Maria Angeles Ballesteros

Tracheal rupture after endotracheal intubation: a literature systematic review

We aim to perform a systematic review and meta-analysis of the cases of postintubation tracheal rupture (PiTR) published in the literature, with the aim of determining the risk factors that contribute to tracheal rupture during endotracheal intubation. A further objective has been to determine the ideal treatment for this condition (surgical repair or conservative management). A MEDLINE review of cases of tracheal rupture after intubation published in the English language and a review of the references in the articles found. The articles included were those that reported at least the demographic data (age and sex), the treatment performed, and the outcome. Those papers that did not detail the above variables were excluded. The search found 50 studies that satisfied the inclusion criteria. These studies included 182 cases of postintubation tracheal rupture. The overall mortality was 22% (40 patients). A statistical analysis was performed determining the relative risk (RR), 95% confidence intervals (95% CI) and/or statistical significance. The analysis was performed on the overall group and after dividing into 2 subgroups: patients in whom the lesion was detected intraoperatively, and other patients. Patient age (p=0.015) and emergency intubation (RR=3.11; 95% CI, 1.81-5.33; p=0.001) were variables associated with an increased mortality. In those patients in whom the PiTR was detected outside the operating theatre (delayed diagnosis), emergency intubation (RR=3.05; 95% CI, 1.69-5.51; p<0.0001), the absence of subcutaneous emphysema (RR=2.17; 95% CI, 1.25-4; p=0.001), and surgical treatment (RR=2.09; 95% CI, 1.08-4.07; p=0.02) were associated with an increased mortality. In addition, age (p=0.1) and male gender (RR=1.89; 95% CI, 0.98-3.63; p=0.13) showed a clear trend towards an increased mortality. PiTR is an uncommon condition but carries a high morbidity and mortality. Emergency intubation is the principal risk factor, increasing the risk of death threefold compared to elective intubation. Conservative treatment is associated with a better outcome. However, the group of patients who would benefit from surgical treatment has not been fully defined. Further studies are required to evaluate the best treatment options.

Impact of restrictive fluid balance focused to increase lung procurement on renal function after kidney transplantation

BACKGROUND Restrictive management of fluid status has been proposed to increase the rates of lung grafts available for transplant. However, no studies have supported the effect of this negative fluid balance in the kidney graft recipients. METHODS We evaluated the effect of restrictive fluid balance in brain-dead donors and their impact in 404 kidney recipients using Kaplan-Meier curves and Cox regression for long-term effects, and logistic regression for short-term effects. Our primary interest was graft survival and the second was occurrence of delayed graft function (DGF). RESULTS A negative or equalized fluid balance with a central venous pressure (CVP) <6 mm Hg affects neither graft survival in kidney recipients (P = 0.983) nor the development of DGF (P = 0.573). A positive fluid balance between brain death and organ retrieval does not reduce either the risk of graft survival or the risk of DGF. CONCLUSION We concluded that restrictive management of fluid balance in a multiorgan donor supports adequate perfusion to vital organ systems even with a CVP <6 mm Hg. A strict fluid balance could avoid volume overload and lung neurogenic oedema, increasing the rate of lung grafts available for transplant without impacting either kidney graft survival or DGF development.

Effect of an intensive lung donor-management protocol on lung transplantation outcomes.

BACKGROUND An intensive lung donor-management protocol based on a strict protocol would increase the lung procurement rate. The aim of this study was to determine the effect of such a protocol on the rate of lung grafts available for transplant. METHODS A lung-management protocol for donors after brain death (DBD) was implemented in 2009. Lung donors from 2009 to 2011 were the prospective cohort, and those from 2003 to 2008 formed the historical control. We analyzed the synergic effect of several measures, such as protective ventilation, ventilator recruitment maneuvers, high positive end-expiratory pressure, fluid restriction with reduced extravascular lung water values, and hormonal resuscitation therapy in multiorgan DBD. The number of lungs available for transplantation was the main outcome measure. For recipients, early survival and the rate of primary graft dysfunction (PGD) grade 3 were the main outcome measures. RESULTS The DBD rate was more than 40 donors per 1 million population in both periods. The rate of lung donors increased from 20.1% to 50% (p < 0.001), quadrupling the number of lung donors (p < 0.001), grafts retrieved (p = 0.02), and patients who received a lung transplant (p < 0.01). No differences were observed in the survival of early recipients (p = 0.203) or in the rate of PGD grade 3 (p = 0.835). CONCLUSION The management of multiorgan DBDs should be approached as a global treatment requiring attentive bedside management. Implementing an intensive lung donor-management protocol based on synergic measures increases lung procurement rates, negative effect on early survival of lung recipients or PGD grade 3.

