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Tuesday
December 14th 2021
ICU and Thoracic Sx joint meeting
Postoperative management of LTx recipients
in the ICU
30-day Operative Mortality Rate by Year
1983 – 2020
2
0%
50%
17%
50%
20%
8%
14%
20%
7%
4%
8% 8%
3%
14%13%
6% 8%
18%17%
7%
6%
8% 7%
5% 6%
1%
8%
4% 2% 3% 2% 3% 5%
2%
4%
3% 1% 2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
20
40
60
80
100
120
140
160
180
200
220
30-DAY
MORTALITY
RATE
(%)
NUMBER
OF
LTx
(n)
YEAR
LTx Mortality ≤ 30d
30-day mortality
2018: 2.5%
2019: 1.4%
2020: 2.2%
>2500 transplants in Toronto
Transplant procedures
 Clamshell
 Bilateral sequential lung transplant
 Double Lumen ETT
 Lungs freed, PA, PV, bronchus dissected
 Lung with lesser physiologic reserve is transplanted first
* if hypoxia on single lung + hemodynamic changes, CPB or more
recently VA ECMO
 Bronchial anastomosis (end to end anastomosis)
 Pulmonary artery anastomosis
 Pulmonary vein anastomosis to left atrium
 Slow reperfusion of lungs with leukocyte filtration
 Chest tube insertions
 Change ETT
 Flexible bronchoscopy to assess anastomosis
Transplant procedures
RE
VIE
WARTIC
LE
ABSTRACT
The number of lung transplanta
providing new challenges to int
units. The outcome of lung tran
acomplex interplay of particular
knowledge of which is fundame
during the early postoperative c
lines arenot available, theautho
postoperative management of lu
care unit, which addresses six
ventilation, (2) fluid and hemody
therapies, (4) prevention and m
antimicrobial therapy, and (6) m
inal complications. The integrat
plinary team is key to optimize
lungtransplantationrecipientsin
(ANE
STH
E
SIO
LO
G
Y 2021; X
X
X
:00–00
De
PostoperativeManagement
of Lung T
ransplant
Recipients in the
Intensive C
are Unit
Matteo Di Nardo, M.D., Jussi Tikkanen, M.D.,
Shahid Husain, M.D., LianneG
. Singer, M.D.,
Marcelo Cypel, M.D., Niall D. Ferguson, M.D.,
Shaf Keshavjee, M.D., Lorenzo Del Sorbo, M.D.
ANESTHESIO
LO
G
Y 2021; XXX:00–00
ung transplantation is a complex treatment for Potential PostoperativeCo
Prevention of PGD
Careful fluid management:
to avoid lung edema preserving adequate end-organ perfusion
Adequate pain management
Early weaning from sedation
Early extubation
Early mobilization
Immunosuppression
Antibiotic profilaxis
Overall goals
idiopathicpulmonary bros
is
,or pulmonary hypertens
ion,or
with a body mas
sindex greater than 25. Intraoperative fac-
Management of Mechanical V
entilation
Mechanical ventilation repres
ents an es
s
ential s
upportive
Table 1. P
ostoperativeAcuteCritical ComplicationsAssociated with LungT
ransplantation
Respiratory Failure Shock O
thers
• Primarygraft dysfunction2
Primarygraft dysfunction0: noedemaonchest X-raywithanyPaO
2
/FIO
2
Primarygraft dysfunction1: edemaonchest X-raywithPaO
2
/FIO
2
> 300
Primarygraft dysfunction2: edemaonchest X-raywithPaO
2
/FIO
2
200–300*
Primarygraft dysfunction3: edemaonchest X-raywithPaO
2
/FIO
2
< 200†
• Donor-associatedpneumonia
• V
entilator-associatedpneumonia
• Acuterejection
• Bronchial anastomotic complications(dehiscence)
• C
ardiogenic pulmonaryedema
• Pulmonaryveinanastomotic obstruction
• Pulmonaryembolism
• Hemothorax
• W
holelungor lobar torsion
• Phrenic nerveinjury
• Hemorrhagic
• Distributive(septic)
• Infection
• Arrhythmias
• C
ardiogenic (right ventricular failure,
left ventricular failure)
• P
ostoperativepericarditis
• G
astroesophageal reflux
• O
bstructive(tamponade, pulmonaryembolism)• Bowelobstruction, perforation,ischemia
• Immunosuppressionsideeffects
• C
NScomplications
• IC
Uacquiredweakness
Primary graft dysfunction is graded at four timepoints, every 24h, over the first 72h after transplantation (0, 24, 48, and 72h). Primary graft dysfunction in recipients treated with
noninvasiveventilationshouldbegradedaccordingtoPao2
/FIO
2
ratioasfor invasivemechanical ventilation.
