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Taking Command of Change to Increase L ung T ransplantation

Taking Command of Change to Increase L ung T ransplantation. Jacqueline Honig, M.D. Assistant Professor of Anesthesia and Critical Care Medicine Director, Cardiothoracic ICU George Washington University Medical Center Associate Medical Director, Washington Regional Transplant Community.

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Taking Command of Change to Increase L ung T ransplantation

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  1. Taking Command of Change to Increase Lung Transplantation Jacqueline Honig, M.D. Assistant Professor of Anesthesia and Critical Care Medicine Director, Cardiothoracic ICU George Washington University Medical Center Associate Medical Director, Washington Regional Transplant Community

  2. Lung Donor Utilization • 1638 people waiting on the lung list • Long wait list stays, death while on the list • Poor utilization of lung from organ donors • Nationally 16-23% of all donors become lung donor • New studies looking at ways to increase utilization • Hanna, K, et al Arch Surg/Vol146 (3), Mar 2011 • Koch, P, et al Critical Care and Shock, 12:130-134, 2006 • Angel, et al American Journal of Respiratory and Critical Care Medicine Vol 174, 710-716, 2006

  3. Reasons for poor utilization • Acute lung injury associated with brain death • Fluids given during the hemodynamic compromise from herniation • Hydrostatic pulmonary edema • Neurogenic pulmonary edema • Pneumonia • Ventilator associated • Aspiration • Modalities needed for caring for the TBI patient • Deep sedation • Chemical paralysis • Prolonged ventilatory time

  4. Strategies to improve lung utilization • Immediate vent management following authorization • Catastrophic brain injury guidelines prior to declaration • Specific ventilatory modalities • ARDSnet-Low tidal volume, generous PEEP • APRV/BIVENT/BILEVEL/PCV IRV • Change or extend criteria for acceptance • PaO2/FiO2 • Smoking history • Time on the ventilator • Ex-Vivo conditioning • Treating all donors as lung donors until… • Ask for help

  5. WRTC • Began to increase our use of both APRV and PCV IRV starting in 2011 • Increase in lung donor potentials • Increase in lungs successfully transplanted from the APRV/PCV IRV group v “conventional” group • Combining 2012 through May 2013 we saw an increase in lungs transplanted from 45% of potential lung donors in the “conventional”group to 58% of potential lung donors in the APRV mode/PCV IRV group • Development of APRV/BIVENT/BILEVEL/PCVIRV protocol to be used on each donor • Enthusiasm by the staff for trying something new to help with an old problem

  6. APRV Protocol-a work in progress • Decision to initiate discussed with the CRC and the medical director • Hemodynamic stability • Timing of procedures • P-high is set to previous plateau pressure but less than 30 • P-low is set at zero • T-high is set at 4-6 seconds • T-low is set at 0.4-0.8 seconds • Oxygen challenge after 30 minutes on 100% Fi02

  7. APRV Protocol- if we must… • Ventilator changed to a “conventional” mode • Tidal volume 6-8 ml/kg • Respiratory rate 8-12 breaths/min • Peep 5 • Fi02 on 100% for 30 minutes • I to E ration of 1:1 • ABG obtained • Return to previous APRV settings immediately following ABG

  8. Challenges • Natural resistance to change by all involved • Staff comfort with “new” modes • Presentations during donor review • Real time visits to the ICU to “play” with the vent • Respiratory therapist comfort with “new” modes • Seems to be improving with time • Transplant center comfort with “new” modes • Seems to be improving with time

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