This document discusses best practices for caring for lung transplant recipients in the ICU. It covers indications for ECMO pre-transplant as a bridge to transplant, features and treatment of primary graft dysfunction post-transplant, and appropriate ventilation and hemodynamic support. It also provides guidance for community hospitals on evaluating and initially managing lung transplant patients who present with complications.
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
Ventilatory management in obstructive airway diseasesVitrag Shah
Presentation on ventilatory management in COPD & Asthma
Updated information till 26/5/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36441-ventilatory-management-obstructive-airway-diseases-presentation.html
This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
Ventilatory management in obstructive airway diseasesVitrag Shah
Presentation on ventilatory management in COPD & Asthma
Updated information till 26/5/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36441-ventilatory-management-obstructive-airway-diseases-presentation.html
This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.
Hergen Buscher is an Intensivist from St Vincent's hospital in Sydney. He has extensive experience with ECMO, in both veno-venous and veno-arterial contexts. Listen to this talk he gave on the most recent developments in ECMO and where things are heading.
This talk was given live in September 2014 for an Intensive Care Network (ICN) NSW meeting.
Go to www.intensivecarenetwork.com for more.
Psychological and Behavioral Implications in Older Adults with CancerSpectrum Health System
Through Case Presentation and Dydactics, participants will gain an understanding of the psychological and behavioral impact cancer has on older adults.
Patient Directed Care; Why it’s important and what does it really mean?Spectrum Health System
Understanding the importance of effective patient centered communication for patient engagement and improved health outcomes. Will discuss the importance of patient directed care and its relationship to the quadruple aim. Will discuss the barriers and a framework for conversations that are critical to patient directed care and cultural competency.
This presentation will review the current research around medical marijuana and discuss the issues around the recent legalization of recreational use. We will explore common clinical questions regarding marijuana use including testing and concurrent controlled substance use.
Leveraging Mobile Apps and Digital Therapeutics to Improve Behavioral HealthSpectrum Health System
In this presentation, the top apps and digital therapeutics for behavioral health, with a focus on stress, depression, and anxiety, will be reviewed including a summary of program offerings and patient outcomes. Strategies for embedding digital health programs as complements to traditional behavioral health treatment will be discussed. The design and results of a recent implementation of mobile app prescriptions as part of standard care in 12 clinical areas with 70 plus prescribing providers will be described. Engagement and acceptability data from patients and providers will be shared. Strategies for developing standard work and governance for this new category of behavioral health treatment will be offered. Discussion will center on how mobile health represents a high value, low-cost care transformation for the future of health care.
Into the Great Wide Open: Introduction to Telemental Health PracticeSpectrum Health System
This presentation will explore the changing landscape of telemedicine, specifically the evolving practice of telemental health. Opportunities and challenges facing telemental health practitioners and patients will be explored to enhance attendees' knowledge on the topic. Ethical and legal considerations will be explored as well.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
2. 2
ICU Care of the Lung
Transplant Recipient
4th Annual Topics in Pulmonary and
Critical Care Medicine
Ryan Hadley MD
Spectrum Health and Richard DeVos Lung
Transplant Program
[Master name: Solid Color Background]
4. Learning Objectives
• Recognize indications and techniques for
peri-transplant application of ECMO
• Understand the salient features of primary
graft dysfunction
• Describe appropriate ventilatory and
hemodynamic support
5. Learning Objectives
• Clinical pearls for lung transplant patients
admitted to outlying hospitals (especially in
off hours)
6. Lung Transplant
• Often only treatment for end stage lung
disease
• 3973 adult lung transplant performed in
20141
• 94 centers perform transplants in North
America
1ISHLT registry
10. Recipient Selection
• Relative contraindications-Many
• Include “Mechanical ventilation and/or
extracorporeal life support (ECLS).
However, carefully selected candidates
without other acute or chronic organ
dysfunction may be successfully
transplanted”1
1Weill JHLT. 2015 Jan; 34(1): 1-15
11. Question
• I have a 55 yo patient with Idiopathic
Pulmonary Fibrosis (IPF) who was
intubated due to acute exacerbation,
should he be evaluated for transplant?
• Should he go on Extracorporeal
Mechanical Oxygenation (ECMO)?
12. Question
• I have a 55 yo patient with Idiopathic
Pulmonary Fibrosis (IPF) who was
intubated due to acute exacerbation,
should he be evaluated for transplant?
Maybe
• Should he go on Extracorporeal
Mechanical Oxygenation (ECMO)?
13. Ideal Pre-transplant ECMO
• Has already consented to transplant and
evaluation (is it truly informed consent on
ECMO)?
