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JAMA:器官捐赠者捐赠的器官的保护策略

2010/12/15 来源:EurekAlert!
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据12月15日刊《美国医学会杂志》上的一项研究披露,与常规使用的方法相比,对可能的器官捐赠者发生脑死亡之后采取某些维护肺脏的措施可以使捐赠的合格肺脏数目增加近一倍。 在那些脑死亡时肺功能相对正常的病人中,只有15-20%的患者的肺脏在此后适用于移植,这种情况可能与病人脑死亡之后所

据12月15日刊《美国医学会杂志》上的一项研究披露,与常规使用的方法相比,对可能的器官捐赠者发生脑死亡之后采取某些维护肺脏的措施可以使捐赠的合格肺脏数目增加近一倍。

在那些脑死亡时肺功能相对正常的病人中,只有15-20%的患者的肺脏在此后适用于移植,这种情况可能与病人脑死亡之后所用的通气策略有部分的关系。根据文章的背景资料,人们对在这些情况下什么是最佳的通气策略存在着争议。

意大利都灵大学San Giovanni Battista Molinette医院的Luciana Mascia, M.D., Ph.D. 及其同事开展了一项研究,旨在检查在被诊断已经发生脑死亡的患者中应用一种保护肺脏的策略是否可减少肺功能障碍的发生并增加可用于移植的肺脏的数目。这些随机对照的试验是在2004年9月至2009年5月间在欧洲的12家医院的加护病房中开展的。这些可能的捐赠者被随机分配接受常规的通气方法或是接受保护性通气方法;保护性通气策略包括了与常规方法的几个不同之处,例如保护性通气会用较低的潮气量(每次呼吸时吸入的和呼出的空气容量)及较高的呼气末正压水平(即增加在接近呼气末时的肺内和气道内的空气压力,使得在呼气后肺内保留的空气量增加)。本试验在接受了118名病人之后停止进行(有59人接受常规通气疗法,另外59人则接受保护性通气疗法),因为研究的经费终止了。

研究人员发现,在经过6小时的观察期后,那些被分配在常规通气组的符合肺捐赠标准的病人数为32人(54%),而在接受保护性通气组中的符合肺捐赠标准的病人数为56人(95%)。在常规通气组中的肺脏被摘取的数目为16(27%),而在接受保护性通气组中的肺脏被摘取的数目为32(54%)。

“总之,我们的结果提示,使用保护性通气方法可预防肺功能在脑死亡之后的衰减,并使可移植肺脏的数目增加大约一倍。”


推荐原文出处:

JAMA doi: 10.1001/jama.2010.1796

Effect of a Lung Protective Strategy for Organ Donors on Eligibility and Availability of Lungs for Transplantation

A Randomized Controlled Trial

Luciana Mascia, MD, PhD; Daniela Pasero, MD; Arthur S. Slutsky, MD; M. Jose Arguis, MD; Maurizio Berardino, MD; Salvatore Grasso, MD; Marina Munari, MD; Silvia Boifava, MD; Giuseppe Cornara, MD; Francesco Della Corte, MD; Nicoletta Vivaldi, MD; Paolo Malacarne, MD; Paolo Del Gaudio, MD; Sergio Livigni, MD; Elisabeth Zavala, MD; Claudia Filippini, PhD; Erica L. Martin, PhD; Pier

AbstractContext Many potential donor lungs deteriorate between the time of brain death and evaluation for transplantation suitability, possibly because of the ventilatory strategy used after brain death.

Objective To test whether a lung protective strategy increases the number of lungs available for transplantation.

Design, Setting, and Patients Multicenter randomized controlled trial of patients with beating hearts who were potential organ donors conducted at 12 European intensive care units from September 2004 to May 2009 in the Protective Ventilatory Strategy in Potential Lung Donors Study.

Interventions Potential donors were randomized to the conventional ventilatory strategy (with tidal volumes of 10-12 mL/kg of predicted body weight, positive end-expiratory pressure [PEEP] of 3-5 cm H2O, apnea tests performed by disconnecting the ventilator, and open circuit for airway suction) or the protective ventilatory strategy (with tidal volumes of 6-8 mL/kg of predicted body weight, PEEP of 8-10 cm H2O, apnea tests performed by using continuous positive airway pressure, and closed circuit for airway suction).

Main Outcome Measures The number of organ donors meeting eligibility criteria for harvesting, number of lungs harvested, and 6-month survival of lung transplant recipients.

Results The trial was stopped after enrolling 118 patients (59 in the conventional ventilatory strategy and 59 in the protective ventilatory strategy) because of termination of funding. The number of patients who met lung donor eligibility criteria after the 6-hour observation period was 32 (54%) in the conventional strategy vs 56 (95%) in the protective strategy (difference of 41% [95% confidence interval {CI}, 26.5% to 54.8%]; P &.001). The number of patients in whom lungs were harvested was 16 (27%) in the conventional strategy vs 32 (54%) in the protective strategy (difference of 27% [95% CI, 10.0% to 44.5%]; P = .004). Six-month survival rates did not differ between recipients who received lungs from donors ventilated with the conventional strategy compared with the protective strategy (11/16 [69%] vs 24/32 [75%], respectively; difference of 6% [95% CI, ?22% to 32%]).

Conclusion Use of a lung protective strategy in potential organ donors with brain death increased the number of eligible and harvested lungs compared with a conventional strategy.

Trial Registration clinicaltrials.gov Identifier: NCT00260676

KEYWORDS: BRAIN DEATH, CRITICAL CARE, LUNG TRANSPLANTATION, POSITIVE-PRESSURE RESPIRATION, RANDOMIZED TRIALS, RESPIRATION, ARTIFICIAL, RESPIRATORY FUNCTION TESTS, TIDAL VOLUME, TISSUE AND ORGAN PROCUREMENT, TISSUE DONORS.

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