*If P
ao2
/FIO
2
ratiois not available, oxygen saturation/FIO
2
ratio235 to315 is used instead of P
ao2
/FIO
2
ratio200 to300. †U
se of extracorporeal membrane oxygenation with pulmonary
edemaisgradedasprimarygraft dysfunction3. E
xtracorporeal membraneoxygenationfor cardiac indication(without pulmonaryedema)isungradable.
C
NS, central nervoussystem; FIO
2
, inspiredoxygenfraction; IC
U
, intensivecareunit.
2016 ISHLT PGD taxonomy
Diamond JM, et al. Am J Respir Crit Care Med 2013
Postoperative management of lung transplant recipients in the ICU
Mechanical Ventilation
Goals:
provide adequate gas exchange
minimize respiratory distress
assess graft function
minimize ventilator-induce lung injury
optimize alveolar recruitment
facilitate bronchial toileting
facilitate early weaning
Protective settings, early weaning and extubation to minimize ventilator-induced lung injury.
Initial ventilator settings:
• Tidal volume: 6 ml/kg predicted body weight (donor)
• Inspiratory plateau pressure <30 cmH2O
• SpO2 > 90% and pH > 7.25
• PEEP (cmH2O) adjusted according to the ARDS network table, but avoiding PEEP level >12-14 cmH2O
FiO2 0.3 0.4 0.5 0.6-0.7 0.8-1
PEEP 5 5-8 8-10 10-12 12-14
- If PaO2/FiO2 > 200 and pH >7.25
• Wean sedation
• Tidal volume: 6-8 ml/Kg predicted body weight (donor),
• Inspiratory plateau pressure: < 25 cmH2O
• Early extubation (SBT twice daily : 8 am, and 4 pm, for the first 2 days post LTx)
- If PaO2/FiO2 < 200
• maintain sedation
• initial ventilator settings with tidal volume: ≤ 6 ml/Kg, predicted body weight (donor)
• Inspiratory plateau pressure: < 25 cmH2O
• Driving pressure < 15 cmH2O
• PEEP: adjust according to ARDS network table*
• Respiratory Rate: < 35 breaths/minute
- If PaO2/FiO2 < 150
• consider neuromuscular blockade
• consider inhaled NO
- If PaO2/FiO2 < 100
• contact ICU attending and LTx team for additional help
• consider ECMO
Mechanical
Ventilation
Continuous multimodal hemodynamic monitoring (Swan Ganz catheter) and careful
fluid management to achieve adequate end-organ perfusion while avoiding lung
reperfusion injury
• mean arterial pressure: 65-75 mmHg
• cardiac index: 2.2-2.5 l·min–1·m–2
• central venous pressure: ≤ 7 mmHg
• wedge pressure or left atrial pressure: ≤ 10 mmHg
• diuresis > 0.5 ml/kg/hour
Hemodynamics
And
Fluid Management
Postoperative management of lung transplant recipients in the ICU
RV
Pre-load
After-load
Contractility
PVR (RV after-load)
Post DLTx
LV
Pre-load
After-load
Contractility
PAS and PAD
PA flow=cardiac output
CVP (RV pre-load)
PAOP (LV pre-load)
Hemodynamic monitoring (PAC)
LV-RV interaction
RV Contractility
(inotropes)
PVR (RV after-load)
Post DLTx
PGD 3
LV After-load: MAP 65-75 mmHg
(vasopressors, vasoldilators,
sedation, PEEP)
Contractility (inotropes)
mPAP < 20 mmHg
CI= 2.2-2.5
CVP (RV pre-load) <8 mmHg
(fluids/furosemide, PEEP)
PAOP (LV pre-load) < 10 mmHg
(fluids/furosemide, PEEP)
LV-RV interaction
PAD-PAOP, pO2, pCO2, MV
settings, sedation, iNO
End organ perfusion monitoring:
SvO2, lactate, u/o, pH, HCO3-, temperature
Lung function monitoring:
P/F, Vd/Vt, compliance, CXR, EVLW (?)
