C. Coccia

Preload index: pulmonary artery occlusion pressure versus intrathoracic blood volume monitoring during lung transplantation.

UNLABELLED In this study, during lung transplantation, we analyzed a conventional preload index, the pulmonary artery occlusion pressure (PAOP), and a new preload index, the intrathoracic blood volume index (ITBVI), derived from the single-indicator transpulmonary dilution technique (PiCCO System), with respect to stroke volume index (SVIpa). We also evaluated the relationships between changes (Delta) in ITBVI and PAOP and DeltaSVIpa during lung transplantation. The reproducibility and precision of all cardiac index measurements obtained with the transpulmonary single-indicator dilution technique (CIart) and with the pulmonary artery thermodilution technique (CIpa) were also determined. Measurements were made in 50 patients monitored with a pulmonary artery catheter and with a PiCCO System at six stages throughout the study. Changes in the variables were calculated by subtracting the first from the second measurement (Delta(1)) and so on (Delta(1) to Delta(5)). The linear correlation between ITBVI and SVIpa was significant (r(2)=0.41; P < 0.0001), whereas PAOP poorly correlated with SVIpa (r(2) = -0.01). Changes in ITBVI correlated with changes in SVIpa (Delta(1), r(2) = 0.30; Delta(2), r(2) = 0.57; Delta(4), r(2) = 0.26; and Delta(5), r(2) = 0.67), whereas PAOP failed. The mean bias between CIart and CIpa was 0.15 l. min(-1). m(-2) (1.37). In conclusion, ITBVI is a valid indicator of cardiac preload and may be superior to PAOP in patients undergoing lung transplantation. IMPLICATIONS The assessment of intrathoracic blood volume index (ITBVI) by the transpulmonary single-indicator technique is a useful tool in lung transplant patients, providing a valid index of cardiac preload that may be superior to pulmonary artery occlusion pressure. However, more prospective, randomized studies are necessary to evaluate the role and limitations of this technique.

Preimplantation retrograde pneumoplegia in clinical lung transplantation

Abstract Objective: Retrograde pneumoplegia seems to improve early graft function in experimental and clinical lung transplantation. We evaluated the role of retrograde flushing in addition to antegrade pneumoplegia in clinical lung transplantation. Methods: Fourteen patients undergoing lung transplantation were randomized into 2 groups: in group I we performed antegrade pulmonary artery flushing with alprostadil (prostaglandin E 1 ) and modified Euro-Collins solution at the time of retrieval. In group II additional retrograde flushing through the pulmonary veins was performed at the back table, before reimplantation. Hemodynamic variables, mean airway pressure, and blood gas analysis were monitored at different time points. Postoperative volumetric monitoring was performed to assess extravascular lung water. The reimplantation response was assessed by a radiographic score; extubation time and intensive care unit stay were recorded. Results: During retrograde flushing, blood and clots coming out from the pulmonary artery were observed; 2 lungs harvested from a donor with multiple bone fractures had fat emboli in the retrograde perfusate. Hemodynamic monitoring did not demonstrate any difference between the 2 groups. The ratio of arterial oxygen tension to inspired oxygen fraction, extravascular lung water, duration of intubation, and length of stay in the intensive care unit were improved in group II, but the differences did not reach statistical significance. Intrapulmonary shunt fraction was significantly improved in group II at each time point ( P = .02), as well as indexed alveolar-arterial oxygen tension gradient ( P = .04), mean airway pressure ( P = .04), and chest x-ray score ( P = .03). Conclusions: Preimplantation retrograde flushing is not detrimental and helps to improve early graft function. (J Thorac Cardiovasc Surg 1999;118:107-14)

Preload and haemodynamic assessment during liver transplantation: a comparison between the pulmonary artery catheter and transpulmonary indicator dilution techniques

