Stefan Schwarz

BACKGROUND: Lung transplantation is performed on a 24/7 schedule to minimize organ ischemic time. Recent preclinical studies demonstrated superior graft preservation at 10°C compared with storage in an ice cooler (gold standard). METHODS: In this prospective, multicenter, nonrandomized clinical trial, we studied transplants from donors with overnight cross-clamp times (6:00 p.m. to 4:00 a.m.) that had an earliest allowed starting time of 6:00 a.m. Lungs meeting criteria for transplantation were retrieved, transported, and immediately transferred to a 10°C temperature-controlled incubator until implantation; 70 patients and 140 matched controls were included in this study. RESULTS: Total preservation times for lungs in the study group were 12 hours, 28 minutes (interquartile range, 10 hours, 14 minutes to 14 hours, 12 minutes) and 14 hours, 9 minutes (interquartile range, 12 hours, 3 minutes to 15 hours, 45 minutes) for the first and second lung implanted, respectively. Primary graft dysfunction grade 3 at 72 hours (primary outcome) was 5.7% in the study group versus 9.3% in matched controls (difference, −3.6; 95% confidence interval [CI], −10.5 to 5.3). No meaningful differences were observed in the need for postoperative extracorporeal membrane oxygenation (5.7 vs. 9.3%), median intensive care unit stay (5 vs. 5 days), or median hospital stay (25 vs. 30 days) between the two groups. One-year Kaplan–Meier survival was similar between the two groups (94 vs. 87%; hazard ratio, 0.65; 95% CI, 0.26 to 1.6). CONCLUSIONS: Extension of cold static preservation times at 10°C appears to be safe and has the potential to improve transplantation logistics and performance. (Funded by the UHN Foundation; Clinicaltrials.gov number, NCT04616365).

OBJECTIVE: Mechanical ventilation with an automated ventilator is recommended during cardiopulmonary resuscitation with a secured airway. We investigated the influence of intermittent positive-pressure ventilation, bilevel ventilation, and the novel ventilator mode chest compression synchronized ventilation, a pressure-controlled ventilation triggered by each chest compression, on gas exchange, hemodynamics, and return of spontaneous circulation in a pig model. DESIGN: Animal study. SETTING: University laboratory. SUBJECTS: Twenty-four three-month-old female domestic pigs. INTERVENTIONS: The study was performed on pigs under general anesthesia with endotracheal intubation. Arterial and central venous catheters were inserted and IV rocuronium (1 mg/kg) was injected. After 3 minutes of cardiac arrest (ventricular fibrillation at t = 0 min), animals were randomized into intermittent positive-pressure ventilation (control group), bilevel, or chest compression synchronized ventilation group. Following 10 minute uninterrupted chest compressions and mechanical ventilation, advanced life support was performed (100% O2, up to six defibrillations, vasopressors). MEASUREMENTS AND MAIN RESULTS: Blood gas samples were drawn at 0, 4 and 13 minutes. At 13 minutes, hemodynamics was analyzed beat-to-beat in the end-inspiratory and end-expiratory cycle comparing the IPPV with the bilevel group and the CCSV group. Data were analyzed with the Mann-Whitney U test. Return of spontaneous circulation was achieved in five of eight (intermittent positive-pressure ventilation), six of eight (bilevel), and four of seven (chest compression synchronized ventilation) pigs. The results of arterial blood gas analyses at t = 4 minutes and t = 13 minutes (torr) were as follows: PaO2 intermittent positive-pressure ventilation, 143 (76/256) and 262 (81/340); bilevel, 261 (109/386) (p = 0.195 vs intermittent positive-pressure ventilation) and 236 (86/364) (p = 0.878 vs intermittent positive-pressure ventilation); and chest compression synchronized ventilation, 598 (471/650) (p < 0.001 vs intermittent positive-pressure ventilation) and 634 (115/693) (p = 0.054 vs intermittent positive-pressure ventilation); PaCO2 intermittent positive-pressure ventilation, 40 (38/43) and 45 (36/52); bilevel, 39 (35/41) (p = 0.574 vs intermittent positive-pressure ventilation) and 46 (42/49) (p = 0.798); and chest compression synchronized ventilation, 28 (27/32) (p = 0.001 vs intermittent positive-pressure ventilation) and 26 (18/29) (p = 0.004); mixed venous pH intermittent positive-pressure ventilation, 7.34 (7.31/7.35) and 7.26 (7.25/7.31); bilevel, 7.35 (7.29/7.37) (p = 0.645 vs intermittent positive-pressure ventilation) and 7.27 (7.17/7.31) (p = 0.645 vs intermittent positive-pressure ventilation); and chest compression synchronized ventilation, 7.34 (7.33/7.39) (p = 0.189 vs intermittent positive-pressure ventilation) and 7.35 (7.34/7.36) (p = 0.006 vs intermittent positive-pressure ventilation). Mean end-inspiratory and end-expiratory arterial pressures at t = 13 minutes (mm Hg) were as follows: intermittent positive-pressure ventilation, 28.0 (25.0/29.6) and 27.9 (24.4/30.0); bilevel, 29.1 (25.6/37.1) (p = 0.574 vs intermittent positive-pressure ventilation) and 28.7 (24.2/36.5) (p = 0.721 vs intermittent positive-pressure ventilation); and chest compression synchronized ventilation, 32.7 (30.4/33.4) (p = 0.021 vs intermittent positive-pressure ventilation) and 27.0 (24.5/27.7) (p = 0.779 vs intermittent positive-pressure ventilation). CONCLUSIONS: Both intermittent positive-pressure ventilation and bilevel provided similar oxygenation and ventilation during cardiopulmonary resuscitation. Chest compression synchronized ventilation elicited the highest mean arterial pressure, best oxygenation, and a normal mixed venous pH during cardiopulmonary resuscitation.