JTCVS 2013
Atrial fibrillation/flutter is fairly common after lung transplantation and usually transient. The incidence
peaks at 48-72 hours post-op. The impact of atrial fibrillation/flutter on in-hospital and long-term mortality is
unclear. Most patients return to sinus rhythm before discharge.
Assessment
1. Obtain ECG, review telemetry and confirm diagnosis (Afib/flutter vs other arrhythmias e.g Multifocal
atrial tachycardia, frequent APB’s)
2. Obtain ABG and troponin
3. Assess MAP and mPAP
4. Review pre-op cath/echo if available –assess LV function, LA dimension/index (note if significant LV
dysfunction or severe LA enlargement), review cardiac Hx
5. Assess and optimize triggering risk factors for peri-op arrhythmias
- Electrolytes imbalance, including sodium, potassium, magnesium, calcium, and phosphate
- Altered gas exchange
- Pain
- Intravascular volume status considering hypovolemia or atrial dilation/acute atrial stretch (CVP,
Wedge pressure, ECHO)
- Medications (vasopressors, inotropes, etc.)
- Airway issues (re: endotracheal tube, anastomosis)
- Pericardial effusion/tamponade (CVP, Wedge pressure, ECHO)
New onset Atrial fibrillation/flutter
Treatment
If the patient is hemodynamically unstable (cfr: hypotension, myocardial ischemia, CHF/ acute pulmonary edema)
I. Administer Magnesium 2-4 gr/100ml [Transient adverse effects: hypotension, flushing, tingling, and
dizziness (Monitor Mg level keep >1)]
II. Synchronised Electrical cardioversion
III. Address triggering risk factors
IV. If electrical cardioversion is unsuccessful –recurrent Afib/flutter or paroxysmal Afib/flutter is present.
Call attending staff
Consider re-cardioverison after managing triggering factors.
Reconsider triggering risk factors
Consider Sotalol: 40-160 mg orally every 12 h (Dosing interval adjusted in patients with AKI)
Re-consider electrical cardioversion (after Sotalol treatment)
Consider cardiology/EP consultations – if this is first afib/flutter (<24hours) attempt to be made to
restore rhythm.
Amiodarone should be avoided and considered only as last option after consultation with LTx team
(one time bolus dose 150-300mg infusion over 30-45mins can be considered after consultation with
Lung Transplant team) re-attempt electrical cardioversion post amiodarone bolus if rapid afib persists
followed by continuation of betablocker for maintenance.
New onset Atrial fibrillation/flutter
Treatment
If the patient is hemodynamically stable
history of previous Afib – Rate Control strategy can be considered (target HR<110bpm).
I. Administer Magnesium 2-4 gr/100ml [Transient adverse effects: hypotension, flushing, tingling, and
dizziness]
II. Address triggering risk factors
III. If Afib/flutter persists, Afib/flutter is recurrent, or paroxysmal Afib/flutter is present
a. Reconsider triggering risk factors
b. Consider rate control agents, such as
- metoprolol, esmolol
- Digoxin
-Diltiazem - contact LTx team to adjust IS
- Electrical cardioversion
Amiodarone should be avoided – for rate control
– Propafenone or Flecainide can be considered in consultation with Cardiology/EP and Lung
transplant team (if no evidence of significant CAD and renal dysfunction).
