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4 Ventilatory Management of Potential Organ Donors

4 Ventilatory Management of Potential Organ Donors

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tidal volumes and low respiratory rates, while a PaO2 > 90 mmHg should be obtained

with high FiO2 and low level of PEEP to avoid interference with cerebral venous

drainage. If patients with severe brain injury evolve to brain death, critical care

management of the potential organ donors suggests that the priority should be

shifted from a “cerebral protective” strategy to an “organ protective” strategy able

to optimize organ donation. In this prospective, the lungs of potential organ donors

may play a double role: the lungs are responsible for maintaining systemic homeostasis (optimal oxygenation and optimal acid–base balance), but the lungs act also

as potential organs to be donated and such as they should be protected by further

“hits” that can impair their function.

Traditionally only the maintenance of systemic homeostasis has been considered

as a therapeutic target; indeed clinical management of potential organ donors is

oriented to guarantee optimal oxygenation and perfusion rather than to primarily

protect the cardiothoracic organs.

Following this approach, the report of Crystal City meeting recommended the

following ventilatory strategy [40]: tidal volume between 8 and 15 mL/kg to maintain PaCO2 between 35 and 40 mmHg and peak pressure lower than 30 cmH2O and

PEEP levels equal to 5 cmH2O and elevated fraction of inspired oxygen (FiO2) in

order to guarantee O2 saturation higher than 95 %. Apnea test for brain death declaration is performed disconnecting the patient from the ventilator with high-flow

oxygen, and besides bronchoscopy, frequent suctioning and aspiration precautions

are also recommended. These guidelines are not substantially different from the

above-quoted Brain Trauma Foundation guidelines for management of traumatic

brain injury patients. Although after brain death declaration the ventilatory strategy

is no more oriented to cerebral protection, the shift proposed is mainly oriented to

guarantee systemic homeostasis. The adherence to the international guidelines for

organ donor management has been verified in a multicenter observational study

which confirmed that the ventilatory and hemodynamic management of potential

organ donors was coherent with published recommendations and might have been

suboptimal in preserving lung function. Therefore a potential conflict of interest

may exist between the priority to maintain systemic homeostasis (optimal gas

exchange and acid–base balance) and the priority to protect the lungs based on the

robust evidence that VILI may occur also in “normal” lungs at risk to develop

ARDS predisposing to posttransplant primary graft failure.

Recently a multicenter randomized controlled trial compared the use of a protective

ventilatory strategy to the conventional strategy proposed by the international guidelines in potential organ donors [41]. The protective strategy included low tidal volume

(6–8 mL/kg of predicted body weight), PEEP equal to 8–10 cm H2O, the use of closed

circuit for tracheal suction, alveolar recruitment maneuvers after any disconnection,

and the use of continuous positive airway pressure during apnea test. The application

of this strategy increased the number of eligible and transplanted lungs, while the number of transplanted hearts, livers, and kidneys was similar in both groups [41].

In the same prospective, several studies have proposed to extend lung donor criteria and to apply protocols to fully recruit the lungs. Angel and coworkers proposed

the San Antonio Lung Transplant (SALT) protocol applying levels of PEEP up to



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107



15 cmH2O, limiting inspiratory pressure to 25 cmH2O with neutral fluid balance,

head elevation at 30°, and inflation of the endotracheal cuff at pressure of 25 cmH2O;

this approach compared with the 4-year period before the implementation of the

protocol increased the rate of lung procurement from 12 to 26 % [42]. Noiseux and

coworkers demonstrated that lung recruitment maneuvers (two deep inflations at

pressure of 30 cmH2O for 30 s followed by 1 h of mechanical ventilation with peak

pressure <30 cmH2O and PEEP of 10 cmH2O) resulted in a significant increase in

rate of transplanted lungs from 20 to 33 % without affecting the homeostasis of

other organs [43].

Paries and coworkers in a case–control study demonstrated that the application

of one-lung recruitment maneuver performed just after apnea test (35 cmH2O × 40 s)

improved oxygenation with transient side effects on systemic hemodynamics.

Compared to the historical control, this maneuver improved the rate of lungs that

met eligibility criteria for transplantation.