• Good Pre-ECMO functional status
• Without other relative contraindications (age,
obesity, AMS, social support, drug/tobacco)
• Evaluation complete (e.g. Heart cath,
colonoscopy, etc)
• Not Veno-arterial ECMO by femoral approach
14. When and Why to do ECMO
• End stage Lung failure not supported by
conventional support
• Patient cannot maintain muscular conditioning
due to dysfunctional gas exchange
• When ECMO and its complications are superior
to prolonged mechanical ventilation (e.g.
tracheostomy and feeding tube for cystic fibrosis)
• After evaluation complete or to allow
consent/evaluation
15. Proposed Criteria
Fuehner T
Chest. 2016;150(2):442-50
“Patient Listed or fully
evaluated” is in
contention
Trudzinski FC
Chest. 2017;151(5):1177-8
Hoopes et al. J.
Thoracic and Cardio Surg
145(3) 862-8. 2013
17. Single vs Double lumen VV ECMO
17
Brodie D and
Bacchetta M NEJM
365: 1905-1914. 2011
18. “Sport Model” VA ECMO
18
• IJ venous outflow
• Subclavian artery
inflow
• Allows ambulation
• Percutaneously
placed, no
anesthesia
• Used for cor
pulmonale
Biscotti M and
Bacchetta M Ann.
Thorac Surg. 8: 1487-
9. 2014
20. Death on ECMO while waiting
• Difficult to compare across countries/organ
allocation
• Germany 23% mortality1
• Italy 32% mortality2
• USA 13% mortality3
1) Fuehner T et al. AJRCCM 185(7). 763-8. 2012.
2) Crotti S et al. Chest 144(3): 1018-25. 2013
3) Hoopes et al. J. Thoracic and Cardio Surg 145(3) 862-8. 2013
22. Question
• I have a 55 yo patient with Idiopathic Pulmonary
Fibrosis (IPF) who was intubated due to acute
exacerbation, should he be evaluated for
transplant?
Maybe if good muscular strength and
no other precluding factors
• Should he go on Extracorporeal Mechanical
Oxygenation (ECMO)?
Only if a potential transplant candidate
23. ECMO for respiratory failure in ILD
• 21 patients placed
on ECMO for
respiratory failure in
ILD
• Only 1 survived
without transplant
• 5 received
transplant
• 4 listed “de novo”
Trudzinski FC AJRCCM
2016. 193(5) 527-33
24. Moral of the story
• Ideally, send us your patients early as outpatient
• Send us your inpatient transplant candidates
early (i.e. before intubation)
• If intubated, please send potential candidates
early to avoid critical care myopathy
• ARDS is not usually a transplant diagnosis, but
some have transplanted prolonged ARDS1
1) Hoopes et al. J. Thoracic and Cardio Surg 145(3) 862-8. 2013
25. Planned post-operative ECMO
• Used in pulmonary hypertension (de-
conditioned left ventricle)1,2
• Often employed when single lung
implanted in a patient with pre-operative or
intraoperative pulmonary hypertension
• Always Veno-arterial to prevent excess
flow to lung(s)
1) Tudorache I Transplatation 2015. 99(2): 451-8
2) Pereszlenyi A Eur J Cardiothoracic Surg 2002. 21(5): 858-63
26. Ventilation
• 6cc/kg ideal body weight (IBW) used
• Recipient vs. Donor Height for IBW
• Most wean FIO2 over PEEP
Diamond JM Ann Am Thorac Soc Vol 11, No 4, 598–9, May 2014
27. Hyperinflation of native lung
• Decrease
Minute
Volume
• ? Separate
lung
ventilation
Weill D et al. JHLT 18(11) 1080-1087. 1999
28. Ventilation of Donor
• Higher PEEP and Low tidal volume lead to
higher utilization of lungs in Brain Dead
Donors
• 6cc/kg likely best after transplant too
Mascia L et al. JAMA. 304(23):2620-2627. 2010.
32. PGD criteria
• Edema pattern in allograft and it is NOT
• Cardiogenic “fluid overload”
• Pulmonary venous anastomotic problems
• Hyperacute rejection
• Pneumonia (viral, bacterial, fungal)
Christie JD et al. JHLT 24(10). 1454-9. 2005
33. Primary graft dysfunction
• Graded 0, 24, 48 and 72 hours
• Not graded different for single vs. double
lung
• Higher risk of chronic rejection1
• Worse immediate survival with 30 day
mortality for PGD 32, 3
1) Daud SA et al AJRCCM 175: 507-13. 2007.
2) Lee JC et al. PATS 6: 39-46. 2009.
3) Geube MA et al. Anest Analg. 122(4):1081-8. 2016
34. PGD Prevention and Tx in ICU
• Prevention
• Fluid restrictive maybe beneficial1,2,3
• Ex Vivo Lung Perfusion (EVLP) for
marginal lungs?