If Afib/flutter (persistent or paroxysmal) persists for longer than 24-48 hours consider anticoagulation with iv heparin
and discuss bleeding risk with the LTx team.
New onset Atrial fibrillation/flutter
Maintain a caloric intake of 25-30 kcal/kg; if indirect calorimetry is not available,
maintain normal glucose blood level (45-65% of total calories), lipid: 20-35% of total
calories, protein: 1.3-2.5 g/kg/day
Micronutrients and electrolytes intake: maintain normal sodium, potassium and
magnesium levels. Supplement calcium, vitamin A, C and D
• Early enteral nutrition to prevent muscle mass loss
• Use of non-pharmacologic (sleeping with 30° bed position) and pharmacologic
interventions (proton pump inhibitors and prokinetics) to prevent and manage gastro-
oesophageal reflux and DIOS (CF)
Early abdominal computed tomography with iv. contrast in presence of even minor
clinical suspicion of abdominal complications
Nutritional support
And
GI Management
Maintenance therapy: triple-drug therapy
including calcineurin inhibitors, cell-cycle inhibitors and steroids
Induction Therapy: in patients at risk of renal dysfunction
consider basiliximab
Immunosuppression
Antibiotics: empiric broad spectrum antibiotic prophylaxis for 72
hours, awaiting final results of donor and recipient
bronchoalveolar lavage cultures.
Consider multidrug resistance coverage.
Treatment of confirmed infections with tailored therapy.
Antivirals: cytomegalovirus prophylaxis (according to
donor/recipient status)
Pneumocystis Jirovecii prophylaxis
Antifungals: consider prophylaxis in colonized recipients.
Treatment of confirmed fungal infection
Antimicrobials
Donor factors
Bacterial or fungal
allograft colonization
Allograft latent infection
(toxoplasma, cytomegalovirus,
other viruses, endemic
mycosis, tuberculosis)
Recipient factors: preoperative
Age
Diabetes
Hypogammaglobulinemia
Renal failure
No immunity against cytomegalovirus,
toxoplasmosis, rubeola virus, varicella
zoster virus
Latent infection tuberculosis,
cytomegalovirus, herpes simplex virus,
varicella zoster virus, Epstein–Barr virus,
endemic mycosis
Colonization with multidrug resistant micro-
organisms
Immunosuppressive therapy
Rejection
Environmental exposure (gardener, animals,
caves, travel)
Native lung colonization
Recipient factors: preoperative
Allograft injury
(ischemia, preservation, reperfusion)
Complexity and length
of surgery
Post-surgical care (mechanical ventilation,
intravenous catheters, drains, bladder
catheter, extracorporeal membrane
oxygenation)
Transfusion
Intensive care stay
• Adequate pain control
• Early mobilization to prevent ICU-acquired weakness
• Early delirium screening and treatment
• Sleep hygiene
• Benzodiazepines-free sedation
• Hyperammonemia screening and source control
• Posterior reversible encephalopathy syndrome prevention
Prevention of
Neurological dysfunction
Measure ammonia in every LTx patient on any admission to the ICU systematically for 14 days on the transplant admission
and readmission on the transplant admission
After 14 days, measure ammonia in every LTx patient requiring prolonged sedation (every day till the patient is awake and
alert)
Measure ammonia in every LTx patient with altered LOC
If ammonia >72 mmol/L (normal range 18-72 mmol/L; critical level >100 mmol/L)
- start immediately conventional HD (SLEDD is not as efficient in ammonia removal), especially if >ammonia is >100
mmol/L
- send blood cultures and consider BAL
- start empiric IV Abx (moxifloxacin 400mg/day, and doxycycline 100 mg q12h)
- monitor neuro-vitals q1h
- Contact ICU attending (ICU attending calls staff nephrologist)
- contact LTx team
- contact Tx ID (cultures for Mycoplasma Hominis, Ureaplasma urealyticum and Ureaplasma parvum)
- monitor ammonia level q12h until normalized, then q24h for 3 days, and then as per protocol
Hyperammonemia
Thank you!

