lung transplantation by david pilcher
TRANSCRIPT
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The Alfred Intensive Care Unit, Melbourne, Australia
General & post-operative managementfor the general Intensivist
Lung Transplantation
David PilcherIntensive Care Specialist, The Alfred
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The Alfred Intensive Care Unit, Melbourne, Australia
Summary
Background – donors & recipients
Post-operative management
Complications:
Primary Graft Failure
Dynamic Hyper-inflation
Outcomes
The Future
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The Alfred Intensive Care Unit, Melbourne, Australia
116
14 149
27
11
11
22
10
9
7
9
9
5
8
2
0
2
1
0
10
20
30
40
50
60
1-4 5-9 10-19 20-29 30-39 40-49 50+
Nu
mb
er
of
Ce
nte
rs
Average number of lung transplants per year
Other
North America
Europe
Adult and Pediatric Lung TransplantsAverage Center Volume by Location
(January 2009 – June 2015)
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The Alfred Intensive Care Unit, Melbourne, Australia
Adult Lung Transplants - major Indications
0
500
1,000
1,500
2,000
2,500
3,000
3,500
Nu
mb
er
of
Tra
ns
pla
nts
Year
COPD A1ATD CF IIP ILD-not IIP Retransplant
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The Alfred Intensive Care Unit, Melbourne, Australia
0
12
24
36
48
60
72
0%
20%
40%
60%
80%
100%
Me
dia
n r
ecip
ien
t a
ge
(ye
ars
) (b
lue
lin
e)
% o
f T
ran
sp
lan
ts
Year
0-10 11-17 18-34 35-49 50-59 60-65 66+ Median age
Adult and Pediatric Lung Transplants Recipient Age by Year (Transplants: 1987 – 2015)
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The Alfred Intensive Care Unit, Melbourne, Australia
DONOR SELECTION
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The Alfred Intensive Care Unit, Melbourne, Australia
Call
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The Alfred Intensive Care Unit, Melbourne, Australia
RECIPIENT SELECTION
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The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung diseaseEmphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
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The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung diseaseEmphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
SINGLE LUNG?
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The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung diseaseEmphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
DOUBLE LUNG
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The Alfred Intensive Care Unit, Melbourne, Australia
SURGERY &
POST-OPERATIVE CARE
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The Alfred Intensive Care Unit, Melbourne, Australia
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The Alfred Intensive Care Unit, Melbourne, Australia
Thoracotomy Clamshell
Bronchial anastomosis
Bypass only rarely (Pulm hypertension)
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The Alfred Intensive Care Unit, Melbourne, Australia
Bilateral Sequential Lung Transplant
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The Alfred Intensive Care Unit, Melbourne, Australia
Transplant - physiology
Infection
Denervation
No bronchial blood supply
No lymphatics
“Leaky” lungs
Lungs
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The Alfred Intensive Care Unit, Melbourne, Australia
RespiratoryICC drainage
Chest X-ray
Bronchoscopy(when practical)
Poor gas exchange
Primary Graft Dysfunction – “leaky” lungs
ABG at 6 – 12 hours predicts outcome
Post-op management
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The Alfred Intensive Care Unit, Melbourne, Australia
Cardiovascular
Hypotension - epidural
ECG changes
Low filling pressures
CVP less than 7 mmHg = better outcomes
Manage by CVS-Resp guideline
Post-op management
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The Alfred Intensive Care Unit, Melbourne, Australia
Neurological
Pain
Anxiety
Psychosis & confusion
Management
Paracetamol
Epidural
No NSAIDS or Tramadol
Post-op management
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The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
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The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
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The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Haemodynamic Guideline
Target blood pressure
Target cardiac index
Vasoconstrictor
CVP 7 mmHg
iv fluids / diuretics
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The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Respiratory Guideline
Manage as per PaO2/FiO2 ratio
Wean mechanical ventilation
Check list
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The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Analgesia &
ImmunosuppressionEpidural & pain team
Immunosuppression “sticker”
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The Alfred Intensive Care Unit, Melbourne, Australia
Post-operative Complications
S**t happens
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The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft FailureDynamic HyperinflationRejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs
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The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft FailureDynamic HyperinflationRejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs
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The Alfred Intensive Care Unit, Melbourne, Australia
Primary Graft Dysfunction
Risk Factors:
Poor gas exchange in donor
Pulmonary thrombo-embolism
Intra-operative colloid
Very long ischaemic time
Causes:
Lymphatics disruption
Inadequate preservation
Surgical trauma
Inflammatory mediators
TreatmentSupportiveDiureticAvoid excess iv fluidPulmonary vasodilator
Consider alternative diagnosis
Pulmonary Venous AnastomosisRejection
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The Alfred Intensive Care Unit, Melbourne, Australia
Dynamic Hyperinflation
Causes:
Hyperinflated Native Lung
Transplant Graft Dysfunction
Proportion needing ILV
TLC % Predicted < 150% 7%
TLC % Predicted > 150% 26%
TLC % Predicted > 175% 44%
TreatmentIndependent lung ventilation
Native LungLow RRNormal tidal volume No PEEP
Transplanted lungHigh RRSmall tidal volumeHigh PEEP
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The Alfred Intensive Care Unit, Melbourne, Australia
Other Post-op Management
ImmunosuppressionSteroids
Mycophenolate
Tacrolimus or Cyclosporin
(Basiliximab – IL2R antagonist)
Infection ProphylaxisCMV prophylaxis (for all except Neg. donor /Neg. recipient)
PCP prophylaxis (starts at 3 weeks post op)
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The Alfred Intensive Care Unit, Melbourne, Australia
Are things getting better?
New organ preservation techniquesPerfadex
New surgical techniquesRetrograde flush
Bilateral thoracotomy
No more aprotonin
New anaesthetic techniquesCrystalloids & epidurals
New ICU managementProtocolised care
Recognition of potential complications
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The Alfred Intensive Care Unit, Melbourne, Australia
OUTCOMES
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The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality
ICU length of stay
Duration of ventilation
Hospital length of stay
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The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality 4%
ICU length of stay
Duration of ventilation
Hospital length of stay
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The Alfred Intensive Care Unit, Melbourne, Australia
So how do they do?
Overall mortality 4%
ICU length of stay 4.1 days (3.3 – 7.6)
Duration of ventilation 24 hours (13 – 73)
Hospital length of stay 23 days (17 – 35)
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The Alfred Intensive Care Unit, Melbourne, Australia
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Su
rviv
al
(%)
Years
1990-1998 (N=9,794) 1999-2008 (N=21,666) 2009-6/2014 (N=20,067)
Adult Lung TransplantsSurvival by Era
(1990 – 2014)
The Alfred
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The Alfred Intensive Care Unit, Melbourne, Australia
THE FUTURE
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The Alfred Intensive Care Unit, Melbourne, Australia
The Future
DCD lungs
Elderly donors
Ex-vivo perfusion/preservation
ECMO - bridge to transplant
Xenotransplantation
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The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
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The Alfred Intensive Care Unit, Melbourne, Australia
Australian DCD vs BD v the World0
25
50
75
100
0 1 2 3 4
Su
rviv
al
(%)
Years
Aus DCD
Aus Brain
Dead Donors
World
The Future……….is now
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The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
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The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
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The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….will always be the future
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
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The Alfred Intensive Care Unit, Melbourne, Australia
Thank you
Any more questions?