Minambres and coworkers in a cohort study with historical control demonstrated

that a protocol with tidal volume of 8 ml/kg, PEEP of 8–10 cmH2O, apnea test performed with continuous positive airways pressure, recruitment maneuvers performed every 2 h and after disconnection from the ventilator, negative fluid balance,

and hormonal replacement therapy increased the rate of the lungs eligible for transplant without adverse effect on kidney graft survival [44].

Bernard and colleagues proposed the use of beta 2 agonists, assuming that they

could reduce the incidence of edema and could therefore increase the values of P/F

of donor’s lungs, but one randomized study showed no improvement in oxygenation, without any increase of the number of transplantable lungs [45].

A recent review of Ruchi Bansal and colleagues proposed a ventilation of the

potential donor to prevent overdistension using low tidal volumes and a plateau

pressure <30 cm H2O. The other objectives were the maintenance of an adequate

alveolar recruitment with PEEP between 8 and 10 cm H2O and the reduction of the

potential toxic effects of oxygen by the use of low values of FiO2 while maintaining

the oxygen saturation between 92 and 95 % [46]. The most interesting aspect of the

study was that the protocol was applied to ideal and marginal lungs for

oxygenation.

This approach is coherent with the meta-analysis of Rech et al. which showed

that in the management of the donor organ, protective mechanical ventilation is supported by the strongest level of evidence, while other strategies, such as hormone

replacement therapy, currently have a less strong evidence [41, 47].

Conclusion



In conclusion, the low availability of transplantable lungs in relation to the number of patients waiting for transplantation has led to solutions to increase organ

availability.

The main goal of ventilatory management of the potential organ donor, as

pointed out by Slutsky and Ranieri [27], is the lung protection by the application

of a low tidal volume equal to 6–8 ml/kg PBW associated with a PEEP of 8–10 cm

H2O to maintain P/F ratio >300, PaCO2 between 35 and 40 mmHg, and a pH of



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between 7.35 and 7.45. Bronchoscopy is necessary during the period of observation to investigate the anatomy of the lung, for the aspiration of secretions, and for

the execution of microbiological tests. In order to prevent atelectasis, the use of a

closed circuit for the tracheal aspiration, the execution of recruitment maneuvers

after each disconnection from the ventilator, and the application of a continuous

positive airway pressure during the apnea test are recommended. The hemodynamic management should be restrictive and appropriate to maintain hemodynamic values of CVP between 6 and 8 mmHg and PCWP between 8 and 12 mmHg.

Indications for protective mechanical ventilation are supported by strong scientific evidence that recognizes the evolving brain damage in brain death as the

predisposing factor for the development of ARDS. Moreover, an inappropriate

mechanical ventilation may increase the risk of VILI in potential organ donor.

Finally, the application of a protective mechanical ventilation should increase the

number of transplantable lungs significantly, without affecting the number of

other transplanted organs. This approach is based on a strong level of evidence

and has gradually been adopted in recent guidelines.



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39. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of

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7



Management of Perioperative

Arrhythmias

Fabio Guarracino and Rubia Baldassarri



7.1



Introduction



The perioperative period is defined as the length of time between the preoperative

assessment and 36–48 h after surgery. Perioperative arrhythmias are one of the most

common cardiac complications in noncardiac surgery. In addition, the arrhythmic

events are a major cause of perioperative morbidity and mortality.

Although most of the perioperative arrhythmic events occur in patients undergoing lung surgery with more or less extensive resection of the parenchyma (lobectomy, pneumonectomy), disturbances of the heart rhythm can occur in any surgical

setting.

Early detection of perioperative cardiac arrhythmias is fundamental. In fact,

although the majority of the arrhythmic events are either self-limited or well tolerated in critically ill patients, malignant arrhythmias may cause severe cardiac dysfunction in some cases and can even lead to cardiac arrest (Table 7.1).

The arrhythmic events can also lead to severe haemodynamic alteration and

increase the perioperative risk of the patients scheduled for noncardiac surgery.

