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The Alfred Intensive Care Unit, Melbourne, Australia
General & post-operative management
for the general Intensivist
Lung Transplantation
David Pilcher
Intensive Care Specialist, The Alfred
The Alfred Intensive Care Unit, Melbourne, Australia
Summary
Background – donors & recipients
Post-operative management
Complications:
Primary Graft Failure
Dynamic Hyper-inflation
Outcomes
The Future
The Alfred Intensive Care Unit, Melbourne, Australia
11
6
14 14
9
2
7
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+
NumberofCenters
Average number of lung transplants per year
Other
North America
Europe
Adult and Pediatric Lung Transplants
Average Center Volume by Location
(January 2009 – June 2015)
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
NumberofTransplants
Year
COPD A1ATD CF IIP ILD-not IIP Retransplant
The Alfred Intensive Care Unit, Melbourne, Australia
0
12
24
36
48
60
72
0%
20%
40%
60%
80%
100%
Medianrecipientage(years)(blueline)
%ofTransplants
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)
The Alfred Intensive Care Unit, Melbourne, Australia
DONOR SELECTION
The Alfred Intensive Care Unit, Melbourne, Australia
Call
The Alfred Intensive Care Unit, Melbourne, Australia
RECIPIENT SELECTION
The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung disease
Emphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung disease
Emphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
SINGLE LUNG?
The Alfred Intensive Care Unit, Melbourne, Australia
Who gets what?
Depends on the disease processes:
Restrictive lung disease: pulmonary fibrosis
Obstructive lung disease
Emphysema / COAD
Alpha 1 antitrypsin deficiency
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
DOUBLE LUNG
The Alfred Intensive Care Unit, Melbourne, Australia
SURGERY &
POST-OPERATIVE CARE
The Alfred Intensive Care Unit, Melbourne, Australia
The Alfred Intensive Care Unit, Melbourne, Australia
Thoracotomy Clamshell
Bronchial anastomosis
Bypass only rarely
(Pulm hypertension)
The Alfred Intensive Care Unit, Melbourne, Australia
Bilateral Sequential Lung Transplant
The Alfred Intensive Care Unit, Melbourne, Australia
Transplant - physiology
Infection
Denervation
No bronchial blood supply
No lymphatics
“Leaky” lungs
Lungs
The Alfred Intensive Care Unit, Melbourne, Australia
Respiratory
ICC 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
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
The Alfred Intensive Care Unit, Melbourne, Australia
Neurological
Pain
Anxiety
Psychosis & confusion
Management
Paracetamol
Epidural
No NSAIDS or Tramadol
Post-op management
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
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
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Respiratory Guideline
Manage as per PaO2/FiO2 ratio
Wean mechanical ventilation
Check list
The Alfred Intensive Care Unit, Melbourne, Australia
Post-op management guideline
Analgesia &
Immunosuppression
Epidural & pain team
Immunosuppression “sticker”
The Alfred Intensive Care Unit, Melbourne, Australia
Post-operative Complications
S**t happens
The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft Failure
Dynamic Hyperinflation
Rejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs
The Alfred Intensive Care Unit, Melbourne, Australia
Causes of death
Early Mortality
Primary Graft Failure
Dynamic Hyperinflation
Rejection
Late Mortality
Bronchiolitis obliterans
Chronic Rejection
Malignancy
Infection
Lungs
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
Treatment
Supportive
Diuretic
Avoid excess iv fluid
Pulmonary vasodilator
Consider alternative diagnosis
Pulmonary Venous Anastomosis
Rejection
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%
Treatment
Independent lung ventilation
Native Lung
Low RR
Normal tidal volume
No PEEP
Transplanted lung
High RR
Small tidal volume
High PEEP
The Alfred Intensive Care Unit, Melbourne, Australia
Other Post-op Management
Immunosuppression
Steroids
Mycophenolate
Tacrolimus or Cyclosporin
(Basiliximab – IL2R antagonist)
Infection Prophylaxis
CMV prophylaxis (for all except Neg. donor /Neg. recipient)
PCP prophylaxis (starts at 3 weeks post op)
The Alfred Intensive Care Unit, Melbourne, Australia
Are things getting better?
