Smith Jason W, Matheson Paul J, Morgan Gary, Matheson Amy, Downard Cynthia, Franklin Glen A, Garrison R Neal
Department of Surgery, University of Louisville, Louisville, KY; Department of Physiology and Biophysics, University of Louisville, Louisville, KY.
Department of Surgery, University of Louisville, Louisville, KY; Department of Physiology and Biophysics, University of Louisville, Louisville, KY; Louisville Veterans Affairs Medical Center, Louisville, KY.
J Am Coll Surg. 2015 Apr;220(4):539-47. doi: 10.1016/j.jamcollsurg.2014.12.056. Epub 2015 Feb 9.
Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology, exaggerated systemic inflammatory response, end-organ microcirculatory dysfunction, and tissue hypoxia. A new treatment, direct peritoneal resuscitation (DPR), stabilizes vital organ blood flow after conventionally resuscitated shock to improve these derangements.
A prospective case-control study of adjunctive DPR compared 26 experimental patients (brain dead organ donors) to 52 controls (protocolized conventionally resuscitated donors). Actual organ procurement rates were compared with the Scientific Registry of Transplant Recipient predicted organ yield per patient. Achievement of donor management goals and effective hepatic blood flow were recorded.
Fourteen of 26 (53.8%) patients treated with DPR achieved all donor management goals compared with 17 of 52 (32.7%) patients treated with conventionally resuscitated (odds ratio = 2.4; 95% CI, 0.92-6.3; p = 0.06). Patients treated with DPR were more than 2 times as likely to achieve final pO2 >100 on 40% FiO2 compared with controls (odds ratio = 2.8; 95% CI, 1-7.69; p = 0.03). Also, DPR-treated patients required less IV crystalloid during the first 12 hours of management (DPR: 3,167 ± 1,893 mL vs 4,154 ± 2,100 mL; p = 0.046) and required less vasopressor agents at 12 hours post resuscitation (odds ratio = 7.7; 95% CI, 0.82-42; p = 0.02). Direct peritoneal resuscitation patients had enhanced effective hepatic blood flow and significantly higher organs transplanted per donor rates compared with controls (3.7 ± 1.7 vs 3.1 ± 1.3; p = 0.024).
Direct peritoneal resuscitation reduced IV fluid requirement and IV pressor use as well as increased hepatic blood flow and organs transplanted per donor. Direct peritoneal resuscitation studies show it to be a safe, effective method to augment organ donor resuscitation and additional large-scale trials should be conducted to validate these findings.
脑死亡器官捐献者存在中枢血流动力学改变、激素生理功能受损、全身炎症反应过度、终末器官微循环功能障碍及组织缺氧等情况。一种新的治疗方法，即直接腹腔复苏（DPR），可在常规复苏休克后稳定重要器官的血流，以改善这些紊乱状况。
一项关于辅助性DPR的前瞻性病例对照研究，将26例实验患者（脑死亡器官捐献者）与52例对照患者（按方案进行常规复苏的捐献者）进行比较。将实际器官获取率与移植受者科学登记处预测的每位患者器官产量进行比较。记录捐献者管理目标的达成情况及有效肝血流量。
接受DPR治疗的26例患者中有14例（53.8%）实现了所有捐献者管理目标，而接受常规复苏治疗的52例患者中有17例（32.7%）实现了这些目标（优势比 = 2.4；95%可信区间，0.92 - 6.3；p = 0.06）。与对照组相比，接受DPR治疗的患者在吸入氧浓度为40%时达到最终动脉血氧分压>100的可能性高出2倍多（优势比 = 2.8；95%可信区间，1 - 7.69；p = 0.03）。此外，接受DPR治疗的患者在管理的前12小时所需静脉晶体液较少（DPR组：3167 ± 1893毫升 vs 4154 ± 2100毫升；p = 0.046），且复苏后12小时所需血管升压药较少（优势比 = 7.7；95%可信区间，0.82 - 42；p = 0.02）。与对照组相比，直接腹腔复苏患者的有效肝血流量增加，每位捐献者移植的器官率显著更高（3.7 ± 1.7 vs 3.1 ± 1.3；p = 0.024）。
直接腹腔复苏减少了静脉液体需求和静脉升压药的使用，同时增加了肝血流量及每位捐献者移植的器官数量。直接腹腔复苏研究表明其是一种安全、有效的增强器官捐献者复苏的方法，应开展更多大规模试验以验证这些发现。