The availability of systems for the continuous monitoring of the electrocardiogram (EKG) has allowed for real-time evaluation of any arrhythmic event occurring

in either the operating room or the postoperative care units.

Prior to this, the true incidence of perioperative cardiac arrhythmias has long

been underestimated. It should be considered that the evaluation of the heart rhythm

was based on periodic EKGs recorded at more or less regular intervals of time [1].

In addition, the application of the Holter technique, which provides continuous

recording of the heart rhythm, has allowed for the detection of arrhythmic events

that occur outside of both the operating room and the intensive care units where the

F. Guarracino (*) • R. Baldassarri

Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria

Pisana, Pisa, Italy

e-mail: fabiodoc64@hotmail.com

© Springer International Publishing Switzerland 2016

D. Chiumello (ed.), Topical Issues in Anesthesia and Intensive Care,

DOI 10.1007/978-3-319-31398-6_7



111



112

Table 7.1 Cardiac

arrhythmias: classification



F. Guarracino and R. Baldassarri

Site



Heart rate



Supraventricular: origin above the AV node (atrial

or nodal)

Supraventricular premature beats

Paroxysmal supraventricular tachycardia (PSVT)

Atrial fibrillation (AF)

Atrial flutter

Wolff-Parkinson-White (WPW)

Ventricular: origin under the AV node

Ventricular premature beats (VBPs)

Ventricular tachycardia (VT)

Ventricular fibrillation (VF)

Tachyarrhythmia (>100 b/min)

Bradyarrhythmia (<50 b/min)



Table 7.2 Incidence of intraoperative arrhythmias

Bradyarrhythmias

Complete AV block

AV block



Tachyarrhythmias

Supraventricular 90 %

AF 45 %

TR AV 35 %

Atrial flutter 8 %

TA 1 %

TS 1 %



Ventricular 10 %

VT

VF



AV atrioventricular, BAV atrioventricular block, AF atrial fibrillation



patients are under EKG monitoring. The data emerging from the recent literature

report an incidence of perioperative arrhythmias of 10–30 % in cardiothoracic surgery versus 4–20 % in noncardiac surgery [2] (Table 7.2). Although cardiac

arrhythmias can occur in healthy patients under stress conditions, such as surgery,

temporary haemodynamic impairment and electrolyte disturbance, in most cases,

the arrhythmic event is the expression of an underlying cardiac disease that may

also be undiagnosed. For example, the majority of the hyperkinetic arrhythmias,

such as atrial fibrillation (AF) and ventricular tachycardia (VT), are associated

with a pre-existing cardiopulmonary disease. In the recent guidelines [2] for the

perioperative management of cardiac patients undergoing noncardiac surgery, continuous EKG monitoring is highly recommended in all patients undergoing surgery

(class IC). Still, according to the mentioned guidelines, EKG monitoring should

start before either the induction of general anaesthesia or the performance of a

peripheral block [3]. The early detection of arrhythmic events should be aimed at

the evaluation of both the severity of the arrhythmia and the associated haemodynamic implications. The early detection and treatment of malignant, life-threatening arrhythmias are mandatory in surgical patients, especially those at high risk.

An adequate haemodynamic support is required in cases of arrhythmias inducing

severe cardiovascular dysfunction. The identification of the aetiological



7



Management of Perioperative Arrhythmias



Table 7.3 Diagnostic tools for the detection of

arrhythmias



113

Electrocardiogram (ECG)

Echocardiography

Holter (dynamic ECG)

Event monitor (prolonged monitoring)

Tilt table test

Electrophysiological studies (EPSs)



mechanisms of malignant arrhythmias is aimed at correcting any electrolyte or

metabolic imbalances as well as at the introduction of a specific antiarrhythmic

therapy.



7.2



Diagnosis



The diagnosis of malignant arrhythmia is not always easy or immediate. In case of

complex arrhythmias, the patients should be referred to the cardiologist for a careful

evaluation of either the patient’s clinical conditions or the ECG alterations.

Adjunctive diagnostic tests could be necessary to achieve the diagnosis.

In this context, an accurate preoperative assessment of either a history of preexisting arrhythmias or clinical symptoms suggestive for alteration of the heart

rhythm is mandatory in the patients enrolled for noncardiac surgery.

