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Post LTx ICU standardized
management protocol
General goals
1. Prevention of PGD
Major risk factors for PGD:
-donor smoking
-FIO2 during allograft reperfusion
-single lung/lobar transplant
-use of intra-op cardiopulmonarybypass
-body mass index >25
-pre-operative pulmonary arterial hypertension
-blood transfusion >1L
2. Careful fluid management to avoid lung edema preserving adequate end-
organ perfusion
-Intravascular volume is carefully managed with the combinations
of blood products, colloids/cristalloids, and diuretics, to aim for
euvolemia or slightly negative fluid balance, preserving adequate
end-organ perfusion
3. Adequate pain management
4. Early weaning from sedation
5. Early extubation
6. Early mobilization
7. Immunosuppression
8. Antibiotic prophylaxis
Hemodynamic management
in LTx during the first 72 hours
1. Goal: to preserve adequate end-organ perfusion, minimizing the risk of
lung edema, by targeting the lowest CO (hence, the lowest lung perfusion
to minimize potential reperfusion injury) while avoiding shock, till
pulmonary capillary leak syndrome has resolved.
2. Confirm correct positioning of the PA catheter:
Correct measurement of the right atrial pressure (RAP) and PAOP requires
measuring the average of the A wave when the pressure waveform is correlated
to the simultaneously obtained ECG. The A wave of the RAP can be located in
the PR interval of the ECG, while the A wave of the PAOP can be found at the
end of or immediately after the QRS complex.
Post LTx ICU standardized management.docx
3. Monitor and record the following parameters as indicated below or more
frequently if clinically required
Parameters: Targets:
1. MAP (SAP, DAP) (q1h) 65 - 75 mmHg
2. HR (q1h) 60 - 100 b/min
3. CI (q1-4h) 2.2 – 2.5 L/min/m2
4. mPAP (PAS, PAD) (q1h) ≤ 20 mmHg
5. CVP (q1h) < 8 mmHg
6. PAOP (q4h) < 10 mmHg
7. PAD-WEDGE P (q4h) < 5 mmHg
8. SvO2 (q1-8h) > 60%
9. PH, PaO2, PaCO2 (HCO3) (q8h) > 7.30, > 60 mmHg, 30 - 45 mmHg
10.Lactate (q8h) ≤ 2.5 mmol/L
11.U/O (q1h) > 0.5 ml/kg/hr
12.Temperature (q1h) 35 - 38 °C
Consider the following algorithms especially in case of:
 Increased lactate >2.5
 Reduced SvO2/MvO2 <60
 P:F <300
 New onset of end organ dysfunction
Algorithms
Post LTx ICU standardized management.docx
Mechanical ventilation
management
in LTx in the first 72 hours
Goals
1. Provide adequate gas exchange
2. Minimize respiratory distress
3. Minimize ventilator-induce lung injury
4. Optimize alveolar recruitment
5. Facilitate bronchial toileting
6. Facilitate early weaning and extubate as early as possible (even in the
evening)
Initial mechanical ventilation settings
Strategy Targets
Pressure controlled ventilation -> early weaning
Minimize tidal volume/distending pressure -> Vt 4-6 cc/kg PBW
Pplat < 30 cmH2O
DrivingP < 14 cmH2O
Minimize FiO2 -> SpO2 ≥ 90%
Optimize PEEP -> maintain alveolar recruitment
PEEP/FiO2 table: (modified standard ventilation table)
FiO2 0.3 0.4 0.5 0.6-0.7 0.8-1*
PEEP 5 5-8 8-10 10-12 12-14
*consider ECLS for severe hypoxemia and high airway pressure (Pplat >30 cmH2O,
DrivingP > 14 cmH2O)
Minimize respiratory rate -> RR < 25 b/min
(especially in Single LTx for COPD) pH > 7.30
Maximize expiratory time -> I:E ≤ 1:3, 1:4
(especially in Single LTx for COPD)
Perform the first ABG after ICU admission on 100% FiO2
Follow the spontaneous breathing trial (SBT) policy (twice daily: during the initial major
assessment, and during the last assessment of ventilation round, for the first 2 days post
LTx): SBT duration is 30-60 min according to the risk of extubation failure.