New organ preservation techniques
Perfadex
New surgical techniques
Retrograde flush
Bilateral thoracotomy
No more aprotonin
New anaesthetic techniques
Crystalloids & epidurals
New ICU management
Protocolised care
Recognition of potential complications
The Alfred Intensive Care Unit, Melbourne, Australia
OUTCOMES
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
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
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)
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
Survival(%)
Years
1990-1998 (N=9,794) 1999-2008 (N=21,666) 2009-6/2014 (N=20,067)
Adult Lung Transplants
Survival by Era
(1990 – 2014)
The Alfred
The Alfred Intensive Care Unit, Melbourne, Australia
THE FUTURE
The Alfred Intensive Care Unit, Melbourne, Australia
The Future
DCD lungs
Elderly donors
Ex-vivo perfusion/preservation
ECMO - bridge to transplant
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
Australian DCD vs BD v the World
0
25
50
75
100
0 1 2 3 4
Survival(%)
Years
Aus DCD
Aus Brain
Dead Donors
World
The Future……….is now
The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
The Alfred Intensive Care Unit, Melbourne, Australia
The Future……….is now
DCD lungs
Elderly donors
ECMO - bridge to transplant
Ex-vivo perfusion/preservation
Xenotransplantation
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
The Alfred Intensive Care Unit, Melbourne, Australia
Thank you
Any more questions?

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Lung Transplantation by David Pilcher

  • 1. The Alfred Intensive Care Unit, Melbourne, Australia General & post-operative management for the general Intensivist Lung Transplantation David Pilcher Intensive Care Specialist, The Alfred
  • 2. The Alfred Intensive Care Unit, Melbourne, Australia Summary Background – donors & recipients Post-operative management Complications: Primary Graft Failure Dynamic Hyper-inflation Outcomes The Future
  • 3. The Alfred Intensive Care Unit, Melbourne, Australia 11 6 14 14 9 2 7 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+ NumberofCenters Average number of lung transplants per year Other North America Europe Adult and Pediatric Lung Transplants Average Center Volume by Location (January 2009 – June 2015)
  • 4. 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 NumberofTransplants Year COPD A1ATD CF IIP ILD-not IIP Retransplant
  • 5. The Alfred Intensive Care Unit, Melbourne, Australia 0 12 24 36 48 60 72 0% 20% 40% 60% 80% 100% Medianrecipientage(years)(blueline) %ofTransplants 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)
  • 6. The Alfred Intensive Care Unit, Melbourne, Australia DONOR SELECTION
  • 7. The Alfred Intensive Care Unit, Melbourne, Australia Call
  • 8. The Alfred Intensive Care Unit, Melbourne, Australia RECIPIENT SELECTION
  • 9. The Alfred Intensive Care Unit, Melbourne, Australia Who gets what? Depends on the disease processes: Restrictive lung disease: pulmonary fibrosis Obstructive lung disease Emphysema / COAD Alpha 1 antitrypsin deficiency Cystic fibrosis Bronchiectasis Pulmonary hypertension
  • 10. The Alfred Intensive Care Unit, Melbourne, Australia Who gets what? Depends on the disease processes: Restrictive lung disease: pulmonary fibrosis Obstructive lung disease Emphysema / COAD Alpha 1 antitrypsin deficiency Cystic fibrosis Bronchiectasis Pulmonary hypertension SINGLE LUNG?
