Airway pressure release ventilation and successful lung donation

HYPOTHESIS

Donor management with airway pressure release ventilation (APRV) improves oxygenation and increases lung donation while maintaining equivalent graft survival.

DESIGN

Retrospective case series.

SETTING

Private, tertiary care, level I trauma center.

PATIENTS

Forty-five consecutive organ donors.

INTERVENTIONS

Management with assist/control ventilation (ACV) or APRV.

MAIN OUTCOME MEASURES

Demographic characteristics, medical history, mode of brain death, and partial pressure of arterial oxygen (Pao(2))/fraction of inspired oxygen (Fio(2)) ratios on admission and after 100% oxygen challenge, percentage of lungs transplanted, and graft survival.

RESULTS

Twenty potential donors were managed with ACV and 25 were managed with APRV during the study period. The APRV patients were younger than the ACV patients (mean [SD] age, 34 [11] vs 41 [12] years, respectively; P = .05). Otherwise, there was no difference between the ACV and APRV groups with respect to demographic characteristics, medical history, or mode of brain death. Although the ACV and APRV groups had similar Pao(2)/Fio(2) ratios on admission and the mean time on the ventilator was the same, the APRV group had a higher Pao(2)/Fio(2) ratio than the ACV group (mean [SD], 498 [43] vs 334 [104] mm Hg, respectively; P < .001) after 100% oxygen challenge. The ACV group ultimately donated 7 of 40 potential lungs (18%) compared with 42 of 50 potential lungs (84%) in the APRV group (P < .001). There was no difference in the number of other organs per donor procured from the 2 groups. Survival of grafts managed with both APRV and ACV compared favorably with national averages.

CONCLUSION

The use of APRV prior to procurement may increase the rate of successful lung donation.

Acute abdominal vascular emergencies

Abdominal vascular emergencies are relatively uncommon, frequently catastrophic, and highly lethal. Despite improved understanding of the pathophysiology and natural history of these disorders, delays in diagnosis and treatment remain the most important factors contributing to the observed high mortality. A high index of clinical suspicion together with a sound understanding of the clinical presentation, natural history, and management of these disorders are critical to improving outcomes. This article focuses on abdominal vascular emergencies presenting with acute visceral ischemia or catastrophic intra-abdominal hemorrhage.

Intentional Coverage of a Main Renal Artery During Endovascular Juxtarenal Aortic Aneurysm Repair in Symptomatic High-Risk Patients

PURPOSE

To describe the efficacy and morbidity of intentionally covering a main renal artery during symptomatic juxtarenal endovascular aneurysm repair (EVAR).

CASE REPORTS

Two patients with symptomatic juxtarenal abdominal aortic aneurysm (AAA) were felt to be at prohibitive risk for open repair. Each underwent EVAR with intentional coverage of 1 main renal artery to achieve adequate proximal hemostatic seal. One patient died at 24 months; the second is symptom-free at 10 months. Both aneurysms initially decreased in diameter. Both patients had increased serum creatinine and required increased therapy for hypertension, but neither required hemodialysis. Renal volume decreased 48.7% and 68.0%, respectively.

CONCLUSION

Intentional coverage of a main renal artery during EVAR for a symptomatic juxtarenal aneurysm resulted in effective short-term AAA repair with no need for dialysis. Despite the increased requirement for antihypertensive medications and the observed decline in renal function, this technique provides an option for treatment of this difficult patient subset.