After 5 days of continuous MV, or after failed extubation: consider tracheostomy, which
allows easier mobility and better patient comfort, oral hygiene, and clearance of
pulmonary secretions
Monitoring
Monitor and record the following parameters as indicated below or more frequently if
clinically required:
1. Ppeak (q1h)
2. Pplat (q1h)
3. Intrinsic PEEP (q1h)
4. Vt (q1h)
5. RR (q1h)
6. I:E (q1h)
7. Endotracheal tube/tracheostomy tube: check position and quality quantity of
secretions (q1h)
8. Analgesia (q1h)
9. Hemodynamics (see protocol)
10. Agitation/delirium (q1h)
11. CXR daily for the first 3 days
12. Chest tubes (q1h): hourly output (call if > 100 ml/h), air-leak
13. ABG: document P/F ratio post ICU admission at hour: 1 (the first ABG is
measured with FiO2 100% for 10 min but no longer than 10 min), 24, 48, and 72.
And as clinical indicated.
Management
P/F ≥ 200 and pH >7.25:
Follow SBT policy
Wean iNO as tolerated per policy
Wean sedation and analgesia, treat agitation
Assess CXR, endotracheal secretions (suctioning), and chest tube output/leak
Wean MV to assisted modality of MV (eg. PSV) if tolerated, maintaining inspiratory Pplat <
25 cmH2O
Follow the spontaneous breathing trial (SBT) policy (twice daily : 8 am, and 4 pm, for the
first 2 days post LTx)
After 5 days of continuous MV, or after failed extubation: consider tracheostomy
P/F < 200:
Maintain sedation/analgesia, targeting SAS 1-3
Assess CXR, endotracheal secretions, and chest tube output/leak
Maintain controlled modality of MV with protective settings (see above)
P/F < 150:
As above
Consider neuromuscular blockade
Consider iNO
P/F < 100:
Contact ICU attending and LTx team for additional help
Consider ECLS
Citywide spontaneous breathing trial (SBT) Policy
Procedure Overview
1. Twice a day, the RRT will perform a SBT Patient Safety Screen in
consultation with the inter-professional patient care team. The RRT will
assess and determine if an SBT is to be performed by responding to the
following questions:
a. Does the patient make spontaneous inspiratory efforts (e.g. patient
triggered breaths, diaphragm excursion)? If not, consider reducing
minute ventilation (VE), or changing patient to a spontaneous mode
to detect breathing efforts.
NOTE: Ensure to return ventilator back to previous settings if
no spontaneous inspiratory efforts are noted.
b. Is the patient’s PaO2/FiO2 ratio of ≥200 and their FiO2 ≤ 0.50?
c. Is the patient receiving <0.2 mcg/kg/min or equivalent and on no
more than 1 vasoactive drug.
d. In patients with acute brain injury the RRT needs to assess the
following question:
i. Is the patient’s neurological condition stable with no
concerns about elevated intracranial pressure? (e.g. ICP has
been stable and not requiring treatment for >24 hours, this
includes active CO2 control.)
2. If all of the above questions are answered YES, the RRT will conduct an
SBT.
3. If any of the above questions are answered NO, the RRT will not perform
an SBT. The RRT will continue mechanical ventilation and repeat the SBT
safety screen in 24 hours or earlier as appropriate. The results of the SBT
screen should be discussed with the interprofessional team.
4. To place the patient on an SBT the RRT will do the following:
a. All patients being weaned from ventilatory support will be monitored
continuously by telemetry and pulse oximetry.
b. Ensure the patient is in a sitting or semi-recumbent position.
c. Place the patient on the following ventilator settings:
i. Mode: CPAP [2]
ii. PEEP of 0 cmH2O [3]
iii. FiO2 – unchanged from screening setting
iv. Ensure tube compensation functions are turned off , if
applicable
d. Monitor closely for “tolerance” (see definition below). If SBT is not
tolerated, immediately return patient to ventilator settings that were
previously set before initiation of the SBT trial or settings to meet
physiological goals and patient comfort.
e. Two (2) minutes after the SBT settings have been initiated the, RRT
will calculate and document the rapid shallow breathing index
(RSBI) of the patient. RSBI is the ratio of respiratory frequency (f,
breaths/min) to tidal volume (Vt, litres) computed as f/Vt.
f. Note: If RSBI > 110 active monitoring of patient for the next fifteen
minutes is required.
g. The patient should be monitored on these settings for 30 to 60
minutes to determine if the SBT has been successful.
5. The RRT will determine if the patient tolerated the spontaneous breathing
trial by assessing if the patient demonstrates any of the following failure
criteria:
a. Respiratory rate of >35 breaths per minute AND signs of respiratory
distress for greater than 5 minutes.