Background and objective: Liver transplantation is characterized by several changes in intravascular blood volume due to vasodilatation based on neurohumoral mediators, intraoperative bleeding and anaesthesia technique effects. Today, with the transpulmonary indicator dilution technique, cardiac index-(CIart) can be evaluated and preload assessed in terms of the intrathoracic blood volume index (ITBVI). The aim was to analyse in patients undergoing liver transplantation two preload variables, pulmonary artery occlusion pressure (PAOP) and ITBVI with respect to cardiac index (CIpa) and stroke volume index (SVIpa), the correlation between ITBVI and PAOP, and secondary the relationship between the changes (Δ) of ITBVI and PAOP and the changes of CIpa and SVIpa, and the relationships between ΔITBVI and ΔPAOP. The reproducibility and precision of all CIart and CIpa measurements were also evaluated. Methods: A prospective study was performed in 60 patients monitored with a pulmonary artery catheter and with the PiCCO® system. The variables were evaluated with a linear regression model. Results: Linear regression analysis between ITBVI-CIpa and ITBVI-SVIpa were r2 = 0.47 (P < 0.0001) and r2 = 0.55 (P < 0.0001) respectively, while PAOP poorly correlated to CIpa (r2 = 0.02), SVIpa (r2 = 0.015) and ITBVI (r2 = 0.002). Only changes in ITBVI were correlated with changes in CIpa (Δ1, r2 = 0.37; Δ2, r2 = 0.32), and SVIpa (Δ1, r2 = 0.60; Δ2, r2 = 0.47). The mean bias between CIart and CIpa was 0.13 L min−1 m−2 (2 SD = 1.04 L min−1 m−2) (r2 = 0.86, P < 0.0001). Conclusions: In comparison with PAOP, ITBVI seems a more reliable indicator of cardiac preload in patients undergoing liver transplantation.

Acute lung injury in thoracic surgery.

Purpose of review This review will analyze the risk factors of acute lung injury (ALI) in patients undergoing thoracic surgery. Evidence for the occurrence of lung injury following mechanical ventilation and one-lung ventilation (OLV) and the strategies to avoid it will also be discussed. Recent findings Post-thoracotomy ALI has become one of the leading causes of operative death. The pathogenesis of ALI implicates a multiple-hit sequence of various triggering factors (e.g. preoperative conditions, surgery-induced inflammation, ventilator-induced injury, fluid overload, and transfusion). Conventional ventilation during OLV is performed with high tidal volumes equal to those being used in two-lung ventilation, high FiO2, and without positive end-expiratory pressure. This practice was originally recommended to improve oxygenation and decrease shunt fraction during OLV. However, a number of recent studies using experimental models or human patients have shown low tidal volumes to be associated with a decrease in inflammatory mediators and a reduction in pulmonary postoperative complications. However, the application of such protective strategies could be harmful if not still properly used. Summary The goal of ventilation is to minimize lung trauma by avoiding overdistension and repetitive alveolar collapse, while providing adequate oxygenation. Protective ventilation is not simply synonymous of low tidal volume ventilation, but it also involves positive end-expiratory pressure, lower FiO2, recruitment maneuvers, and lower ventilatory pressures.

Fenoldopam Mesylate and Renal Function in Patients Undergoing Liver Transplantation: A Randomized, Controlled Pilot Trial

To test the relative effects on serum creatinine (CRE), blood urea nitrogen (BUN), and urine output of small-dose dopamine and fenoldopam in patients undergoing liver transplantation, we randomized 43 patients to 1 of 2 continuous infusions over 48 h, starting with anesthesia induction: fenoldopam, 0.1 &mgr;g · kg−1 · min−1 or dopamine, 2 &mgr;g · kg−1 · min−1. We used predetermined hemodynamic and intravascular volume goals (intrathoracic blood volume index 800–1000 mL/m2, extravascular lung water index <7 mL/kg) to manage patients with an algorithm for use of mannitol and furosemide to maintain urine output >1 mL · kg−1 · h−1. At postoperative day 3, the median CRE increase was 0.2 mg/dL (interquartile range [IQR] −0.2–0.5) with fenoldopam and 0.5 mg/dL (IQR 0.3–0.9, P = 0.004) in the dopamine group. The BUN increase was median 2 mg/dL (IQR −2–8) versus 8.5 mg/dL (IQR 5–12, P = 0.01), respectively, with fenoldopam versus dopamine. Urine output was similar; however, significantly fewer fenoldopam patients required furosemide compared with dopamine patients (median 1 [IQR 0–3] versus 3 [IQR 2–4], respectively, P = 0.003). The hemodynamic effects of dopamine and fenoldopam were similar. Compared with dopamine, in the setting of liver transplantation, fenoldopam is associated with better CRE and BUN values.

