Increased Intraoperative Fluid Administration Is Associated with Severe Primary Graft Dysfunction After Lung Transplantation

Abstract

Background Severe primary graft dysfunction (PGD) is a major cause of early morbidity and mortality in patients after lung transplantation. The etiology and pathophysiology of PGD is not fully characterized and whether intraoperative fluid administration increases the risk for PGD remains unclear from previous studies. We therefore tested the hypothesis that increased total intraoperative fluid volume during lung transplantation is associated with the development of grade-3 PGD. Methods This retrospective cohort analysis included patients who had lung transplantation at the Cleveland Clinic between January 2009 and June 2013. We used multivariable logistical regression with adjustment for donor, recipient, and perioperative confounding factors to examine the association between total intraoperative fluid administration and development of grade-3 PGD in the initial 72 postoperative hours. Secondary outcomes included time to initial extubation and intensive care unit length of stay. Results Grade-3 PGD occurred in 123 of 494 patients (25%) who had lung transplantation. Patients with grade-3 PGD received a larger volume of intraoperative fluid (median 5.0 [3.8, 7.5] L) than those without grade-3 PGD (3.9 [2.8, 5.2] L). Each intraoperative liter of fluid increased the odds of grade-3 PGD by approximately 22% (adjusted odds ratio [95%CI] of 1.22 (1.12,1.34), P <0.001). The volume of transfused red blood cell concentrate was associated with grade-3 PGD (1.1 [0.0, 1.8] L for PGD-3 versus 0.4 [0.0, 1.1 for non-grade-3 PGD] L; adjusted OR CI 95% 1.7 (1.08, 2.7); P = 0.002). Increased fluid administration was associated with longer intensive care unit stay (adjusted hazard ratio (97.5% CI): 0.92 [0.88, 0.97], P < 0.001), but not time to initial tracheal extubation (hazard ratio [97.5% CI]: 0.97[0.93,1.02], P =0.17). Conclusions Increased intraoperative fluid volume is associated with the most severe form of PGD after lung transplant surgery. Limiting fluid administration may reduce the risk for development of grade-3 PGD and thus improve early postoperative morbidity and mortality after lung transplantation.

Perioperative statin use is associated with decreased incidence of primary graft dysfunction after lung transplantation

“…PGD is the main cause of early post-operative morbidity and mortality in patients after lung transplantation. 24 In addition, it is associated with increased risk for bronchiolitis obliterans syndrome, long-term deterioration in pulmonary function, and reduced overall long-term survival. [4][5][6][7][8] In a prospective multicenter cohort, Diamond et al 8 results of 41,200 lung transplantations that were performed in an 8-year period in 10 major centers in the United States.…”

“…In double-lung transplantations, reperfusion time of the second lung was designated as the overall reperfusion time as previously reported by others. 24 Initial mechanical ventilation of the transplanted lungs consisted of pressure-controlled ventilation titrated to a target tidal volume of 6-8 ml/kg ideal body weight, inspired oxygen concentration r50% if tolerated, and positive end-expiratory pressure of 8-10 cm H 2 O. Weaning from mechanical ventilation and tracheal extubation were performed post-operatively as soon as possible based on the assessment of the attending intensivist and the transplant pulmonologist and followed standardized postoperative treatment algorithms. If profound hypoxemia with or without severe hemodynamic decompensation persisted despite adequate mechanical ventilation and hemodynamic pharmacologic support, patients were supported by ECMO after reperfusion.…”

Early postoperative complications after lung transplantation

“…Реципиенты, перенесшие трансфузию значительных объемов эритроцитарной массы, имеют высокие риски развития ПДЛТ 3-й ст. Установлено 2-кратное повышение риска развития ПДЛТ при трансфузии более 1 литра эритроцитарной массы [25,46]. Использование ЭКМО в периоперационном периоде ассоциировано с развитием геморрагических, сосудистых и септических осложнений, а также явлений почечной недостаточности, требующих заместительной почечной терапии [47].…”

Risk Factor Analysis for Intraoperative Extracorporeal Membrane Oxygenation Weaning Failure After Lung Transplantation

“…The factors that explain the relationship between operation time and ECMO weaning remain unknown. One possible explanation is that fluid administration increases as the operation time becomes longer, and this added fluid aggravates pulmonary edema and causes hypoxemia [27]. Total fluid (including blood products) intake during the surgery in the ECMO weaning failure group was much more than that in the successful ECMO weaning group (13,429 mL versus 11,014 mL, p ¼ 0.073).…”