Note: respiratory distress may be characterized by
anxiety, diaphoresis, accessory muscle use, tracheal
tugging, and/or altered level of consciousness. An
elevated respiratory rate in isolation may not indicate
respiratory distress
b. A sustained SpO2<88% for more than two (2) minutes
c. A change (increase or decrease) in baseline heart rate of > 25%
d. A change (increase or decrease) in baseline mean arterial blood
pressure of >25%
6. If the patient displays any of the above symptoms or signs of intolerance
to the SBT, the RRT will conclude that the patient failed the SBT. The RRT
will restart mechanical ventilation as per previous settings or settings to
meet physiological goals and patient comfort.
7. The RRT will document which SBT failure criteria the patient met. The
results of the SBT should be discussed with the Interprofessional team.
Note: If a patient has failed 3 consecutive SBTs, the RRT will
communicate that to the interprofessional team in order to reassess
weaning and care plan.
8. If the patient tolerates the SBT for >30 to 60 minutes without meeting any
intolerance criteria, the RRT will place the patient on minimal ventilator
support (e.g. PS of 5cmH2O & PEEP of 5cmH2O and will inform the
interprofessional team that the patient has passed their SBT. At this time
the interprofessional team should consider extubation. If the patient
passes the SBT trial and is not extubated, the RRT will document the
reason for this decision.
References
1. Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, Johnson MM, Browder RW, Bowton DL,
Haponik EF. Effect on the duration of mechanical ventilation of identifying patients capable of breathing
spontaneously. N Engl J Med 1996;335:1864–1869.
2. Yang K, Tobin MJ, A prospective study of indexes predicting the outcome of weaning from mechanical
ventilation. N Engl J Med 1991;324:1445-1450
3. Straus C, Louis B, Isabey D, Lemaire F, Harf A, Brochard L. Contribution of the endotracheal tube and the
upper airway to breathing workload. Am J Respir Crit Care Med 1998;157:23–30
4. Cabello B, Thille AW, Roche-Campo F, Brochard L, Gómez FJ, Mancebo J. Physiological comparison of three
spontaneous breathing trials in difficult-to-wean patients. Intensive Care Medicine 2010;36:1171–1179.
Management of new onset
of atrial fibrillation/flutter
post-LTx (duration < 48 hours)
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)
-
Treatment
1. 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.
a. Call attending staff
b. Consider re-cardioverison after managing triggering
factors.
c. Reconsider triggering risk factors
d. Consider Sotalol: 40-160 mg orally every 12 h
Dosing interval should be adjusted in patients
with acute kidney injury or chronic kidney
disease:
Monitor
QT interval prolongation – will require QTc
monitoring (baseline ECG, serial ECG post
sotalol treatment, avoid other QT prolonging
drugs (eg. PPI)
Torsades de pointes
Heart failure exacerbation
Risk of torsades de pointes greater in patients
with heart failure
Bronchospasm
Contraindicated in patients with pretreatment
QTc interval>470 ms (men) or 480 ms
(women).
c. Re-consider electrical cardioversion (after Sotalol
treatment)
d. Consider cardiology/EP consultations – if this is first
afib/flutter (<24hours) attempt to be made to restore
rhythm.
e. 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.
2. If the patient is hemodynamically stable
3. 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 (trial with esmolol can be
consider in patients with “soft” blood pressure),
- Digoxin (if normal renal function digitalization
dose e.g 0.5mg i/v or po bid total 1gm on day 1
followed by maintenance dose.
-Diltiazem (start with short acting divided dose
followed by continuous dose)- contact LTx team to
adjust IS
- Electrical cardioversion
c. Amiodarone should be avoided – for rate control
4. Alternative to Amiodarone for rhythm control in cases of paroxysmal Afib –
Propafenone or Flecainide can be considered in consultation with
Cardiology/EP and Lung transplant team (if no evidence of significant CAD
and renal dysfunction).
4. If Afib/flutter (persistent or paroxysmal) persists for longer than 24-48
hours consider anticoagulation with iv heparin (no bolus) and discuss
bleeding risk with the LTx team.
References
1. Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE, Calkins H, Aranki S, Kaneko T, Cassivi
S, Smith SC Jr, Darbar D, Wee JO, Waddell TK, Amar D, Adler D; American Association for Thoracic Surgery. 2014
AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical
procedures. J Thorac Cardiovasc Surg. 2014 Sep;148(3):e153-93.
2. Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE, Calkins H, Aranki S, Kaneko T, Cassivi
S, Smith SC Jr, Darbar D, Wee JO, Waddell TK, Amar D, Adler D; American Association of Thoracic Surgery. 2014 AATS
guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures.
Executive summary. J Thorac Cardiovasc Surg. 2014 Sep;148(3):772-91.
3. Isiadinso I, Meshkov AB, Gaughan J, Sandhu P, Lim S, Cordova F, Criner G. Atrial arrhythmias after lung and
heart-lung transplant: effects on short-term mortality and the influence of amiodarone. J Heart Lung Transplant. 2011
Jan;30(1):37-44.
4. Mason DP, Marsh DH, Alster JM, Murthy SC, McNeill AM, Budev MM, Mehta AC, Pettersson GB, Blackstone
EH. Atrial fibrillation after lung transplantation: timing, risk factors, and treatment. Ann Thorac Surg. 2007 Dec;84(6):1878-
84.
5. Henri C, Giraldeau G, Dorais M, Cloutier AS, Girard F, Noiseux N, Ferraro P, Rinfret S. Atrial fibrillation after
pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors. Circ Arrhythm
Electrophysiol. 2012 Feb;5(1):61-7.
6. Orrego CM, Cordero-Reyes AM, Estep JD, Seethamraju H, Scheinin S, Loebe M, Torre-Amione G. Atrial
arrhythmias after lung transplant: underlying mechanisms, risk factors, and prognosis. J Heart Lung Transplant. 2014
Jul;33(7):734-40.
Management of
Hyperammonemia
post-LTx
Monitoring
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
Intervention
If ammonia >72 mmol/L (normal range 18-72 mmol/L; critical level >100 mmol/L)
- start immediately continuous conventional HD (SLEDD is not as efficient in
ammonia removal)
- 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)
- send blood cultures and send BAL
- start empiric IV Abx (moxifloxacin 400mg/day, and doxycycline 100 mg
q12h)
- monitor ammonia level q12h until normalized, then q24h for 3 days, and
then as per protocol
References
1. Anwar S, Gupta D, Ashraf MA, Khalid SA, Rizvi SM, Miller BW, Brennan DC. Symptomatic hyperammonemia
after lung transplantation: Lessons learnt. Hemodialysis international International Symposium on Home Hemodialysis
2014;18:185-191.
2. Berry GT, Bridges ND, Nathanson KL, Kaplan P, Clancy RR, Lichtenstein GR, Spray TL. Successful use of
alternate waste nitrogen agents and hemodialysis in a patient with hyperammonemic coma after heart-lung
transplantation. Archives of neurology 1999;56:481-484.
3. Bharat A, Cunningham SA, Scott Budinger GR, Kreisel D, DeWet CJ, Gelman AE, Waites K, Crabb D, Xiao L,
Bhorade S, Ambalavanan N, Dilling DF, Lowery EM, Astor T, Hachem R, Krupnick AS, DeCamp MM, Ison MG, Patel R.
Disseminated ureaplasma infection as a cause of fatal hyperammonemia in humans. Science translational medicine
2015;7:284re283.
4. Clay AS, Hainline BE. Hyperammonemia in the icu. Chest 2007;132:1368-1378.
5. Hocker S, Rabinstein AA, Wijdicks EF. Pearls & oy-sters: Status epilepticus from hyperammonemia after lung
transplant. Neurology 2011;77:e54-56.
6. JM UK-I, Yu E, Bartlett E, Soobrah R, Kucharczyk W. Acute hyperammonemic encephalopathy in adults:
Imaging findings. AJNR American journal of neuroradiology 2011;32:413-418.
7. LaBuzetta JN, Yao JZ, Bourque DL, Zivin J. Adult nonhepatic hyperammonemia: A case report and differential
diagnosis. The American journal of medicine 2010;123:885-891.
8. Lichtenstein GR, Kaiser LR, Tuchman M, Palevsky HI, Kotloff RM, O'Brien CB, Furth EE, Raps EC, Berry GT.
Fatal hyperammonemia following orthotopic lung transplantation. Gastroenterology 1997;112:236-240.
9. Lichtenstein GR, Yang YX, Nunes FA, Lewis JD, Tuchman M, Tino G, Kaiser LR, Palevsky HI, Kotloff RM, Furth
EE, Bavaria JE, Stecker MM, Kaplan P, Berry GT. Fatal hyperammonemia after orthotopic lung transplantation. Annals of
internal medicine 2000;132:283-287.
