Anesthesiologists (ASA) et la durée de l'intervention ont été étudiées. Le critère d'évaluation principal était l'incidence d'hypoxémie. RéSULTATS: Vingt-neuf pour cent des patients sous sédation modérée à profonde ont développé une hypoxémie. Une incidence élevée d'hypoxémie a été observée chez les patients subissant des interventions en salle d'hémodynamie (54 %) et chez les patients subissant des bronchoscopies (56 %). L'hypoxémie est principalement survenue lors d'interventions plus longues (> 120 min) et particulièrement dans les phases plus tardives des interventions. Aucune relation n'a été observée entre la sévérité de l'hypoxémie et l'IMC ou le statut physique ASA. CONCLUSION: Cette étude a démontré qu'un nombre considérable de patients sont à risque d'hypoxémie pendant la sédation procédurale, une corrélation positive ayant été démontrée avec une durée prolongée des interventions médicales. D'autres recherches prospectives sont nécessaires pour étudier les conséquences cliniques de cette hypoxémie cumulée.

New Techniques for Optimization of Donor Lungs/Hearts.

Injuries sustained by donor heart and lung allografts during the transplantation process are multiple and cumulative. Optimization of allograft function plays an essential role in short- and long-term outcomes after transplantation. Therapeutic targets to prevent or attenuate injury are present in the donor, the preservation process, during transplantation, and in postoperative management of the recipient. The newest and most promising methods of optimizing donor heart and lung allografts are found in alternative preservation strategies, which enable functional assessment of donor organs and provide a modality to initiate therapies for injured allografts or prevent injury during reperfusion in recipients.

Echocardiography in extracorporeal life support: A key player in procedural guidance, tailoring and monitoring.

Extracorporeal life support (ECLS) is a mainstay of current practice in severe respiratory, circulatory or cardiac failure refractory to conventional management. The inherent complexity of different ECLS modes and their influence on the native pulmonary and cardiovascular system require patient-specific tailoring to optimize outcome. Echocardiography plays a key role throughout the ECLS care, including patient selection, adequate placement of cannulas, monitoring, weaning and follow-up after decannulation. For this purpose, echocardiographers require specific ECLS-related knowledge and skills, which are outlined here.