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Postoperative management of lung transplant recipients in the ICU

  • 1. Tuesday December 14th 2021 ICU and Thoracic Sx joint meeting Postoperative management of LTx recipients in the ICU
  • 2. 30-day Operative Mortality Rate by Year 1983 – 2020 2 0% 50% 17% 50% 20% 8% 14% 20% 7% 4% 8% 8% 3% 14%13% 6% 8% 18%17% 7% 6% 8% 7% 5% 6% 1% 8% 4% 2% 3% 2% 3% 5% 2% 4% 3% 1% 2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 20 40 60 80 100 120 140 160 180 200 220 30-DAY MORTALITY RATE (%) NUMBER OF LTx (n) YEAR LTx Mortality ≤ 30d 30-day mortality 2018: 2.5% 2019: 1.4% 2020: 2.2% >2500 transplants in Toronto
  • 3. Transplant procedures  Clamshell  Bilateral sequential lung transplant  Double Lumen ETT  Lungs freed, PA, PV, bronchus dissected  Lung with lesser physiologic reserve is transplanted first * if hypoxia on single lung + hemodynamic changes, CPB or more recently VA ECMO  Bronchial anastomosis (end to end anastomosis)  Pulmonary artery anastomosis  Pulmonary vein anastomosis to left atrium  Slow reperfusion of lungs with leukocyte filtration  Chest tube insertions  Change ETT  Flexible bronchoscopy to assess anastomosis
  • 5. RE VIE WARTIC LE ABSTRACT The number of lung transplanta providing new challenges to int units. The outcome of lung tran acomplex interplay of particular knowledge of which is fundame during the early postoperative c lines arenot available, theautho postoperative management of lu care unit, which addresses six ventilation, (2) fluid and hemody therapies, (4) prevention and m antimicrobial therapy, and (6) m inal complications. The integrat plinary team is key to optimize lungtransplantationrecipientsin (ANE STH E SIO LO G Y 2021; X X X :00–00 De PostoperativeManagement of Lung T ransplant Recipients in the Intensive C are Unit Matteo Di Nardo, M.D., Jussi Tikkanen, M.D., Shahid Husain, M.D., LianneG . Singer, M.D., Marcelo Cypel, M.D., Niall D. Ferguson, M.D., Shaf Keshavjee, M.D., Lorenzo Del Sorbo, M.D. ANESTHESIO LO G Y 2021; XXX:00–00 ung transplantation is a complex treatment for Potential PostoperativeCo
  • 6. Prevention of PGD Careful fluid management: to avoid lung edema preserving adequate end-organ perfusion Adequate pain management Early weaning from sedation Early extubation Early mobilization Immunosuppression Antibiotic profilaxis Overall goals
  • 7. idiopathicpulmonary bros is ,or pulmonary hypertens ion,or with a body mas sindex greater than 25. Intraoperative fac- Management of Mechanical V entilation Mechanical ventilation repres ents an es s ential s upportive Table 1. P ostoperativeAcuteCritical ComplicationsAssociated with LungT ransplantation Respiratory Failure Shock O thers • Primarygraft dysfunction2 Primarygraft dysfunction0: noedemaonchest X-raywithanyPaO 2 /FIO 2 Primarygraft dysfunction1: edemaonchest X-raywithPaO 2 /FIO 2 > 300 Primarygraft dysfunction2: edemaonchest X-raywithPaO 2 /FIO 2 200–300* Primarygraft dysfunction3: edemaonchest X-raywithPaO 2 /FIO 2 < 200† • Donor-associatedpneumonia • V entilator-associatedpneumonia • Acuterejection • Bronchial anastomotic complications(dehiscence) • C ardiogenic pulmonaryedema • Pulmonaryveinanastomotic obstruction • Pulmonaryembolism • Hemothorax • W holelungor lobar torsion • Phrenic nerveinjury • Hemorrhagic • Distributive(septic) • Infection • Arrhythmias • C ardiogenic (right ventricular failure, left ventricular failure) • P ostoperativepericarditis • G