Intraoperative arrhythmias can lead to severe cardiovascular alteration that will

require immediate diagnosis and treatment to restore haemodynamic stability. In the

operative setting, diagnostic tests are not available. Therefore, the diagnosis of

arrhythmia is based on the analysis of the ECG alterations, and, in selected cases,

echocardiography can help to achieve the diagnosis.

Postoperative arrhythmias can be evaluated either by the direct analysis of ECG

monitoring or by the performance of specific cardiac tests (Table 7.3).

It should be considered that the severity of either the cardiac arrhythmias or the

associated cardiovascular impairments depends on several factors including the origin and type of arrhythmic event, the patient’s clinical conditions and the type of

surgery. Potentially harmful arrhythmias such as ventricular fibrillation (VF) and

asystole induce severe cardiac dysfunction and can lead to cardiac arrest.



7.3



Ventricular Arrhythmias



In approximately 10 % of the patients with ventricular arrhythmias, an organic cardiomyopathy is not evident. The ECG pattern and the most common diagnostic tests

(echocardiography, coronary angiography) are generally normal. In these cases,

more advanced investigation with NMR can identify structural myocardial defects

responsible for the arrhythmia.

Nevertheless, in the majority of the patients, the cause of the ventricular arrhythmia is underlying cardiac disease, including organic cardiomyopathy (dilated or



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F. Guarracino and R. Baldassarri



hypertrophic), myocardial scar and myocardial structural alterations [5, 6]. The

most common ventricular arrhythmias are the ventricular premature beats (VPBs)

and the VT.

VT can be classified according to:

• The site of origin: from the right ventricle (RV) or the left ventricle (LV). The VT

arising from the RV outflow tract (RVOT) is the most common idiopathic VT [7].

• The structural characteristics: monomorphic, polymorphic, sustained and

non-sustained.

• The response to pharmacologic agents and catecholamines.

Ventricular arrhythmias include clinical syndromes such as Brugada syndrome,

Torsades de pointes (TdP) and long QT syndrome that are characterized by diagnostic altered ECG patterns [8].



7.3.1



Diagnosis



The preoperative detection of new-onset ventricular arrhythmias (VPBs, VT)

requires a proper patient evaluation to identify acute or chronic myocardial ischaemia. Diagnostic evaluation with echocardiography and invasive tests such as

coronary angiography with eventual myocardial revascularization are recommended

in these cases. More specific electrophysiological tests are required in select

patients.



7.3.2



Treatment



The management of ventricular arrhythmias depends primarily on the associated

cardiovascular dysfunction.

• Isolated VPBs and non-sustained monomorphic VTs do not generally require

any suppressive therapy because they are not associated with a worsening of the

clinical outcome. The removal of the underlying trigger is generally sufficient to

terminate the arrhythmias.

• In patients with a history of ventricular arrhythmias, the preoperative antiarrhythmic therapy should not be discontinued before surgery (class IC).

The American College of Cardiology/American Heart Association/ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death recommend that:

• Sustained, monomorphic VTs with haemodynamic instability should be treated with

electric cardioversion; amiodarone is indicated in haemodynamically stable patients.

• Immediate defibrillation is recommended to terminate VF and sustained polymorphic VT.



7



Management of Perioperative Arrhythmias



115



• In the case of recurrent episodes of sustained polymorphic VT, especially when

myocardial ischaemia is either suspected or cannot be excluded, beta-blockers

are recommended; amiodarone can be reasonably helpful when long QT syndrome is not present.

• In haemodynamically stable monomorphic VT, the use of amiodarone to prevent

recurrences is indicated.

In cases of TdP, the following is recommended:

• Withdrawal of the underlying triggers (drugs, electrolyte disturbances) that is

generally sufficient to terminate the arrhythmias.

• Intravenous magnesium sulphate is indicated in the presence of long QT

syndrome.

• Recurrent pause-dependent TdP without long QT syndrome can be treated with

isoproterenol.

• Patients with TdP and sinus bradycardia can receive beta-blockers and temporary pacing.

