Experience in the intensive management of early postoperative lung transplantation patients of the Complexo Hospitalar Santa Casa Group of Porto Alegre, Brazil

Introduction

After James Hardy's pioneer initiative (1963) and the advance of lung preservation techniques, the progress of immuno-suppressive treatment with the discovery of cyclosporine and the implementation of international guidelines for the selection of lung transplantation donors and candidates [1–3], lung transplantation became the treatment of choice for many lung diseases in the terminal state. However, lung transplantation morbidity and mortality rates remain elevated, and early postoperative state care is indispensable for a positive outcome. The aim of the present study is to examine the experience in the intensive management of early postoperative lung transplantation patients of the Complexo Hospitalar Santa Casa Group of Porto Alegre, Brazil.

Methods

A retrospective cohort study was performed, based on early postoperative data (May 1989 to January 2009) of cadaver donor lung transplantation patients of the Complexo Hospitalar Santa Casa Group of Porto Alegre, Brazil. Statistical analysis was made with SPSS using chi-square tests and Fisher tests for categorical variables, and using Mann–Whitney tests and Student t tests for quantitative variables.

Results

Of 300 lung transplantation patients, 108 cases had been reviewed at the time of this study. One hundred were single-lung transplantation patients. Sixty-two were males. The mean age was 52 years (9 to 72 years). Thirty-seven percent of patients had lung emphysema; 36% had idiopathic pulmonary fibrosis; 9.3% had lymphangioleiomyomatosis; 2.8% had cystic fibrosis; 2.8% had pneumoconiosis; 1.9% had α₁-antitripsin deficiency; 1.9% had McLoud disease; 1% had pulmonary emphysema and pulmonary fibrosis; 0.9% had sarcoidosis, 0.9% had bronchiolitis obliterans; and 0.9% had pulmonary arterial hypertension. During the surgical procedure, the ischemia mean time was 187.5 minutes (5 to 360 minutes), and 15.7% of patients were in extracorporeal circulation. The mean systolic pulmonary arterial pressure at the beginning of surgery was 37.25 mmHg (11 to 88 mmHg), and was 26.42 mmHg (10 to 44 mmHg) at the end of surgery. In the early postoperative state, the mean APACHE score was 17.43 (9 to 33) and the mean SAPS III was 30 (14 to 49). The mean time of stay in the ICU was 9.5 days (1 to 192 days), the mean time of intubation was 12.5 hours (1 to 432 hours) after the surgery, and 14% of patients needed reintubation. The mean PaO₂/FiO₂ ratio in the immediate postoperative period was 203, and was 266 in the first 24 hours postoperative. The mean systolic pulmonary arterial pressure was 26.1 mmHg (11 to 76 mmHg), and the mean wedge pulmonary arterial pressure was 9.8 mmHg (1 to 22 mmHg). The median time of vasopressor was 26 hours (1 to 336 hours). Thirty-four patients had ischemia/reperfusion injury (light = 7.4%, mild = 7.4% and severe = 15.7%) and 43.5% had acute rejection in the first 30 days postoperative (light = 12%, mild = 13% and severe = 10%). Forty-three patients had infectious complications in the early postoperative stage; the respiratory system was the most compromised (40%). Only four patients had surgical complications that forced their return to the operating room (hemothorax = three patients, bilateral pneumothorax = one patient). The most common clinical complications were acute renal insufficiency (13%, and 8.3% of them needed dialysis), intestinal perforation (3.7%), delirium (2%), and stroke (0.9%). The mortality rate at 28 days was 22%, and at 90 days was 25%.

The variables that correlated with mortality at 28 and 90 days were ischemia/reperfusion injury (P = 0.022 and P = 0.05, respectively), the PaO₂/FiO₂ ratio in the first 24 hours postoperative (P = 0.003 and P = 0.004, respectively), acute renal insufficiency with need for dialysis (P < 0.001), need for reintubation (P = 0.03 and P = 0.012, respectively), and acute rejection in the first month postoperative (P = 0.029 and P = 0.012, respectively).

Conclusion

Lung transplantation is the treatment of choice for many lung diseases in the terminal state. However, a number of postoperative complications can affect the outcome. Improvement of early postoperative care to prevent complications is indispensable for a positive outcome.