10. Moffatt-Bruce SD, Pesavento T, Von Viger J, Nunley D, Pope-Harman A, Martin S, Ross P. Successful
management of immunosuppression in a patient with severe hyperammonemia after lung transplantation. The Journal of
heart and lung transplantation : the official publication of the International Society for Heart Transplantation 2008;27:801-
803.

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Post LTx ICU standardized management.docx

  • 1. Post LTx ICU standardized management protocol
  • 2. General goals 1. Prevention of PGD Major risk factors for PGD: -donor smoking -FIO2 during allograft reperfusion -single lung/lobar transplant -use of intra-op cardiopulmonarybypass -body mass index >25 -pre-operative pulmonary arterial hypertension -blood transfusion >1L 2. Careful fluid management to avoid lung edema preserving adequate end- organ perfusion -Intravascular volume is carefully managed with the combinations of blood products, colloids/cristalloids, and diuretics, to aim for euvolemia or slightly negative fluid balance, preserving adequate end-organ perfusion 3. Adequate pain management 4. Early weaning from sedation 5. Early extubation 6. Early mobilization 7. Immunosuppression 8. Antibiotic prophylaxis
  • 3. Hemodynamic management in LTx during the first 72 hours
  • 4. 1. Goal: to preserve adequate end-organ perfusion, minimizing the risk of lung edema, by targeting the lowest CO (hence, the lowest lung perfusion to minimize potential reperfusion injury) while avoiding shock, till pulmonary capillary leak syndrome has resolved. 2. Confirm correct positioning of the PA catheter:
  • 5. Correct measurement of the right atrial pressure (RAP) and PAOP requires measuring the average of the A wave when the pressure waveform is correlated to the simultaneously obtained ECG. The A wave of the RAP can be located in the PR interval of the ECG, while the A wave of the PAOP can be found at the end of or immediately after the QRS complex.
  • 7. 3. Monitor and record the following parameters as indicated below or more frequently if clinically required Parameters: Targets: 1. MAP (SAP, DAP) (q1h) 65 - 75 mmHg 2. HR (q1h) 60 - 100 b/min 3. CI (q1-4h) 2.2 – 2.5 L/min/m2 4. mPAP (PAS, PAD) (q1h) ≤ 20 mmHg 5. CVP (q1h) < 8 mmHg 6. PAOP (q4h) < 10 mmHg 7. PAD-WEDGE P (q4h) < 5 mmHg 8. SvO2 (q1-8h) > 60% 9. PH, PaO2, PaCO2 (HCO3) (q8h) > 7.30, > 60 mmHg, 30 - 45 mmHg 10.Lactate (q8h) ≤ 2.5 mmol/L 11.U/O (q1h) > 0.5 ml/kg/hr 12.Temperature (q1h) 35 - 38 °C Consider the following algorithms especially in case of:  Increased lactate >2.5  Reduced SvO2/MvO2 <60  P:F <300  New onset of end organ dysfunction
  • 11. Goals 1. Provide adequate gas exchange 2. Minimize respiratory distress 3. Minimize ventilator-induce lung injury 4. Optimize alveolar recruitment 5. Facilitate bronchial toileting 6. Facilitate early weaning and extubate as early as possible (even in the evening) Initial mechanical ventilation settings Strategy Targets Pressure controlled ventilation -> early weaning Minimize tidal volume/distending pressure -> Vt 4-6 cc/kg PBW Pplat < 30 cmH2O DrivingP < 14 cmH2O Minimize FiO2 -> SpO2 ≥ 90% Optimize PEEP -> maintain alveolar recruitment PEEP/FiO2 table: (modified standard ventilation table) FiO2 0.3 0.4 0.5 0.6-0.7 0.8-1* PEEP 5 5-8 8-10 10-12 12-14 *consider ECLS for severe hypoxemia and high airway pressure (Pplat >30 cmH2O, DrivingP > 14 cmH2O) Minimize respiratory rate -> RR < 25 b/min (especially in Single LTx for COPD) pH > 7.30 Maximize expiratory time -> I:E ≤ 1:3, 1:4 (especially in Single LTx for COPD) Perform the first ABG after ICU admission on 100% FiO2 Follow the spontaneous breathing trial (SBT) policy (twice daily: during the initial major assessment, and during the last assessment of ventilation round, for the first 2 days post LTx): SBT duration is 30-60 min according to the risk of extubation failure. After 5 days of continuous MV, or after failed extubation: consider tracheostomy, which allows easier mobility and better patient comfort, oral hygiene, and clearance of pulmonary secretions
