Ultrasound Scanning in Lung Procurement. Protocol for Decision-Making With the Purpose of Increasing Transplant Eligible Lungs.

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.

Effects of early hemodynamic resuscitation on left ventricular performance and microcirculatory function during endotoxic shock.

BACKGROUND: Microcirculation and macrohemodynamics are severely compromised during septic shock. However, the relationship between these two compartments needs to be further investigated. We hypothesized that early resuscitation restores left ventricular (LV) performance and microcirculatory function but fails to prevent metabolic disorders. We studied the effects of an early resuscitation protocol (ERP) on LV pressure/volume loops-derived parameters, sublingual microcirculation, and metabolic alterations during endotoxic shock. METHODS: Twenty-five pigs were randomized into three groups: LPS group: Escherichia coli lipopolysaccharide (LPS); ERP group: LPS + ERP based on volume expansion, dobutamine, and noradrenaline infusion; Sham group. LV pressure/volume-derived parameters, systemic hemodynamics, sublingual microcirculation, and metabolic profile were assessed at baseline and after completing the resuscitation protocol. RESULTS: LPS significantly decreased LV end-diastolic volume, myocardial contractility, stroke work, and cardiac index (CI). Early resuscitation preserved preload, and myocardial contractility, increased CI and heart rate (p < .05). LPS severely diminished sublingual microvascular flow index (MFI), perfused vascular density (PVD), and the proportion of perfused vessels (PPV), while increased the heterogeneity flow index (HFI) (p < .05). Despite MFI was relatively preserved, MVD, PVD, and HFI were significantly impaired after resuscitation (p < .05). The macro- and microcirculatory changes were associated with increased lactic acidosis and mixed venous O2 saturation when compared to baseline values (p < .05). The scatter plot between mean arterial pressure (MAP) and MFI showed a biphasic relationship, suggesting that the values were within the limits of microvascular autoregulation when MAP was above 71 ± 6 mm Hg (R (2) = 0.63). CONCLUSIONS: Early hemodynamic resuscitation was effective to restore macrohemodynamia and myocardial contractility. Despite MAP and MFI were relatively preserved, the persistent microvascular dysfunction could explain metabolic disorders. The relationship between micro- and systemic hemodynamia and their impact on cellular function and metabolism needs to be further studied during endotoxic shock.

Central venous to mixed venous blood oxygen and lactate gradients are associated with outcome in critically ill patients.

OBJECTIVE: Blood O(2) saturation and lactate concentration gradients from superior vena cava (SVC) to pulmonary artery (PA) occur in critically ill patients. These gradients (DeltaSO(2) and Delta[Lac]) may be positive or negative. We tested the hypothesis that positive DeltaSO(2) and Delta[Lac] are associated with improved survival in critically ill patients. DESIGN AND SETTING: Multinational, prospective observational study conducted in six medical and surgical ICUs. PATIENTS: Consecutive sample of 106 adults requiring insertion of a pulmonary artery catheter (PAC). Average age was 59.5 +/- 15.5 years, APACHE II score was 15.5 +/- 6.7 (mean +/- SD). Main outcome measure was 28-day mortality. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We drew blood samples from the proximal and distal ports of PACs every 6 h from the time of PAC insertion (Initial measurement) until its removal (Final measurement). Samples were analyzed for SO(2), [Lac], glucose concentration and blood gases. Hemodynamic measurements were obtained after blood samples. We monitored patients for 30.9 +/- 11.0 h. Overall mortality rate was 25.5%. More survivors had mean and final DeltaSO(2) > or = 0 and Delta[Lac] > or = 0 than decedents (p < 0.01; p < 0.05 respectively). On the average, DeltaSO(2) and Delta[Lac] were positive in survivors and negative in decedents. Survival odds ratios for final measurements of DeltaSO(2) > or = 0 and Delta[Lac] > or = 0 were 19.22 and 7.70, respectively (p < 0.05). CONCLUSIONS: A strong association exists between positive DeltaSO(2) and Delta[Lac] and survival in critically ill patients. Whether therapy aimed at increasing DeltaSO(2) and Delta[Lac] results in improved ICU survival remains to be determined.

Nutrición en pacientes con fístulas entero cutáneas / Nutrition in patients with cutaneous

Las fístulas digestivas son complicaciones relativamente frecuentes, su manejo es complejo y debe ser realizado por un equipo multiciplinario, en el que la nutrición tiene un rol primordial. Se realizó un estudio retrospectivo de los pacientes con fístulas enterocutáneas y se valoró la influencia del soporte nutricional en el tratamiento de las mismas. El estudio abarcó 93 pacientes que fueron asistidos en la unidad de nutrición y en la unidad de cuidado intensivo. Los pacientes tenían una edad promedio de 62 ± 12 años, el 59 por ciento correspondió al sexo masculino. Según su evolución final fueron considerados curados (N: 63), y no curados que comprendían pacientes fallecidos (N: 23) y dados de alta con fístula (N: 7). La mortalidad global de 24,7 por ciento. La evaluación nutricional de los pacientes incluyó medidas antropométricas, altura, peso inicial y peso usual, la pérdida de peso fue calculada en 11,9 ± 18 por ciento estos valores no fueron significativamente diferentes entre los pacientes curados y no curados...

Nutrición en pacientes con fístulas entero cutáneas / Nutrition in patients with cutaneous

Las fístulas digestivas son complicaciones relativamente frecuentes, su manejo es complejo y debe ser realizado por un equipo multiciplinario, en el que la nutrición tiene un rol primordial. Se realizó un estudio retrospectivo de los pacientes con fístulas enterocutáneas y se valoró la influencia del soporte nutricional en el tratamiento de las mismas. El estudio abarcó 93 pacientes que fueron asistidos en la unidad de nutrición y en la unidad de cuidado intensivo. Los pacientes tenían una edad promedio de 62 ± 12 años, el 59 por ciento correspondió al sexo masculino. Según su evolución final fueron considerados curados (N: 63), y no curados que comprendían pacientes fallecidos (N: 23) y dados de alta con fístula (N: 7). La mortalidad global de 24,7 por ciento. La evaluación nutricional de los pacientes incluyó medidas antropométricas, altura, peso inicial y peso usual, la pérdida de peso fue calculada en 11,9 ± 18 por ciento estos valores no fueron significativamente diferentes entre los pacientes curados y no curados...(AU)