astroesophageal reflux • O bstructive(tamponade, pulmonaryembolism)• Bowelobstruction, perforation,ischemia • Immunosuppressionsideeffects • C NScomplications • IC Uacquiredweakness Primary graft dysfunction is graded at four timepoints, every 24h, over the first 72h after transplantation (0, 24, 48, and 72h). Primary graft dysfunction in recipients treated with noninvasiveventilationshouldbegradedaccordingtoPao2 /FIO 2 ratioasfor invasivemechanical ventilation. *If P ao2 /FIO 2 ratiois not available, oxygen saturation/FIO 2 ratio235 to315 is used instead of P ao2 /FIO 2 ratio200 to300. †U se of extracorporeal membrane oxygenation with pulmonary edemaisgradedasprimarygraft dysfunction3. E xtracorporeal membraneoxygenationfor cardiac indication(without pulmonaryedema)isungradable. C NS, central nervoussystem; FIO 2 , inspiredoxygenfraction; IC U , intensivecareunit.
  • 8. 2016 ISHLT PGD taxonomy
  • 9. Diamond JM, et al. Am J Respir Crit Care Med 2013
  • 11. Mechanical Ventilation Goals: provide adequate gas exchange minimize respiratory distress assess graft function minimize ventilator-induce lung injury optimize alveolar recruitment facilitate bronchial toileting facilitate early weaning
  • 12. Protective settings, early weaning and extubation to minimize ventilator-induced lung injury. Initial ventilator settings: • Tidal volume: 6 ml/kg predicted body weight (donor) • Inspiratory plateau pressure <30 cmH2O • SpO2 > 90% and pH > 7.25 • PEEP (cmH2O) adjusted according to the ARDS network table, but avoiding PEEP level >12-14 cmH2O FiO2 0.3 0.4 0.5 0.6-0.7 0.8-1 PEEP 5 5-8 8-10 10-12 12-14 - If PaO2/FiO2 > 200 and pH >7.25 • Wean sedation • Tidal volume: 6-8 ml/Kg predicted body weight (donor), • Inspiratory plateau pressure: < 25 cmH2O • Early extubation (SBT twice daily : 8 am, and 4 pm, for the first 2 days post LTx) - If PaO2/FiO2 < 200 • maintain sedation • initial ventilator settings with tidal volume: ≤ 6 ml/Kg, predicted body weight (donor) • Inspiratory plateau pressure: < 25 cmH2O • Driving pressure < 15 cmH2O • PEEP: adjust according to ARDS network table* • Respiratory Rate: < 35 breaths/minute - If PaO2/FiO2 < 150 • consider neuromuscular blockade • consider inhaled NO - If PaO2/FiO2 < 100 • contact ICU attending and LTx team for additional help • consider ECMO Mechanical Ventilation
  • 13. Continuous multimodal hemodynamic monitoring (Swan Ganz catheter) and careful fluid management to achieve adequate end-organ perfusion while avoiding lung reperfusion injury • mean arterial pressure: 65-75 mmHg • cardiac index: 2.2-2.5 l·min–1·m–2 • central venous pressure: ≤ 7 mmHg • wedge pressure or left atrial pressure: ≤ 10 mmHg • diuresis > 0.5 ml/kg/hour Hemodynamics And Fluid Management
  • 15. RV Pre-load After-load Contractility PVR (RV after-load) Post DLTx LV Pre-load After-load Contractility PAS and PAD PA flow=cardiac output CVP (RV pre-load) PAOP (LV pre-load) Hemodynamic monitoring (PAC) LV-RV interaction
  • 16. RV Contractility (inotropes) PVR (RV after-load) Post DLTx PGD 3 LV After-load: MAP 65-75 mmHg (vasopressors, vasoldilators, sedation, PEEP) Contractility (inotropes) mPAP < 20 mmHg CI= 2.2-2.5 CVP (RV pre-load) <8 mmHg (fluids/furosemide, PEEP) PAOP (LV pre-load) < 10 mmHg (fluids/furosemide, PEEP) LV-RV interaction PAD-PAOP, pO2, pCO2, MV settings, sedation, iNO End organ perfusion monitoring: SvO2, lactate, u/o, pH, HCO3-, temperature Lung function monitoring: P/F, Vd/Vt, compliance, CXR, EVLW (?)