  • 12. Monitoring Monitor and record the following parameters as indicated below or more frequently if clinically required: 1. Ppeak (q1h) 2. Pplat (q1h) 3. Intrinsic PEEP (q1h) 4. Vt (q1h) 5. RR (q1h) 6. I:E (q1h) 7. Endotracheal tube/tracheostomy tube: check position and quality quantity of secretions (q1h) 8. Analgesia (q1h) 9. Hemodynamics (see protocol) 10. Agitation/delirium (q1h) 11. CXR daily for the first 3 days 12. Chest tubes (q1h): hourly output (call if > 100 ml/h), air-leak 13. ABG: document P/F ratio post ICU admission at hour: 1 (the first ABG is measured with FiO2 100% for 10 min but no longer than 10 min), 24, 48, and 72. And as clinical indicated. Management P/F ≥ 200 and pH >7.25: Follow SBT policy Wean iNO as tolerated per policy Wean sedation and analgesia, treat agitation Assess CXR, endotracheal secretions (suctioning), and chest tube output/leak Wean MV to assisted modality of MV (eg. PSV) if tolerated, maintaining inspiratory Pplat < 25 cmH2O Follow the spontaneous breathing trial (SBT) policy (twice daily : 8 am, and 4 pm, for the first 2 days post LTx) After 5 days of continuous MV, or after failed extubation: consider tracheostomy P/F < 200: Maintain sedation/analgesia, targeting SAS 1-3 Assess CXR, endotracheal secretions, and chest tube output/leak Maintain controlled modality of MV with protective settings (see above) P/F < 150: As above Consider neuromuscular blockade Consider iNO P/F < 100: Contact ICU attending and LTx team for additional help Consider ECLS
  • 13. Citywide spontaneous breathing trial (SBT) Policy Procedure Overview 1. Twice a day, the RRT will perform a SBT Patient Safety Screen in consultation with the inter-professional patient care team. The RRT will assess and determine if an SBT is to be performed by responding to the following questions: a. Does the patient make spontaneous inspiratory efforts (e.g. patient triggered breaths, diaphragm excursion)? If not, consider reducing minute ventilation (VE), or changing patient to a spontaneous mode to detect breathing efforts. NOTE: Ensure to return ventilator back to previous settings if no spontaneous inspiratory efforts are noted. b. Is the patient’s PaO2/FiO2 ratio of ≥200 and their FiO2 ≤ 0.50? c. Is the patient receiving <0.2 mcg/kg/min or equivalent and on no more than 1 vasoactive drug. d. In patients with acute brain injury the RRT needs to assess the following question: i. Is the patient’s neurological condition stable with no concerns about elevated intracranial pressure? (e.g. ICP has been stable and not requiring treatment for >24 hours, this includes active CO2 control.) 2. If all of the above questions are answered YES, the RRT will conduct an SBT. 3. If any of the above questions are answered NO, the RRT will not perform an SBT. The RRT will continue mechanical ventilation and repeat the SBT safety screen in 24 hours or earlier as appropriate. The results of the SBT screen should be discussed with the interprofessional team. 4. To place the patient on an SBT the RRT will do the following: a. All patients being weaned from ventilatory support will be monitored continuously by telemetry and pulse oximetry. b. Ensure the patient is in a sitting or semi-recumbent position. c. Place the patient on the following ventilator settings: i. Mode: CPAP [2] ii. PEEP of 0 cmH2O [3]
  • 14. iii. FiO2 – unchanged from screening setting iv. Ensure tube compensation functions are turned off , if applicable d. Monitor closely for “tolerance” (see definition below). If SBT is not tolerated, immediately return patient to ventilator settings that were previously set before initiation of the SBT trial or settings to meet physiological goals and patient comfort. e. Two (2) minutes after the SBT settings have been initiated the, RRT will calculate and document the rapid shallow breathing index (RSBI) of the patient. RSBI is the ratio of respiratory frequency (f, breaths/min) to tidal volume (Vt, litres) computed as f/Vt. f. Note: If RSBI > 110 active monitoring of patient for the next fifteen minutes is required. g. The patient should be monitored on these settings for 30 to 60 minutes to determine if the SBT has been successful. 5. The RRT will determine if the patient tolerated the spontaneous breathing trial by assessing if the patient demonstrates any of the following failure criteria: a. Respiratory rate of >35 breaths per minute AND signs of respiratory distress for greater than 5 minutes. Note: respiratory distress may be characterized by anxiety, diaphoresis, accessory muscle use, tracheal tugging, and/or altered level of consciousness. An elevated respiratory rate in isolation may not indicate respiratory distress b. A sustained SpO2<88% for more than two (2) minutes c. A change (increase or decrease) in baseline heart rate of > 25% d. A change (increase or decrease) in baseline mean arterial blood pressure of >25% 6. If the patient displays any of the above symptoms or signs of intolerance to the SBT, the RRT will conclude that the patient failed the SBT. The RRT will restart mechanical ventilation as per previous settings or settings to meet physiological goals and patient comfort. 7. The RRT will document which SBT failure criteria the patient met. The results of the SBT should be discussed with the Interprofessional team.