Inhaled areosolized prostacyclin and pulmonary hypertension during anesthesia for lung transplantation

TREATMENT of pulmonary hypertension is a most important aspect of the anaesthetic management for lung transplantation and requires administration of pulmonary vasodilators and inotropic support. Intravenous administration of vasodilators such as nitrates or prostaglandins does not have a selective action on pulmonary vasculature leading to systemic hypotension and increasing intrapulmonary shunt. Inhaled areosolized prostacyclin (IAP) is attracting attention as a selective pulmonary vasodilator in various clinical conditions associated with pulmonary hypertension. The present study was designed to evaluate the effect of IAP during anesthesia for lung transplantation.

Severe reperfusion lung injury after double lung transplantation

AimTo demonstrate the effects of combined inhaled nitric oxide and surfactant replacement as treatment for acute respiratory distress syndrome. This treatment has not previously been documented for reperfusion injury after double lung transplantation.MethodA 24-year-old female with cystic fibrosis underwent double lung transplantation. During implantation of the second lung a marked increase in pulmonary artery pressure associated with systemic hypotension, hypoxemia and low cardiac output were observed. Notwithstanding the patient received support from cardiovascular drugs and pulmonary vasodilators cardiopulmonary by-pass was necessary. In the intensive care unit the patient received the same drug support, inhaled nitric oxide and two bronchoscopic applications of bovine surfactant.ResultsA rapid improvement in PaO2/FiO2 within 2–3 hours of administration of surfactant was seen. The patient is well at follow-up 1 year post-transplant.ConclusionThere is a potential role for a combined therapy with inhaled nitric oxide and surfactant replacement in reperfusion injury after lung transplantation.

Pediatric renal transplantation: anesthesia and perioperative complications.