  • 18. Atrial fibrillation/flutter is fairly common after lung transplantation and usually transient. The incidence peaks at 48-72 hours post-op. The impact of atrial fibrillation/flutter on in-hospital and long-term mortality is unclear. Most patients return to sinus rhythm before discharge. Assessment 1. Obtain ECG, review telemetry and confirm diagnosis (Afib/flutter vs other arrhythmias e.g Multifocal atrial tachycardia, frequent APB’s) 2. Obtain ABG and troponin 3. Assess MAP and mPAP 4. Review pre-op cath/echo if available –assess LV function, LA dimension/index (note if significant LV dysfunction or severe LA enlargement), review cardiac Hx 5. Assess and optimize triggering risk factors for peri-op arrhythmias - Electrolytes imbalance, including sodium, potassium, magnesium, calcium, and phosphate - Altered gas exchange - Pain - Intravascular volume status considering hypovolemia or atrial dilation/acute atrial stretch (CVP, Wedge pressure, ECHO) - Medications (vasopressors, inotropes, etc.) - Airway issues (re: endotracheal tube, anastomosis) - Pericardial effusion/tamponade (CVP, Wedge pressure, ECHO) New onset Atrial fibrillation/flutter
  • 19. Treatment If the patient is hemodynamically unstable (cfr: hypotension, myocardial ischemia, CHF/ acute pulmonary edema) I. Administer Magnesium 2-4 gr/100ml [Transient adverse effects: hypotension, flushing, tingling, and dizziness (Monitor Mg level keep >1)] II. Synchronised Electrical cardioversion III. Address triggering risk factors IV. If electrical cardioversion is unsuccessful –recurrent Afib/flutter or paroxysmal Afib/flutter is present. Call attending staff Consider re-cardioverison after managing triggering factors. Reconsider triggering risk factors Consider Sotalol: 40-160 mg orally every 12 h (Dosing interval adjusted in patients with AKI) Re-consider electrical cardioversion (after Sotalol treatment) Consider cardiology/EP consultations – if this is first afib/flutter (<24hours) attempt to be made to restore rhythm. Amiodarone should be avoided and considered only as last option after consultation with LTx team (one time bolus dose 150-300mg infusion over 30-45mins can be considered after consultation with Lung Transplant team) re-attempt electrical cardioversion post amiodarone bolus if rapid afib persists followed by continuation of betablocker for maintenance. New onset Atrial fibrillation/flutter
  • 20. Treatment If the patient is hemodynamically stable history of previous Afib – Rate Control strategy can be considered (target HR<110bpm). I. Administer Magnesium 2-4 gr/100ml [Transient adverse effects: hypotension, flushing, tingling, and dizziness] II. Address triggering risk factors III. If Afib/flutter persists, Afib/flutter is recurrent, or paroxysmal Afib/flutter is present a. Reconsider triggering risk factors b. Consider rate control agents, such as - metoprolol, esmolol - Digoxin -Diltiazem - contact LTx team to adjust IS - Electrical cardioversion Amiodarone should be avoided – for rate control – Propafenone or Flecainide can be considered in consultation with Cardiology/EP and Lung transplant team (if no evidence of significant CAD and renal dysfunction). If Afib/flutter (persistent or paroxysmal) persists for longer than 24-48 hours consider anticoagulation with iv heparin and discuss bleeding risk with the LTx team. New onset Atrial fibrillation/flutter
