Implementation of a management guideline aimed at minimizing the severity of primary graft dysfunction after lung transplant

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 139; no. 1; pp. 154 - 161
• Main Authors: Currey, Judy, PhD, RN, Pilcher, David V., MD, Davies, Andrew, MD, Scheinkestel, Carlos, MD, Botti, Mari, PhD, RN, Bailey, Michael, PhD, MSc, BSc, Snell, Greg, MD
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 2010; AATS/WTSA
• Subjects: Cardiothoracic Surgery; Female; Guidelines as Topic; Humans; Lung Transplantation; Male; Middle Aged; Postoperative Care; Primary Graft Dysfunction - physiopathology; Severity of Illness Index; Treatment Outcome; 12; arterial P o 2; fraction of inspired oxygen; Pa o 2; ICU; intensive care unit; CVP; PGD; central venous pressure; primary graft dysfunction; Fi o 2
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2009.08.031

Objective Primary graft dysfunction, a severe form of lung injury that occurs in the first 72 hours after lung transplant, is associated with morbidity and mortality. We sought to assess the impact of an evidence-based guideline as a protocol for respiratory and hemodynamic management. Methods Preoperative and postoperative data for patients treated per the guideline (n = 56) were compared with those of a historical control group (n = 53). Patient data such as ratio of arterial P o2 to inspired oxygen fraction, central venous pressure, cumulative fluid balance, vasopressor dose, and serum urea and creatinine were measured and documented at specific times. Primary outcome was severity of primary graft dysfunction within the first 72 hours. Results Primary graft dysfunction grade was progressively lower in patients treated after introduction of the guideline ( P = .01). Lower postoperative fluid balances ( P = .01) and vasopressor doses ( P = .007) were seen, with no associated renal dysfunction. There were no differences in duration of mechanical ventilation or mortality. Nonadherence to the guideline occurred in 10 cases (18%). Conclusions Implementation of an evidence-based guideline for managing respiratory and hemodynamic status is feasible and safe and was associated with reduction in severity of primary graft dysfunction. Further studies are required to determine whether such a guideline would lead to a consistent reduction in severity of primary graft dysfunction at other institutions. Creation of a protocol for postoperative care provides a template for further studies of novel therapies or management strategies for primary graft dysfunction.