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.

Trasplante pulmonar en Uruguay: avances en curso para la consolidación del programa / Lung transplant in Uruguay: progress in motion for the consolidation of the program / Transplante pulmonar no Uruguai: avanços atuais para a consolidação del programa

Introducción: en Uruguay funciona desde el año 2003 un programa de trasplante pulmonar (TP) mediante un convenio binacional con la República Argentina, con Fundación Favaloro, centro regional de referencia. Objetivos: describir los resultados del programa y herramientas en curso para mejorar la procuración pulmonar en Uruguay. Material y método: estudio descriptivo, retrospectivo, entre 2003 y 2017. Recopilación de datos del registro electrónico y análisis mediante SPSS. Resultados: ingresaron a lista 70 pacientes, 27 fueron trasplantados, 95% se reinsertaron a actividades sociales o laborales. Las etiologías fueron enfisema (33%), fibrosis quística (26%) y fibrosis pulmonar idiopática (11%). Las complicaciones más frecuentes fueron infecciones respiratorias y alteraciones de la vía aérea. La mortalidad postrasplante es 34% y la supervivencia mediana condicional supera los ocho años. La elevada mortalidad en lista (32%) impulsó el establecimiento de nuevas estrategias de procuración pulmonar. Destacamos: seguimiento longitudinal de pacientes, modificación de umbral de convocatoria, realización de maniobras de reclutamiento alveolar, realización sistemática de fibrobroncoscopía; minimización de tiempos de traslado y entrenamiento de equipo quirúrgico uruguayo para ablación. La procuración pulmonar pasó de 0 por millón de población (pmp) en 2014 y 2015 a 1,8 pmp en 2017. Conclusiones: el Programa Uruguayo de Trasplante Pulmonar ha tenido importantes avances. Los últimos dos años han sido claves para el crecimiento de la procuración pulmonar. Los resultados, la sobrevida y la morbimortalidad son comparables a los descritos internacionalmente. Las perspectivas a futuro serán consolidar el programa en un centro de referencia y realización de ablación e implante en nuestro territorio. (AU)

Introduction: a program for Lung Transplant (LT) has been operative in Uruguay since 2003, by means of a bi-national agreement with Fundación Favaloro, a regional reference center in Argentina. Method: descriptive, retrospective study performed between 2003 and 2017. Data in the electronic register was compiled and analyzed using SPSS (Statistical Package for the Social Sciences). Results: 70 patients were entered in the list, 27 of which underwent transplant surgery, 95% of them resumed social like and/or work. Etiologies included emphysema (33%), cystic fibrosis (26%) and idiopathic pulmonary fibrosis (11%). The most frequent complications were respiratory infections and alterations in the airway. Post-transplant mortality is 34% and conditional median survival is higher than 8 years. The increased mortality in the list (32%) encouraged development of new strategies for lung procurement. The following facts are pointed out: longitudinal follow-up of patients, modification of the calling threshold, the performance of alveolar recruitments maneuvers, the systematic performance of fibrobroncoscopy, minimization of transport times and training of the Uruguayan surgical team for ablation. Lung procurement increased from 0 per million of population (pm) in 2014 to 1.8 pmp in 2017. Conclusions: the Uruguayan program for LT has evidenced significant progress. The last two years have been essential for the increase of lung procurement. Results, survival and morbi-mortality are comparable to those described globally. Future perspectives will focus on consolidating the program in a reference center and performing ablation and implants in our country.