• Treatment
• Supportive (inhaled NO, ECMO)
• Avoid fluid accumulation
1) Currey J. et. al. Cardiothoracic Trans. 139(1). 154-161. 2010.
2) Geube MA et al. Anest Analg. 122(4):1081-8. 2016
3) Pilcher DV et. al. J. Thorac Card Surg. 129: 912-8. 2005
37. Post operative antibiotics
• Other than small bowel, only non-sterile
organ transplant
• Cover for
• ventilator associated organisms
• Recipient colonized organisms (e.g.
cystic fibrosis)
• Fungal prophylaxis
.
38. Learning Objectives
Recognize indications and techniques for
peri-transplant application of ECMO
Used to maintain muscles, life until Tx
Understand the salient features of primary
graft dysfunction
Essentially like ARDS
Describe appropriate ventilatory and
hemodynamic support
Minimize fluids and LPV (like ARDS)
39. Lung Transplant in the Community
• Common ICU presentations
• Respiratory Failure
• Non-pulmonary surgical needs
• Shock, usually septic
• Acute renal failure
• Altered mental status
• Diverticulitis/Appendicitis
.
40. Lung Transplant in the Community
• What do I do if I admit a lung transplant
patient at 2 am?
• Don’t worry too much about treating for
rejection, this requires biopsy and
exclusion of infection
• Ok to hold or continue cell cycle inhibitor
(Mycophenolate (MMF) or azathioprine
(AZA)
• Usually held if infection is suspected
• Not really a big deal either way for 1 dose
41. Lung Transplant in the Community
• Start stress dose steroids if in shock
• If intubated, do a BAL for bacterial,
fungal, AFB, viral, galactomannen, PJP
• Presumptive antibiotics are OK
• Usually vancomycin/Zosyn/azithro
• If respiratory failure same abx plus
antifungal (Cancidis or voriconazole)
• Tamiflu if flu season
• If vori added, decreased CNI by 50%.
42. Lung Transplant in the Community
• In most patients, CMV DNA quant can be
sent, but prophylactic CMV treatment not
usually indicated
.
43. Lung Transplant in the Community
• Do not draw a random tacrolimus or
cyclosporine (CSA) level, these are not
helpful
• A level 10 hours after last dose (trough)
is helpful
• Do not draw mycophenolate levels…ever
.
44. Lung Transplant in the Community
• tacrolimus/cyclosporine and steroids
usually continued unless adverse Rxn
• If NPO
• Can hold prophy meds
• give CSA by feeding tube, if able
• do NOT give tacro by feeding tube
• Give tacro sublingual at ½ normal dose,
open capsule and pour under tongue.
• Prednisone Solumedrol
45. Lung Transplant in the Community
• Stop medication if adverse drug reaction is
suspected
• Tacro and CSAAMS, elevated K, Cr
• AZAleukopenia, elevated LFT’s
• MMFvomiting, diarrhea, leukopenia
• Bactrimleukopenia, elevated K, Cr
• ValgangcyclovirLow WBC, elevated
LFT
47. PRES
• AMS
• Headache
• Vision changes
• Hypertension
• Seizure
• Tx=BP control and
withhold CNI
Bartynski WS. Am J Neuorad.
29(5) 924-30. 2008
48. Acutely elevated Cr
• Usually hypovolemia +/- supratheraputic
calcineurin inhibitor (tacro or cyclosporine)
• check 10 hour level, if more than 10 hours
since last dose OK to check “random
level”
• Hold CNI until level returns
• Gentle hydration
• Know baseline Cr if able, CKD is
common!
49. Lung Tx pt with abdominal pain
• Higher risk for diverticulitis or appendicitis
or perforation
• Low threshold for CT scan
Hoekstra HJ British J of Surg. 88(3). 433-38. 2001.
50. Lung Tx pt not right on the vent
• A variety of physiologies possible after
transplant
• Bronchiolitis Obliterans Syndrome (BOS)=
Obstructive physiology
• Restrictive allograft syndrome (RAS)=
restrictive physiology
• Single lung Tx may have 2 separate
physiologies
• Anastomotic issues
54. Summary
• Please send potential lung transplant
patients early
• Watch for ADR
• Minimal evidence for post-transplant
ventilatory or hemodynamic strategies
• LPV and avoidance of fluid excess
55. Questions
• We are happy to take questions about
transplant patients or potential transplant
patients at any time.
• ryan.hadley@spectrumhealth.org
• Office 616-391-2802
• c602-740-0609 or text (but no HIPPA PHI
by text please, only “general” questions)