T o date, hundreds of thousands of deaths have been attributed to coronavirus disease 2019 (COVID-19) 1. Millions of infections by SARS-CoV-2, the virus responsible for COVID-19, have been reported, although its full extent has yet to be determined owing to limited testing 2. Government interventions to slow viral spread have disrupted daily life and economic activity for billions of people. Strategies to ease restraints on human mobility and interaction without provoking a major resurgence of transmission and mortality will depend on accurate estimates of population levels of infection and immunity 3. Current testing for the virus largely depends on labor-intensive molecular techniques 4. Individuals with positive molecular tests represent only a small fraction of all infections, given limited deployment and the brief time window when real-time (RT)-PCR testing has the highest sensitivity 5-7. The proportion of undocumented cases in the original epidemic focus was estimated to be as high as 86% 8 , and asymptomatic infections are suspected to play a substantial role in transmission 9-14. Widely available, reliable antibody detection assays would enable more accurate estimates of SARS-CoV-2 prevalence and incidence. On February 4, 2020, the Secretary of the US Department of Health and Human Services issued an emergency use authorization (EUA) for the diagnosis of SARS-CoV-2 15 , allowing nucleic acid detection and immunoassay tests to be offered based on manufacturer-reported data without formal US Food and Drug Administration (FDA) clearance 16. In response, dozens of companies began to market laboratory-based immunoassays and point-of-care (POC) tests. Rigorous, comparative performance data are crucial to inform clinical care and public health responses.
Introduction:The optimal pain management strategy after lung transplantation is unknown. This study compared analgesic outcomes of intercostal nerve blockade by cryoanalgesia (Cryo) versus thoracic epidural analgesia (TEA). Methods: Seventy-two patients who underwent bilateral lung transplantation via clamshell incision at our center from 2016 to 2018 were managed with TEA (N = 43) or Cryo (N = 29). We evaluated analgesic-specific complications, opioid use in oral morphine equivalents (OME), and pain scores (0-10) through postoperative day 7. Adjusted linear regression was used to assess for non-inferiority of Cryo to TEA. Results: The overall mean pain scores (Cryo 3.2 vs TEA 3.8, P = 0.21), maximum mean pain scores (Cryo 4.7 vs TEA 5.5, P = 0.16), and the total opioid use (Cryo 484 vs TEA 705 OME, P = 0.12) were similar in both groups, while the utilization of postoperative opioid-sparing analgesia, measured as use of lidocaine patches, was lower in the Cryo group (Cryo 21% vs TEA 84%, P \ 0.001). Analgesic outcomes remained similar between the cohorts after adjustment for pertinent patient and analgesic characteristics (P = 0.26), as well as after exclusion of Cryo patients requiring rescue TEA (P = 0.32). There were no Cryo complications, with four patients requiring subsequent TEA for pain control. Two TEA patients experienced hemodynamic instability following a test TEA bolus requiring code measures. Additionally, TEA placement was Erin Isaza and Jesse Santos contributed equally.
Primary graft dysfunction (PGD) is a complex inflammatory syndrome that can lead to respiratory failure after lung transplantation (LTx). The pathogenesis of PGD is multifactorial and can be driven by attributes of both the donor and recipient, perioperative characteristics, and technical handling of the graft. Despite significant advancements in patient and donor selection, perioperative management and surgical technique, PGD is still a major contributor to morbidity and mortality after lung transplant. Although there are no known durable treatment options for PGD after LTx, an increasing body of evidence and experience in high-volume lung transplant centers show that extracorporeal life support (ECLS) is a reliable option for both preventing PGD and supporting critically ill patients with PGD. Both veno-venous (V-V) ECLS and veno-arterial (V-A) ECLS are proven and feasible strategies for mitigating the morbidity and mortality associated with post-LTx PGD. In this evidence-based review, we provide an overview of the epidemiology and physiology of PGD as well as a growing body of data that supports ECLS as a major tool to manage PGD. We describe the role of ECMO in PGD prevention and management, worldwide outcomes of LTx with ECLS support, and outline our step-wise approach to managing this complex respiratory syndrome leading up to institution of ECLS.
Introduction: Despite having a similar population, Latin America performs 11x less lung transplant procedure than Europe. Improving brain death diagnosis and converting potential donors into real donors is key to improve these numbers. Ultrasonography (US) is common practice in Intensive Care Units. Available literature on its use in the management of brain death donors and lung procurement is extremely scarce. The selection and rejection of lungs for transplantation is usually done with chest X-rays, however US has shown better sensitivity and specificity for the diagnosis of pulmonary pathologies. Lung US allows to identify the reversible causes low PaO2/FiO2 ratio (PaFi), thus allowing to establish specific interventions which, if proved successful, could turn lungs into transplant-eligible lungs. Methods: Introducing a simple Protocol aiming at identifying and treating the main reversible causes of a low PaFi. Respiratory causes of a low PaFi ratio can be either parenchymal or pleural. Parenchymal causes: Pulmonary edema (either neurogenic or cardiogenic) determines the visualization of bilateral and symmetrical B lines. Fluid restriction prioritizing inotropic drugs to revert hypotension and usage of hypertonic solutions can reduce edema. Atelectasis, contusion and pneumonia can appear as patterns for unilateral B lines and/or consolidations. The presence of a static or dynamic air bronchogram can differentiate them. In atelectasis, fiberoptic bronchoscopy can revert the situation. In all other cases, a single lung transplant can be considered, which is a valid option in aged recipients when donors are scarce. Pneumothorax and pleural effusion are both pleural causes of a low PaFi. They can be easily diagnosed through an ultrasound scan, not there being a reason for rejection. Its resolution can turn these lungs into transplant eligible lungs. The pneumothorax -frequently anterior in ventilated patients in dorsal decubitus-may be overlooked in the chest x-ray. Diagnosis is made by the absence of pleural sliding and presence of a lung pint. Pleural effusion is anechoic, present quad sign and the sinusoid sign. The acquisition of skills to diagnose all these conditions does not require much reading and has a fast-learning curve (25 cases monitored). Results: This Protocol is currently used for donor decision-making and will be implemented prospectively by the lung transplant team to assess its ability to increase the number of lungs suitable for transplantation. Conclusions: US is a useful technique to identify reversible and treatable causes of a low PaFi, helping decision-making to increase the number of transplant eligible lungs.
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