Influence of donor-recipient gender mismatch in early outcome after lung transplantation.

OBJECTIVE Donor and recipient genders are not considered in lung transplantation (LT) programs. However, recent data have suggested a possible biologic effect of gender combination on the outcome of LT. We ought to evaluate the effect of gender combinations on early survival in a single-institution experience in transplant recipients. METHODS We analyzed the potential effect of donor-recipient gender combinations (male [M] or female [F]) on early survival of all patients whose LTs were performed between January 1999 and December 2006. Patients were distributed into 4 groups: M donor to M recipient (M-M group); M donor to F recipient (M-F group); F donor to F recipient (F-F group); and F donor to M recipient (F-M group). The comparison between groups was performed using two-tailed Fisher exact test and analysis of variance (ANOVA). RESULTS During the study period, 152 LTs were performed in 149 patients, including 99 male donors and 53 female donors. The mean age of the recipients was 54 +/- 10 years (range, 14-70). The 30-day survival rate was 86% (95% confidence interval [CI], 77%- 92%) for the M-M group, 67% (95% CI, 41%-87%) for the F-M group, 89% (95% CI, 52%-100%) for the M-F group, and 83% (95% CI, 66%-93%) for the F-F group. No differences were observed between group survivals according to the Fisher test (P = .27). CONCLUSIONS We found no association between donor-recipient gender mismatch and improved survival in lung transplant recipients. Further investigation is needed to finally understand the possible role of gender combinations in LT.

Aggressive lung donor management increases graft procurement without increasing renal graft loss after transplantation

To determine the impact of an aggressive protocol on the rate of lung grafts available for transplant. We analyzed the impact of this management on kidney graft survival after kidney transplantation.

Increased numbers of circulating CD8 effector memory T cells before transplantation enhance the risk of acute rejection in lung transplant recipients.

The effector and regulatory T cell subpopulations involved in the development of acute rejection episodes in lung transplantation remain to be elucidated. Twenty-seven lung transplant candidates were prospectively monitored before transplantation and within the first year post-transplantation. Regulatory, Th17, memory and naïve T cells were measured in peripheral blood of lung transplant recipients by flow cytometry. No association of acute rejection with number of peripheral regulatory T cells and Th17 cells was found. However, effector memory subsets in acute rejection patients were increased during the first two months post-transplant. Interestingly, patients waiting for lung transplant with levels of CD8+ effector memory T cells over 185 cells/mm3 had a significant increased risk of rejection [OR: 5.62 (95% CI: 1.08-29.37), p=0.04]. In multivariate analysis adjusted for age and gender the odds ratio for rejection was: OR: 5.89 (95% CI: 1.08-32.24), p=0.04. These data suggest a correlation between acute rejection and effector memory T cells in lung transplant recipients. The measurement of peripheral blood CD8+ effector memory T cells prior to lung transplant may define patients at high risk of acute lung rejection.

Prediction of Kidney Transplant Outcome by Donor Quality Scoring Systems: Expanded Criteria Donor and Deceased Donor Score

Due to disparity between organ supply and demand, use of kidneys from suboptimal donors has become increasingly common. Several donor quality systems have been developed to identify kidneys with an increased risk for graft dysfunction and loss. The purpose of our study was to compare the utility of deceased donor score (DDS) and expanded criteria donor (ECD) status to predict kidney transplant outcomes in a single center. We analysed 280 deceased donor renal transplantation procedures, collecting data from the prospectively maintained institutional database. Kidney transplant outcome variable included delayed graft function, 1-year glomerular filtration rate (GFR1y), and death-censored graft loss (DCGL). Kidneys were obtained from marginal donors in 45.7% of transplant recipients by DDS and in 24.9% by ECD. DDS-defined marginal donors suffered delayed graft function (DGF) more frequently than nonmarginal donors (40.8% vs 25.0%; P = .006), whereas ECD did not develop DGF at a greater rate. GFR1Y was significantly worse among patients receiving kidneys from marginal donors: DDS 40.3 ± 12.9 vs 57.7 ± 19.4 mL/min/1.73 m(2) (P < .001) and ECD 39.4 ± 14.1 vs 53.8 ± 19.1 mL/min/1.73 m(2) (P < .0001). The most severe donor category defined by DDS (grade D) showed an independently worse death-censored graft survival hazard rate [HR] 2.661, 95% confidence interval [CI], 1.076-6.582; P = .034). DDS and ECD scoring systems are based on donor information available at the time of transplantation that predict 1-year graft function. Moreover in our center, DDS was better to predict DGF and death-censored graft survival than ECD.

