RESUMEN
OBJECTIVES: Despite years of experience with lung transplantation, the rate of perioperative mortality remains high. The objective of this study was to look at our experience in the early postoperative period following lung transplantation in an effort to identify possible pre-, intra- and postoperative risk factors associated with mortality. PATIENTS AND METHODS: A retrospective study of 68 consecutive patients receiving lung transplants over a period of 56 months. The conditions that led to transplantation were obstructive disease (40%), interstitial disease (33%) and suppurative disease (27%). Pre-, intra- and postoperative characteristics of donors and recipients were analyzed for their relation to morbidity and mortality. Statistical studies were done using SPSS 10.0 software. A p-value less than.05 was considered significant. Univariate analysis identified variables associated with the incidence of mortality in the postoperative recovery unit, and the variables with statistically significant associations were entered into multivariate analysis, using a logistic regression model to calculate odds ratio (OR) and 95% confidence intervals (CI). RESULTS: No donor variables correlated with mortality. Patients with suppurative lung disease had a lower mortality rate (0% vs 30%; P = 0.04). Mortality was related to ischemic time longer than 300 minutes (OR = 2) and the use of extracorporeal circulation (OR = 4). A PaO2/FiO2 ratio less than 150 during the first 24 hours following transplantation (OR = 5) and reoperation due to bleeding (OR = 12) were the variables showing the highest correlations with mortality during the early postoperative period. CONCLUSIONS: The mortality rate during the early postoperative period in our series was 22%. The survival rate was better in patients with suppurative lung disease. Bleeding that required reoperation and early graft dysfunction (defined in part by a PaO2/FiO2 ratio less than 150 during the first 24 hours) were the variables that best predicted death in the early postoperative period following lung transplantation.
Asunto(s)
Trasplante de Pulmón/mortalidad , Complicaciones Posoperatorias/mortalidad , Adolescente , Adulto , Niño , Circulación Extracorporea/efectos adversos , Femenino , Humanos , Isquemia , Pulmón/irrigación sanguínea , Enfermedades Pulmonares/patología , Enfermedades Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Hemorragia Posoperatoria/mortalidad , Hemorragia Posoperatoria/cirugía , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Supuración , Recolección de Tejidos y Órganos/métodosRESUMEN
OBJETIVOS: A pesar de la experiencia acumulada, la mortalidad perioperatoria del trasplante pulmonar (TP) continúa siendo elevada. El objetivo de este estudio es revisar nuestra experiencia en el postoperatorio inmediato del TP tratando de identificar las posibles variables pre, intra y postoperatorias asociadas a riesgo de mortalidad. PACIENTES Y MÉTODOS: Estudio retrospectivo de 68 pacientes sometidos de forma consecutiva a TP, durante un período de 56 meses. Las enfermedades que motivaron el TP fueron obstructiva (40 por ciento), intersticial (33 por ciento) y supurativa (27 por ciento). Se analizaron las variables relativas a los donantes y a los receptores (pre, intra y postoperatorias) relacionadas con la morbimortalidad. El estudio estadístico se realizó con el paquete informático SPSS, versión 10.0. Un valor de p inferior a 0,05 se consideró significativo. Se realizó un análisis univariante para identificar las variables asociadas con la incidencia de mortalidad en la unidad de reanimación. Las variables que presentaron significación estadística se sometieron a análisis multivariante, mediante modelo de regresión logística, para calcular la odds ratio (OR) y su intervalo de confianza (IC) del 95 por ciento. RESULTADOS: Ninguna de las variables relativas al donante se relacionó con la mortalidad. Los pacientes con enfermedad supurativa presentaron menor mortalidad (el 0 frente al 30 por ciento; p = 0,04). El tiempo de isquemia superior a 300 min y la utilización de circulación extracorpórea presentaron OR de mortalidad de 2 y 4, respectivamente. La relación PaO2/FiO2 inferior a 150 en las primeras 24 h postrasplante (OR = 5) y la reintervención por hemorragia (OR = 12) fueron las variables con mayor relación con la mortalidad en el postoperatorio inmediato. CONCLUSIONES: La mortalidad durante el postoperatorio inmediato en nuestra serie fue del 22 por ciento. Los pacientes con enfermedad supurativa presentaron una mayor supervivencia. La hemorragia que obliga a la reintervención y la disfunción temprana del injerto (definida en parte por la relación PaO2/FiO2 < 150 en las primeras 24 h) fueron las variables analizadas con mayor valor predictivo de mortalidad en el postoperatorio inmediato del TP (AU)
Asunto(s)
Persona de Mediana Edad , Niño , Adolescente , Adulto , Masculino , Femenino , Humanos , Factores de Riesgo , Supuración , Trasplante de Pulmón , Hemorragia Posoperatoria , Oxígeno , Complicaciones Posoperatorias , Pronóstico , Estudios Retrospectivos , Pulmón , Isquemia , Circulación Extracorporea , Recolección de Tejidos y Órganos , Enfermedades Pulmonares , Recolección de Tejidos y ÓrganosRESUMEN
OBJECTIVE: To study the hemodynamic and gasometric changes observed during lung transplantation, and discuss the differences between unilateral (ULT) and sequential bilateral lung transplantation (SBLT). PATIENTS AND METHODS: We enrolled 13 consecutive patients (8 ULT and 5 SBLT). Gasometric and hemodynamic readings, including right ventricular (RV) function measured as ejection fraction through a catheter, were recorded at the different phases of surgery. ANOVA and Neumann Keuls tests were used for statistical analysis. RESULTS: During ULT no significant changes in RV function were seen and gasometric alterations stayed within clinically tolerable limits. No significant hemodynamic or gasometric changes were observed during the first implantation during SBLT, although there was a significant increase in pulmonary artery pressure as cardiac index decreased, as well as significant depression of RV function and hypoxemia during reperfusion and ventilation of the first lung transplanted. Extracorporeal circulation was needed in one case. CONCLUSIONS: During SBLT, selective reperfusion and ventilation of the first transplanted lung is a moment of great hemodynamic and ventilatory instability. Exhaustive monitoring of RV function is essential for adequate management.
Asunto(s)
Hemodinámica/fisiología , Trasplante de Pulmón/fisiología , Mecánica Respiratoria/fisiología , Adolescente , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Pulmonary hypertension and transient graft dysfunction may complicate the immediate postoperative course of patients undergoing lung transplantation. We report the effect of inhaled nitric oxide (NO) in a patient with pulmonary edema and severe hypoxemia in the period following bilateral lung transplantation. NO was delivered through the inspiratory line and its mean concentration was monitored in the trachea. PaO2/FiO2 improved from 65 to 105 with an NO concentration of 1 ppm, but no further improvement was obtained by increasing the dose to 5 ppm. Pulmonary vascular resistance (PVR) decreased from a baseline value of 251 dynes-sec/cm5 to a low of 213 dynes-sec/cm5 with NO administration. A slight increase in PVR seems to have been the main factor limiting the therapeutic efficacy of inhaled NO in this case.