  • 11. The Alfred Intensive Care Unit, Melbourne, Australia Who gets what? Depends on the disease processes: Restrictive lung disease: pulmonary fibrosis Obstructive lung disease Emphysema / COAD Alpha 1 antitrypsin deficiency Cystic fibrosis Bronchiectasis Pulmonary hypertension DOUBLE LUNG
  • 12. The Alfred Intensive Care Unit, Melbourne, Australia SURGERY & POST-OPERATIVE CARE
  • 13. The Alfred Intensive Care Unit, Melbourne, Australia
  • 14. The Alfred Intensive Care Unit, Melbourne, Australia Thoracotomy Clamshell Bronchial anastomosis Bypass only rarely (Pulm hypertension)
  • 15. The Alfred Intensive Care Unit, Melbourne, Australia Bilateral Sequential Lung Transplant
  • 16. The Alfred Intensive Care Unit, Melbourne, Australia Transplant - physiology Infection Denervation No bronchial blood supply No lymphatics “Leaky” lungs Lungs
  • 17. The Alfred Intensive Care Unit, Melbourne, Australia Respiratory ICC 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
  • 18. 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
  • 19. The Alfred Intensive Care Unit, Melbourne, Australia Neurological Pain Anxiety Psychosis & confusion Management Paracetamol Epidural No NSAIDS or Tramadol Post-op management
  • 20. The Alfred Intensive Care Unit, Melbourne, Australia Post-op management guideline
  • 21. The Alfred Intensive Care Unit, Melbourne, Australia Post-op management guideline
  • 22. 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
  • 23. The Alfred Intensive Care Unit, Melbourne, Australia Post-op management guideline Respiratory Guideline Manage as per PaO2/FiO2 ratio Wean mechanical ventilation Check list
  • 24. The Alfred Intensive Care Unit, Melbourne, Australia Post-op management guideline Analgesia & Immunosuppression Epidural & pain team Immunosuppression “sticker”
  • 25. The Alfred Intensive Care Unit, Melbourne, Australia Post-operative Complications S**t happens
  • 26. The Alfred Intensive Care Unit, Melbourne, Australia Causes of death Early Mortality Primary Graft Failure Dynamic Hyperinflation Rejection Late Mortality Bronchiolitis obliterans Chronic Rejection Malignancy Infection Lungs
  • 27. The Alfred Intensive Care Unit, Melbourne, Australia Causes of death Early Mortality Primary Graft Failure Dynamic Hyperinflation Rejection Late Mortality Bronchiolitis obliterans Chronic Rejection Malignancy Infection Lungs
  • 28. 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 Treatment Supportive Diuretic Avoid excess iv fluid Pulmonary vasodilator Consider alternative diagnosis Pulmonary Venous Anastomosis Rejection
  • 29. 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% Treatment Independent lung ventilation Native Lung Low RR Normal tidal volume No PEEP Transplanted lung High RR Small tidal volume High PEEP
  • 30. The Alfred Intensive Care Unit, Melbourne, Australia Other Post-op Management Immunosuppression Steroids Mycophenolate Tacrolimus or Cyclosporin (Basiliximab – IL2R antagonist) Infection Prophylaxis CMV prophylaxis (for all except Neg. donor /Neg. recipient) PCP prophylaxis (starts at 3 weeks post op)
  • 31. The Alfred Intensive Care Unit, Melbourne, Australia Are things getting better? New organ preservation techniques Perfadex New surgical techniques Retrograde flush Bilateral thoracotomy No more aprotonin New anaesthetic techniques Crystalloids & epidurals New ICU management Protocolised care Recognition of potential complications
  • 32. The Alfred Intensive Care Unit, Melbourne, Australia OUTCOMES
  • 33. 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
  • 34. 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
  • 35. 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)
  • 36. 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 Survival(%) Years 1990-1998 (N=9,794) 1999-2008 (N=21,666) 2009-6/2014 (N=20,067) Adult Lung Transplants Survival by Era (1990 – 2014) The Alfred
  • 37. The Alfred Intensive Care Unit, Melbourne, Australia THE FUTURE
  • 38. The Alfred Intensive Care Unit, Melbourne, Australia The Future DCD lungs Elderly donors Ex-vivo perfusion/preservation ECMO - bridge to transplant Xenotransplantation
  • 39. The Alfred Intensive Care Unit, Melbourne, Australia The Future……….is now DCD lungs Elderly donors ECMO - bridge to transplant Ex-vivo perfusion/preservation Xenotransplantation
  • 40. The Alfred Intensive Care Unit, Melbourne, Australia Australian DCD vs BD v the World 0 25 50 75 100 0 1 2 3 4 Survival(%) Years Aus DCD Aus Brain Dead Donors World The Future……….is now
  • 41. The Alfred Intensive Care Unit, Melbourne, Australia The Future……….is now DCD lungs Elderly donors ECMO - bridge to transplant Ex-vivo perfusion/preservation Xenotransplantation
  • 42. The Alfred Intensive Care Unit, Melbourne, Australia The Future……….is now DCD lungs Elderly donors ECMO - bridge to transplant Ex-vivo perfusion/preservation Xenotransplantation
  • 43. 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
  • 44. The Alfred Intensive Care Unit, Melbourne, Australia Thank you Any more questions?