VT should always be suspected in the presence of wide QRS tachycardia of uncertain diagnosis. In these cases, the use of calcium channel blockers is contraindicated to

terminate the arrhythmia, especially in patients with a history of myocardial ischaemia.

Electric storm (ES) can occur in patients who are refractory to medical therapy.

ES is characterized by recurrent and very frequent (more than 3 in the 24 h) episodes of either polymorphic VT with haemodynamic impairment or VF requiring

continuous defibrillation [9–11].

The causes of the ES are different, and they include myocardial ischaemia, myocardial scarring generating recruitment circuits and genetic predisposition to

develop ventricular arrhythmias under stress conditions, which occurs in catecholaminergic polymorphic ventricular tachycardia (CPTV).

One of the causes of the ES occurring under stress conditions, such as surgical

stress, is the increase in blood levels of catecholamines due to the activation of the

sympathetic nervous system.

The use of an implantable defibrillator is the gold standard therapy for patients

with ES. Because of the procedure-related complications, left cardiac sympathetic

denervation (LCSD) has been proposed as a valid therapeutic option for those

patients, especially young patients, who do not tolerate ICD [12–15].

In particular, thoracoscopic LCSD, which has been available since 1971, has been

progressively improved in the last decades. This surgical technique consists of ablation.



7.4



Supraventricular Arrhythmias



Perioperative supraventricular arrhythmias are quite common and are more frequent

than ventricular arrhythmias in patients undergoing noncardiac surgery. In most

cases, the withdrawal of the trigger (perioperative respiratory failure, electrolyte

alterations) is sufficient to terminate the arrhythmic event.



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F. Guarracino and R. Baldassarri



The association between perioperative neurologic events such as stroke and supraventricular tachyarrhythmias (ST) has been well documented [16]. Despite the increasing number of patients undergoing noncardiac surgery, studies of the incidence and

complications of perioperative AF (POAF) in a large surgical population are still lacking [17]. POAF is the most common perioperative arrhythmia in noncardiac surgery

patients [18, 19]. The cardiac arrhythmias occurring in noncardiac surgery strictly

depend on the patients’ clinical conditions and the type of surgery [1]. Approximately

10–20 % of the patients who undergo noncardiac thoracic surgery experience POAF,

and this is dependent on the type of surgery and the patients’ characteristics (age, therapy with beta-blockers, cardiac valve disease and heart failure) [20–23].

New-onset POAF in noncardiac surgery patients has been associated with an

increased risk of perioperative neurologic complications leading to an increased

perioperative risk [24, 25].



7.4.1



Treatment



According to the current guidelines, the treatment of POAF should be aimed at the

control of the ventricular heart rate. The use of beta-blockers and calcium channels

blockers is recommended as the treatment of choice by the ESC guidelines on AF

management [26].

The use of amiodarone is recommended in patients with heart failure, while

digoxin is not helpful in surgical patients because of the increased perioperative

adrenergic stress.

When surgery can be delayed, select patients with paroxysmal supraventricular

tachycardia (PST) and AF can benefit from transcatheter radiofrequency ablation

to remove the aetiological pattern of the arrhythmia.

According to the guidelines, supraventricular PBs do not require any therapy,

and STs generally respond to vagal manoeuvres. In these cases, adenosine is effective to terminate the ST. The prophylactic use of beta-blockers, amiodarone and

calcium channel blockers should be used in patients with recurrent ST.

AF with haemodynamic instability requires immediate electrical cardioversion.

In the case of new-onset AF in patients undergoing noncardiac surgery, the use of

beta-blockers appears to be associated with a high incidence of cardioversion to

sinus rhythm [27].



7.5



Bradyarrhythmias



Perioperative bradyarrhythmias do not commonly require the implantation of a temporary or permanent cardiac pacing because they respond well to medical therapy.

Cardiac pacing is recommended in the case of either complete heart block or episodes of symptomatic asystole. In asymptomatic patients with bifascicular blocks,

with or without first-degree atrioventricular block, the prophylactic use of cardiac

pacing is generally not recommended. In these cases, the use of external pacing for

transcutaneous pacing is indicated before surgery.



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