Abstract The appropriate choice of anesthesia for patients (pts) undergoing renal transplantation (Ktx) requires minimal toxicity and accurate monitoring for pts at high risk for metabolic, cardiovascular, and respiratory perioperative complications. We evaluated the anesthetic management and postoperative follow-up in pediatric Ktx performed in the last 12 years in our institution. From 1988 to 1999, 75 ASA class II-III pts (45 males, 22 females) younger than 18 years scheduled for Ktx were studied: 49 received a graft from a cadaveric donor (CD) and 26 from a living donor (LD). All pts were treated with dialysis within 24 h before the procedure. Standard monitoring consisted of an electrocardiogram, central venous pressure, non-invasive arterial pressure, pulse oximetry, and inspiratory and expiratory gas analysis. If necessary, an arterial cannula and pediatric pulmonary catheter were introduced. Anesthesia was induced with sodium thiopental, propofol, halothane, or sevoflurane and maintained with isoflurane and/or fentanyl and droperidol in O2:N2O (FiO2 0.4%). As muscle relaxants atracurium or cisatracurium besilate were used, except in allergic pts, in whom vecuronium or rocuronium bromide was administered. Dopamine, 20% mannitol, and furosemide were used to increase diuresis. Continuous morphine and ketoralac infusions were used for postoperative pain relief. The surgical technique was the same in all cases. Complications and renal-function (RF) recovery were evaluated relating to CD and LD using the chi-square test; differences in mean anesthesia and surgical time were evaluated by Students t-test; survival curves were calculated from the day of Ktx to death or last follow-up and estimated by the Kaplan-Meier method. Values of P below 0.05 were considered significant. Postoperative immunosuppressive therapy was based on cyclosporine together with other conventional drugs. Mean anesthesia time was 228 ± 65 min. Mean kidney ischemia time for CD was 16.5 ± 4 h. Four pts (3 CD, 1 LD) died within 72 h postoperatively: 3 due to cardiac failure and 1 to metabolic coma. Six pts showed cardiovascular and 3 had infective complications, all successfully treated. Three pts (2 CD, 1 LD) died within 2 to 12 months after, surgery; 10 (6 CD, 4 LD) had graft failure and are still alive on dialysis; 58 (38 CD, 20 LD) are alive in good health after a mean follow-up of 57.6 ± 36.6 months (range 12–120 months). Fifteen of 26 pts younger than 12 years (21 CD and 5 LD) recovered RF intraoperatively (10 CD, 5 LD); 1 with CD and 1 with LD showed postoperative graft failure and 2 with CD died within 72 h postoperatively, 22 (18 CD and 4 LD) are alive in good health. This group showed no statistical difference compared to pts older than 12 years. Of 16 pts (15 CD and 1 LD) with body weight (BW) less than 25 kg, 6 showed intraoperative (5 CD, 1 LD) recovery of RF. The 3 deaths were all in CD pts, 2 within 72 h and one 2 months after surgery; only 1 LD had postoperative graft failure. Twelve pts (75%) (12 CD, 80%) are alive in good health. Compared to pts with BW of 25 kg or more, this group showed lower intraoperative recovery of RF (P ≤ 0.05). No peri- and postoperative complications occurred in all 26 LD pts (100%). Recent advances in surgery, anesthesia, immunosuppression, and antimicrobial prophylaxis have made Ktx a more predictable procedure even in pediatric pts. For high-risk pts, mortality and morbidity can be controlled by accurate surgical, anesthetic, and postoperative management. Pts younger than 12 years and with BW less than 25 kg are more likely to develop peri- and postoperative complications.

Hemodynamic and metabolic effects of transjugular intrahepatic portosystemic shunt (TIPS) during anesthesia for orthotopic liver transplantation.

Recently, the tranjugular intrahepatic portosystemic shunt (TIPS) has been advocated as a safe bridge to orthotopic liver transplantation (OLT). We retrospectively studied 53 consecutive cirrhotic patients who underwent OLT: 27 patients with TIPS were compared to 26 controls. Hemodynamic and oxyphoretic data (Fick method) were collected during six phases of OLT. There were no significant differences in demographic data and Child-Pugh class, nor in surgical time and blood product requirements before the anhepatic phase between TIPS patients and controls. In the TIPS group, we observed a marked hyperdynamic profile with a lower systemic vascular resistance index, higher cardiac index, and depressed oxygen consumption before native liver removal. During the same period, the TIPS group developed a greater acidosis and was treated with a larger amount of Na-HCO3. Following the anhepatic phase, no differences between the two groups were detected. All transplantations were successful, and no complications related to TIPS were observed. These results seem to be the consequence of a reduced liver function reserve with a direct hemodynamic effect due to the TIPS.

Acute Pulmonary Embolism: Hemodynamic Aspects and Treatment

Pulmonary embolism (PE) is a major international health problem, with an annual estimated incidence of over 100,000 cases in France, 65,000 cases among hospitalized patients in England and Wales, and at least 60,000 new cases per year in Italy. The diagnosis is often untreated, difficult to obtain and is frequently missed [1]. Mortality in the untreated is approximately 30%, but with adequate treatment this can be reduced to 2–8%. Numerous cases go unrecognized and hence untreated, with poor outcomes. Indeed the prevalence of PE at autopsy (approximately 12–15% in hospitalized patients) has not changed over three decades [2].