  • 15. Note: If a patient has failed 3 consecutive SBTs, the RRT will communicate that to the interprofessional team in order to reassess weaning and care plan. 8. If the patient tolerates the SBT for >30 to 60 minutes without meeting any intolerance criteria, the RRT will place the patient on minimal ventilator support (e.g. PS of 5cmH2O & PEEP of 5cmH2O and will inform the interprofessional team that the patient has passed their SBT. At this time the interprofessional team should consider extubation. If the patient passes the SBT trial and is not extubated, the RRT will document the reason for this decision. References 1. Ely EW, Baker AM, Dunagan DP, Burke HL, Smith AC, Kelly PT, Johnson MM, Browder RW, Bowton DL, Haponik EF. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996;335:1864–1869. 2. Yang K, Tobin MJ, A prospective study of indexes predicting the outcome of weaning from mechanical ventilation. N Engl J Med 1991;324:1445-1450 3. Straus C, Louis B, Isabey D, Lemaire F, Harf A, Brochard L. Contribution of the endotracheal tube and the upper airway to breathing workload. Am J Respir Crit Care Med 1998;157:23–30 4. Cabello B, Thille AW, Roche-Campo F, Brochard L, Gómez FJ, Mancebo J. Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients. Intensive Care Medicine 2010;36:1171–1179.
  • 16. Management of new onset of atrial fibrillation/flutter post-LTx (duration < 48 hours)
  • 17. 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) - Treatment 1. 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. a. Call attending staff b. Consider re-cardioverison after managing triggering factors. c. Reconsider triggering risk factors d. Consider Sotalol: 40-160 mg orally every 12 h
  • 18. Dosing interval should be adjusted in patients with acute kidney injury or chronic kidney disease: Monitor QT interval prolongation – will require QTc monitoring (baseline ECG, serial ECG post sotalol treatment, avoid other QT prolonging drugs (eg. PPI) Torsades de pointes Heart failure exacerbation Risk of torsades de pointes greater in patients with heart failure Bronchospasm Contraindicated in patients with pretreatment QTc interval>470 ms (men) or 480 ms (women). c. Re-consider electrical cardioversion (after Sotalol treatment) d. Consider cardiology/EP consultations – if this is first afib/flutter (<24hours) attempt to be made to restore rhythm. e. 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. 2. If the patient is hemodynamically stable 3. 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 (trial with esmolol can be consider in patients with “soft” blood pressure),
  • 19. - Digoxin (if normal renal function digitalization dose e.g 0.5mg i/v or po bid total 1gm on day 1 followed by maintenance dose. -Diltiazem (start with short acting divided dose followed by continuous dose)- contact LTx team to adjust IS - Electrical cardioversion c. Amiodarone should be avoided – for rate control 4. Alternative to Amiodarone for rhythm control in cases of paroxysmal Afib – Propafenone or Flecainide can be considered in consultation with Cardiology/EP and Lung transplant team (if no evidence of significant CAD and renal dysfunction). 4. If Afib/flutter (persistent or paroxysmal) persists for longer than 24-48 hours consider anticoagulation with iv heparin (no bolus) and discuss bleeding risk with the LTx team. References 1. Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE, Calkins H, Aranki S, Kaneko T, Cassivi S, Smith SC Jr, Darbar D, Wee JO, Waddell TK, Amar D, Adler D; American Association for Thoracic Surgery. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg. 2014 Sep;148(3):e153-93. 2. Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE, Calkins H, Aranki S, Kaneko T, Cassivi S, Smith SC Jr, Darbar D, Wee JO, Waddell TK, Amar D, Adler D; American Association of Thoracic Surgery. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. Executive summary. J Thorac Cardiovasc Surg. 2014 Sep;148(3):772-91. 3. Isiadinso I, Meshkov AB, Gaughan J, Sandhu P, Lim S, Cordova F, Criner G. Atrial arrhythmias after lung and heart-lung transplant: effects on short-term mortality and the influence of amiodarone. J Heart Lung Transplant. 2011 Jan;30(1):37-44. 4. Mason DP, Marsh DH, Alster JM, Murthy SC, McNeill AM, Budev MM, Mehta AC, Pettersson GB, Blackstone EH. Atrial fibrillation after lung transplantation: timing, risk factors, and treatment. Ann Thorac Surg. 2007 Dec;84(6):1878- 84. 5. Henri C, Giraldeau G, Dorais M, Cloutier AS, Girard F, Noiseux N, Ferraro P, Rinfret S. Atrial fibrillation after pulmonary transplantation: incidence, impact on mortality, treatment effectiveness, and risk factors. Circ Arrhythm Electrophysiol. 2012 Feb;5(1):61-7. 6. Orrego CM, Cordero-Reyes AM, Estep JD, Seethamraju H, Scheinin S, Loebe M, Torre-Amione G. Atrial arrhythmias after lung transplant: underlying mechanisms, risk factors, and prognosis. J Heart Lung Transplant. 2014 Jul;33(7):734-40.