  • 21. Maintain a caloric intake of 25-30 kcal/kg; if indirect calorimetry is not available, maintain normal glucose blood level (45-65% of total calories), lipid: 20-35% of total calories, protein: 1.3-2.5 g/kg/day Micronutrients and electrolytes intake: maintain normal sodium, potassium and magnesium levels. Supplement calcium, vitamin A, C and D • Early enteral nutrition to prevent muscle mass loss • Use of non-pharmacologic (sleeping with 30° bed position) and pharmacologic interventions (proton pump inhibitors and prokinetics) to prevent and manage gastro- oesophageal reflux and DIOS (CF) Early abdominal computed tomography with iv. contrast in presence of even minor clinical suspicion of abdominal complications Nutritional support And GI Management
  • 22. Maintenance therapy: triple-drug therapy including calcineurin inhibitors, cell-cycle inhibitors and steroids Induction Therapy: in patients at risk of renal dysfunction consider basiliximab Immunosuppression
  • 23. Antibiotics: empiric broad spectrum antibiotic prophylaxis for 72 hours, awaiting final results of donor and recipient bronchoalveolar lavage cultures. Consider multidrug resistance coverage. Treatment of confirmed infections with tailored therapy. Antivirals: cytomegalovirus prophylaxis (according to donor/recipient status) Pneumocystis Jirovecii prophylaxis Antifungals: consider prophylaxis in colonized recipients. Treatment of confirmed fungal infection Antimicrobials
  • 24. Donor factors Bacterial or fungal allograft colonization Allograft latent infection (toxoplasma, cytomegalovirus, other viruses, endemic mycosis, tuberculosis) Recipient factors: preoperative Age Diabetes Hypogammaglobulinemia Renal failure No immunity against cytomegalovirus, toxoplasmosis, rubeola virus, varicella zoster virus Latent infection tuberculosis, cytomegalovirus, herpes simplex virus, varicella zoster virus, Epstein–Barr virus, endemic mycosis Colonization with multidrug resistant micro- organisms Immunosuppressive therapy Rejection Environmental exposure (gardener, animals, caves, travel) Native lung colonization Recipient factors: preoperative Allograft injury (ischemia, preservation, reperfusion) Complexity and length of surgery Post-surgical care (mechanical ventilation, intravenous catheters, drains, bladder catheter, extracorporeal membrane oxygenation) Transfusion Intensive care stay
  • 25. • Adequate pain control • Early mobilization to prevent ICU-acquired weakness • Early delirium screening and treatment • Sleep hygiene • Benzodiazepines-free sedation • Hyperammonemia screening and source control • Posterior reversible encephalopathy syndrome prevention Prevention of Neurological dysfunction
  • 26. Measure ammonia in every LTx patient on any admission to the ICU systematically for 14 days on the transplant admission and readmission on the transplant admission After 14 days, measure ammonia in every LTx patient requiring prolonged sedation (every day till the patient is awake and alert) Measure ammonia in every LTx patient with altered LOC If ammonia >72 mmol/L (normal range 18-72 mmol/L; critical level >100 mmol/L) - start immediately conventional HD (SLEDD is not as efficient in ammonia removal), especially if >ammonia is >100 mmol/L - send blood cultures and consider BAL - start empiric IV Abx (moxifloxacin 400mg/day, and doxycycline 100 mg q12h) - monitor neuro-vitals q1h - Contact ICU attending (ICU attending calls staff nephrologist) - contact LTx team - contact Tx ID (cultures for Mycoplasma Hominis, Ureaplasma urealyticum and Ureaplasma parvum) - monitor ammonia level q12h until normalized, then q24h for 3 days, and then as per protocol Hyperammonemia

Editor's Notes

  1. Operative 30-day mortality rate: #deaths within 30 days post-LTx / #LTx within calendar year