Experiencia de un programa de donación en asistolia Maastricht II en una ciudad de pequeño tamaño: resultados preliminares

OBJECTIVE To study the results of a non-controlled cardiac death (Maastricht type II) donor program in a city of 200,000 inhabitants. The study was initially focused on lung donation and was extended to kidney donation after 9 months. DESIGN A prospective observational study was conducted between October 2012 and December 2013. SETTING The Intensive Care Unit of Marqués de Valdecilla University Hospital in Santander (Spain), and surrounding areas. POPULATIONS Patients (< 55 years) who died of out-of-hospital cardiac arrest. INTERVENTIONS All out-of-hospital cardiac arrests were treated with mechanical cardiac compression (LUCAS II). The diagnosis of death and organ preservation were performed in the ICU. RESULTS A total of 14 calls were received, of which three were discarded. Of the 11 potential donors, 7 were effective donors with a median age of 39.5 years (range: 32-48). A total of 5 single lung transplants and four kidney transplants were performed. In addition, corneas and tissues were harvested. The non-valid donors were rejected mainly due to technical problems. There were no donation refusals on the part of the patient relatives. The lung transplant patient survival rate was 100% after one month and 80% after one year. One month after transplantation, the kidney recipients had a serum creatinine concentration of<2mg/dl. The interval from cardiac arrest to renal preservation was 80minutes (range: 71-89), and the interval from cardiac arrest to lung preservation was 84minutes (range: 77-94). CONCLUSIONS A Maastricht type II donation program in a small city is viable for both abdominal and thoracic organs. The program was initially very cautious, but its potential is easily improvable by increasing donor and by equipping mobile ICU ambulances with mechanical cardiac compression systems. Full management of the donor in the ICU, avoiding the emergency department or operating rooms, reduces the warm ischemia time, thereby improving transplant outcomes.

Prospective Study of Biomarkers of Immune Response in Lung Transplant Recipients

INTRODUCTION Studies on biomarkers of tolerance in organ transplantation have been widely performed during the last decade. AIM To assess biomarkers in relation to evolution of the immune response among lung transplant recipients. METHODS This multicenter study included 27 lung transplant recipients followed before as well as at 7, 14, 30, 60, 90, and 180 days posttransplantation. Biomarkers of the immune response based on flow cytometry technology were validated in each center. They included intracellular cytokine expression, regulatory T-cell level, as well as lymphocyte surface antigen and CD28 expressions. RESULTS The 13 patients who developed acute rejection episodes showed increased numbers of regulatory T cells at 12 months posttransplant. Sixteen patients experiencing infections displayed decreased expression of CD69 on CD8 T cells within the first year of follow-up. CONCLUSION High Treg levels in the peripheral blood of lung transplant recipients were associated with an increased risk of rejection but not infection. Inversely, we observed low levels of activated CD8 T cells in infected patients.

Efectos del retraso y la inadecuación del tratamiento antibiótico en la supervivencia de los pacientes en shock séptico

OBJECTIVE To assess how antibiotic administration delay and inadequacy influence survival in septic shock patients. DESIGN A prospective, observational cohort study was carried out between September 2005 and September 2010. SCOPE Patients admitted to the ICU of a third level hospital. PATIENTS A total of 342 septic shock patients INTERVENTIONS None VARIABLES OF INTEREST The time to antibiotic administration (difference between septic shock presentation and first administered dose of antibiotic) and its adequacy (in vitro susceptibility testing of isolated pathogens) were determined. RESULTS ICU and hospital mortality were 26.4% and 33.5%, respectively. The median delay to administration of the first antibiotic dose was 1.7h. Deceased patients received antibiotics significantly later than survivors (1.3±14.5h vs. 5.8±18.02h; P=.001). Percentage drug inadequacy was 12%. Those patients who received inadequate antibiotics had significantly higher mortality rates (33.8% vs. 51.2%; P=.03). The coexistence of treatment delay and inadequacy was associated to lower survival rates. CONCLUSIONS Both antibiotic administration delay and inadequacy exert deleterious effects upon the survival of septic shock patients, independently of their characteristics or severity.