  • 21. Monitoring 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 Intervention If ammonia >72 mmol/L (normal range 18-72 mmol/L; critical level >100 mmol/L) - start immediately continuous conventional HD (SLEDD is not as efficient in ammonia removal) - 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) - send blood cultures and send BAL - start empiric IV Abx (moxifloxacin 400mg/day, and doxycycline 100 mg q12h) - monitor ammonia level q12h until normalized, then q24h for 3 days, and then as per protocol References 1. Anwar S, Gupta D, Ashraf MA, Khalid SA, Rizvi SM, Miller BW, Brennan DC. Symptomatic hyperammonemia after lung transplantation: Lessons learnt. Hemodialysis international International Symposium on Home Hemodialysis 2014;18:185-191. 2. Berry GT, Bridges ND, Nathanson KL, Kaplan P, Clancy RR, Lichtenstein GR, Spray TL. Successful use of alternate waste nitrogen agents and hemodialysis in a patient with hyperammonemic coma after heart-lung transplantation. Archives of neurology 1999;56:481-484. 3. Bharat A, Cunningham SA, Scott Budinger GR, Kreisel D, DeWet CJ, Gelman AE, Waites K, Crabb D, Xiao L, Bhorade S, Ambalavanan N, Dilling DF, Lowery EM, Astor T, Hachem R, Krupnick AS, DeCamp MM, Ison MG, Patel R. Disseminated ureaplasma infection as a cause of fatal hyperammonemia in humans. Science translational medicine 2015;7:284re283. 4. Clay AS, Hainline BE. Hyperammonemia in the icu. Chest 2007;132:1368-1378. 5. Hocker S, Rabinstein AA, Wijdicks EF. Pearls & oy-sters: Status epilepticus from hyperammonemia after lung transplant. Neurology 2011;77:e54-56. 6. JM UK-I, Yu E, Bartlett E, Soobrah R, Kucharczyk W. Acute hyperammonemic encephalopathy in adults: Imaging findings. AJNR American journal of neuroradiology 2011;32:413-418. 7. LaBuzetta JN, Yao JZ, Bourque DL, Zivin J. Adult nonhepatic hyperammonemia: A case report and differential diagnosis. The American journal of medicine 2010;123:885-891. 8. Lichtenstein GR, Kaiser LR, Tuchman M, Palevsky HI, Kotloff RM, O'Brien CB, Furth EE, Raps EC, Berry GT. Fatal hyperammonemia following orthotopic lung transplantation. Gastroenterology 1997;112:236-240. 9. Lichtenstein GR, Yang YX, Nunes FA, Lewis JD, Tuchman M, Tino G, Kaiser LR, Palevsky HI, Kotloff RM, Furth EE, Bavaria JE, Stecker MM, Kaplan P, Berry GT. Fatal hyperammonemia after orthotopic lung transplantation. Annals of internal medicine 2000;132:283-287. 10. Moffatt-Bruce SD, Pesavento T, Von Viger J, Nunley D, Pope-Harman A, Martin S, Ross P. Successful management of immunosuppression in a patient with severe hyperammonemia after lung transplantation. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation 2008;27:801- 803.