icu care of the lung transplant recipient

11

2

ICU Care of the Lung

Transplant Recipient

4th Annual Topics in Pulmonary and

Critical Care Medicine

Ryan Hadley MDSpectrum Health and Richard DeVos Lung

Transplant Program

[Master name: Solid Color Background]

Conflicts of Interest

• None

• Off label medications discussed

• None

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

Learning Objectives

• Clinical pearls for lung transplant patients

admitted to outlying hospitals (especially in

off hours)

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

Lung Transplant Indication

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Nu

mb

er

of

Tra

ns

pla

nts

Transplant Year

COPD A1ATD CF IIP ILD-not IIP Retransplant

JHLT. 2016 Oct; 35(10): 1149-1205

Lung Transplant Survival

1ISHLT registry

Median survival (years):

Double Lung = 7.3; Conditional = 9.8

Single Lung = 4.6; Conditional = 6.4

0

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Su

rviv

al

(%)

Years

Bilateral/Double Lung(N=31,075)Single Lung (N=18,049)

Recipient Selection

• Absolute contraindications=significant

untreatable

• Extra-pulmonary organ dysfunction

• psychiatric conditions

• substance abuse

• severe chronic infections

• BMI >35

1Weill JHLT. 2015 Jan; 34(1): 1-15

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

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)?

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)?

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

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

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

Veno-venous versus Veno-arterial

16

Gaffney AM. et al. BMJ 341:c5317. 2010

Single vs Double lumen VV ECMO

17

Brodie D and

Bacchetta M NEJM

365: 1905-1914. 2011

“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

Carbon dioxide removal

• Respiratory Dialysis®

• ECCO2R

• Hemolung RAS

• Alung technologies,

inc

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

Post transplant survival

Crotti S

et al.

Chest.

144(3):

1018-1025

Chest.

2013;144(3)

:1018-1025

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

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

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

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

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

Hyperinflation of native lung

• Decrease

Minute

Volume

• ? Separate

lung

ventilation

Weill D et al. JHLT 18(11) 1080-1087. 1999

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.

Primary Graft Dysfunction

Suzuki Y et al. Semin Respir Crit Care Med 34(3): 305-19. 2013.

Primary Graft Dysfunction

Munshi L

et al

Lancet

Resp

Med

1: 318-28

2013.

Primary Graft Dysfunction (PGD)

Christie JD et al. JHLT 24(10). 1454-9. 2005

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

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

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 accumulation1) 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

Ex-Vivo Lung Perfusion

Munshi L et. Al. Lancet Resp Med1: 318-28 2013.

Ex-Vivo Lung Perfusion

Munshi L

et. al.

Lancet

Resp

Med1: 318-

28 2013.

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

.

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)

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

.

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

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%.

Lung Transplant in the Community

• In most patients, CMV DNA quant can be

sent, but prophylactic CMV treatment not

usually indicated

.

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

.

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

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

Lung Transplant with AMS

• Long differential

• Shorter differential

• Drugs (CNI)

• Posterior reversible encephalopathy

syndrome (PRES)

• Infection

PRES

• AMS

• Headache

• Vision changes

• Hypertension

• Seizure

• Tx=BP control and

withhold CNI

Bartynski WS. Am J Neuorad.

29(5) 924-30. 2008

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!

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.

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

Bronchiolitis Obliterans (BOS)Williams KM

et al. JAMA

302(3) 306-

14. 2009

BOS and RAS

BOS

RAS

1) Krishnam et al Radiographics. 27(4).

957-74. 2007

2) Paraskeva et al AJRCCM. 187(12).

1360-8. 2013

Anastomotic Stricture

Murthy SC et al. Ann Thorac Surg 84(2) 401-409. 2007

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

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)

56

Lung Transplant in the Community

• What do I do if I admit a lung transplant

patient at 2 am?

.