Introdução: desde 2003 funciona no Uruguai um programa de Transplante Pulmonar (TP) através de um convenio binacional com Argentina, com Fundación Favaloro, centro regional de referência. Objetivos: descrever os resultados do programa e as ferramentas que estão sendo utilizadas para melhorar a procuração pulmonar no Uruguai. Materiais e métodos: estudo descritivo, retrospectivo do período 2003-2017. Coleta de dados do registro eletrônico e análise com o programa SPSS. Resultados: ingressaram à lista 70 pacientes; 27 foram transplantados dos quais 95% voltaram a atividades sociais e/ou de trabalho. As etiologias foram enfisema (33%), fibrose cística (26%) e fibrose pulmonar idiopática (11%). As complicações mais frequentes foram as infecções respiratórias e alterações da via aérea. A mortalidade pós-transplante foi de 34% e a sobrevida mediana condicional foi superior a 8 anos. Dada la elevada mortalidade na lista de espera (32%) novas estratégias de procuração pulmonar foram estabelecidas. Destacamos: seguimento longitudinal dos pacientes, modificação do umbral de convocatória, realização de manobras de recrutamento alveolar, realização sistemática de fibrobroncoscopia, minimização dos tempos de traslado e capacitação da equipe uruguaia de cirurgia em ablação. A procuração pulmonar passou de 0 por milhão de habitantes (pmp) em 2014 e 2015 a 1.8 pmp em 2017. Conclusões: o Programa Uruguaio de TP mostrou importantes avanços. Os últimos 2 anos foram fundamentais para o crescimento da procuração pulmonar. Os resultados, a sobrevida e a morbimortalidade são comparáveis aos descritos na literatura internacional. As perspectivas para o futuro são consolidar o programa em um centro de referência e a realização de ablação e implante no nosso território.

Fenotipos de disfunción crónica del injerto pulmonar / Phenotypes of chronic pulmonary graft dysfunction

En la actualidad el rechazo crónico en el trasplante pulmonar incluye diferentes formas de presentación clínica englobadas bajo el término "disfunción crónica de injerto", por sus siglas en inglés (CLAD, Chronic lung allograft dysfunction). Se han diferenciado dos fenotipos de CLAD, expresión de rechazo crónico, con presentación clínicoimagenológica, anatomo-patológica y evolutiva diferente. La disfunción crónica del injerto pulmonar con fenotipo obstructivo, correspondiente a la bronquiolitis obliterante (BO) / síndrome de bronquiolitis obliterante (SBO), y la de fenotipo restrictivo correspondiente al síndrome restrictivo del injerto (RAS, restrictive allograft syndrome)1. Se presentan dos casos clínicos de trasplante bipulmonar con disfunción crónica del injerto pulmonar que ejemplifican los fenotipos de rechazo crónico bajo las formas de SBO y RAS, respectivamente. Ambos pacientes recibieron un retrasplante pulmonar. La anatomía patológica de los pulmones explantados confirmó el diagnóstico en ambos casos

Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications.

OBJECTIVE: To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy. METHODS: Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed. RESULTS: A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome. CONCLUSION: This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population.

Craniectomía descompresiva en el trauma encefalocraneano grave: factores pronósticos y complicaciones / Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications

RESUMEN Objetivo: Análisis de las características clínicas, las complicaciones y los factores asociados al pronóstico de los pacientes con trauma encefalocraneano grave en los que se realizó craniectomía descompresiva. Métodos: Estudio retrospectivo de los pacientes asistidos en una Unidad de Cuidados Intensivos, con trauma encefalocraneano grave en los que se realizó craniectomía descompresiva, entre los años 2003 y 2012. Se siguieron los pacientes hasta el egreso de la unidad de cuidados intensivos, analizándose sus características clínico-tomográficas, las complicaciones y los factores asociados al pronóstico (análisis uni y multivariado). Resultados: Se estudiaron 64 pacientes. Se realizó craniectomía descompresiva primaria y lateral en la mayoría de los pacientes. Se halló una alta incidencia de complicaciones (78% neurológicas y 52% no neurológicas). 42 pacientes (66%) presentaron mala evolución y 22 (34%) tuvieron una buena evolución neurológica. De los pacientes que sobrevivieron, el 61% tuvo una buena evolución neurológica. En el análisis univariado, los factores asociados significativamente con mala evolución neurológica fueron: la hipertensión intracraneana post-craniectomía descompresiva, la mayor gravedad y el peor estado neurológico al ingreso. En el análisis multivariado, solo la hipertensión intracraneana post-craniectomía descompresiva se asoció significativamente con mala evolución. Conclusión: Se trata de un grupo de pacientes muy grave, de difícil manejo, con elevada morbimortalidad, donde la hipertensión intracraneana es un factor principal de mala evolución. .

ABSTRACT Objective: To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy. Methods: Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed. Results: A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome. Conclusion: This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population. .