Venkateswaran Rajamiyer V, Patchell Val B, Wilson Ian C, Mascaro Jorge G, Thompson Richard D, Quinn David W, Stockley Robert A, Coote John H, Bonser Robert S
Department of Cardiothoracic Surgery Heart and Lung Transplantation Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
Ann Thorac Surg. 2008 Jan;85(1):278-86; discussion 286. doi: 10.1016/j.athoracsur.2007.07.092.
Lung transplantation activity is frustrated by donor lung availability. We sought to examine the effect of active donor management and hormone administration on pulmonary function and yield in cadaveric heart-beating potential lung donors.
We studied 182 potential lung donors (arterial oxygen tension [PaO2]/fractional inspired oxygen [FIO2] ratio > or = 230). From this group, 60 patients (120 lungs) were allocated, within a randomized trial, to receive methylprednisolone (1 g), triiodothyronine (0.8 microg/kg bolus and 0.113 microg/kg/h infusion), both methylprednisolone and triiodothyronine, or placebo as soon as feasible after consent and initial assessment. Trial donors underwent protocol-guided optimization of ventilation and hemodynamics, lung water assessment, and bronchoscopy. Function was assessed by PaO2/FIO2 ratio, extravascular lung water index (EVLWI), and pulmonary vascular resistance (PVR). A nontrial group of 122 donors (244 lungs) received similar management without bronchoscopy, pulmonary artery flotation catheter monitoring, or lung water assessment.
Within the trial, management commenced within a median of 2 hours (interquartile range, 0.5 to 3.5 hours) of consent and continued for an average of 6.9 +/- 1.2 hours. The PaO2/FIO2 ratio deteriorated (p = 0.028) from 397 +/- 78 (95% CL, 376 to 417) to 359 +/- 126 (95% CL, 328 to 390) and EVLWI from 9.7 +/- 4.5 mL/kg (95% CL, 8.6 to 10.9 mL/kg) to 10.8 +/- 5.2 mL/kg (95% CL, 9.4 to 12.2 mL/kg; p = 0.009). PVR remained unchanged (p = 0.28). At end management, 48 of 120 trial lungs (40%) were transplanted versus 66 of 244 nontrial lungs (27%; p = 0.016). Neither methylprednisolone and triiodothyronine nor T3 increased lung yield or affected PaO2/FIO2 or EVLWI; however, methylprednisolone attenuated the increase in EVLWI (p = 0.009).
Early active management of lung donors increases yield. Steroid administration reduces progressive lung water accumulation.
肺移植工作因供肺的可获得性而受阻。我们试图研究积极的供体管理和激素给药对脑死亡心脏跳动潜在肺供体的肺功能及供肺获取量的影响。
我们研究了182名潜在肺供体（动脉血氧分压[PaO₂]/吸入氧分数[FIO₂]比值≥230）。在这项随机试验中，从该组中分配了60例患者（120个肺），在获得同意并进行初始评估后尽快接受甲泼尼龙（1 g）、三碘甲状腺原氨酸（0.8 μg/kg静脉推注及0.113 μg/kg/h静脉输注）、甲泼尼龙与三碘甲状腺原氨酸联合用药或安慰剂治疗。试验供体接受方案指导下的通气和血流动力学优化、肺水评估及支气管镜检查。通过PaO₂/FIO₂比值、血管外肺水指数（EVLWI）和肺血管阻力（PVR）评估肺功能。122名供体（244个肺）的非试验组接受了类似的管理，但未进行支气管镜检查、肺动脉漂浮导管监测或肺水评估。
在试验中，管理在获得同意后的中位数时间为2小时（四分位间距，0.5至3.5小时）开始，并持续平均6.9±1.2小时。PaO₂/FIO₂比值从397±78（95%可信区间，376至417）降至359±126（95%可信区间，328至390；p = 0.028），EVLWI从9.7±4.5 mL/kg（95%可信区间，8.6至10.9 mL/kg）升至10.8±5.2 mL/kg（95%可信区间，9.4至12.2 mL/kg；p = 0.009）。PVR保持不变（p = 0.28）。在管理结束时，120个试验肺中有48个（40%）被移植，而244个非试验肺中有66个（27%）被移植（p = 0.016）。甲泼尼龙和三碘甲状腺原氨酸以及三碘甲状腺原氨酸均未增加供肺获取量，也未影响PaO₂/FIO₂或EVLWI；然而，甲泼尼龙减弱了EVLWI的升高（p = 0.009）。
对肺供体进行早期积极管理可增加供肺获取量。给予类固醇可减少肺水的进行性积聚。
