Rekonditionering av lungor

Transkript

1 Rekonditionering av lungor en resa från laboratoriet till kliniken Trygve Sjöberg, docent Avd för thoraxkirurgi Universitetssjukhuset Lund

2 Kliniskt problem: Endast 6 timmars preservationstid Orsak: Suboptimal preservationsmetod/lösning

3 Säker 24-timmars preservation med Perfadex

4 Kallt blod - en utmärkt preservationslösning Lungdonation från hjärtdöda Okänd lungfunktion!

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8 THE LANCET Volume 357, Number 9259 Transplantation of lungs from a non-heart-beating donor Stig Steen, Trygve Sjöberg, Leif Pierre, Qiuming Liao, Leif Eriksson, Lars Algotsson Heart-Lung Division, University Hospital of Lund, S Lund, Sweden (Prof S Steen MD, T Sjöberg PhD, L Pierre BSc, Q Liao MD, L Eriksson MD, L Algotsson MD) Background In animals, we have previously done successful lung transplantations using organs from non-heart-beating donors. We have also developed an ex-vivo system of assessing the function of such organs before transplantation. The next stage was to try the technique in human beings. Bearing in mind the sensitive ethical issues involved, our first aim was to find out what procedures would be acceptable, and to use the results to guide a clinical lung transplantation from a non-heart-beating donor. Methods The ethical acceptability of the study was gauged from the results of a broad information programme directed at the general public in Sweden, and from discussions with professionals including doctors, nurses, hospital chaplains, and judges. The donor was a patient dying of acute myocardial infarction in a cardiac intensive-care unit after failed cardiopulmonary resuscitation. The next of kin gave permission to cool the lungs within the intact body, and intrapleural cooling was started 65 min after death. Blood samples were sent for virological testing and cross matching. The next of kin then had time to be alone with the deceased. After 3 h, the body was transported to the operating theatre and the heart-lung block removed. The lungs were assessed ex vivo, and the body was transported to the pathology department for necropsy. Results No contraindications to transplantation were found, and the right lung was transplanted successfully into a 54-year-old woman with chronic obstructive pulmonary disease. The donor lung showed excellent function only 5 min after reperfusion and ventilation, and during the first 5 months of follow-up, the function of the transplanted lung has been good. Interpretation About half the deaths in Sweden are caused by cardiac and cerebrovascular disease. This group could be a potential source of lung donors. When all hospitals and ambulance personnel in Sweden have received training in non-heart-beating lung donation, we hope that there will be enough donor lungs of good quality for all patients needing a lung transplant. Lancet 2001; 357:

9 Donation efter hjärndöd - Ca 80 % av donerade lungor kasseras

10 Kriterier för acceptabla lungor vid donation 100% O 2 5 PEEP 5 minuter PaO 2 40 kpa

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12 Ödembildning i lungorna

13 Blodgasvärden (PaO 2 ) vid erbjudandet och efter rekonditionering kpa Vid erbjudandet Vid erbjudandet Efter rekonditionering Efter rekonditioneringen

14 Den första kliniska transplantationen med initialt kasserade lungor som rekonditionerades gjordes i Lund den 22 maj 2005

15 Hjärndöd donator Trafikolycka Man, 19 år, 190 cm, 70 kg, ORh- Huvud och bröstskador Pågående blödningar i luftvägarna Röntgen visar lungskador P a O 2 = 9 kpa Samtliga transplantationscentra avböjer erbjudandet

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18 PaO 2 : 9 kpa 52 kpa

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20 Topical ECMO (extra corporeal membrane oxygenation)

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24 Dubbellungtransplantation med initialt kasserade och rekonditionerade lungor

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26 Double lung transplantation 5/ /3-07, n=6 PaO 2 i donatorn PaO 2 efter rekond

27 Patient Double lung transplantation 5/ /3-07, n=6 Diagnosis Survival 3 months 6 months 26/ COPD Pulm fibr COPD COPD months rejection 5 35 Cystic fibr COPD + 95d, sepsis

28 Double lung transplantation 5/ /3-07, n=6 Six-minute walking test after transplantation. 6 min walking test Recipient: Median 3 months months months

29 Double lung transplantation 5/ /3-07, n=6 FEV1 after transplantation. FEV1 (L) Recipient: Median 3 months months months

30 Framtiden

31 Donation efter hjärndöd per miljon/år - Idag accepteras 20% för transplantation - Efter rekonditioning 50%? Donation efter hjärtdöd per miljon/år?

32 Steen et al. Resuscitation 2002;55:285-99

33 USA TODAY May 8, 2008

34 March 2007

35 Donation efter hjärtdöd

36 Lancet 2001;357: