Australasian Anaesthesia 2011 - Australian and New Zealand ...

100 Australasian Anaesthesia 2011Care of the potential lung transplant donor – optimisation, prevention of decline and future prospects. 101LIVING LOBE DONATIONSeveral centres worldwide perform living lobe donation. This clearly is more complex surgery and includes potentialmorbidity to an otherwise healthy donor. Two donors may donate a lobe each providing the recipient with two lobes.It is not offered in Australasia at this time.DCDDonation after cardiac death as against brain stem death provides an emerging donor pool. This is discussedelsewhere within this journal. Essentially those patients failing brain death testing but with brain injury deemedunsurvivable, and having their treatment withdrawn may donate. If irreversible cardiac death occurs within anaccepted time, organ procurement of lungs, liver and kidneys may be performed. Between 1989 and 2010, over200 additional donors provided a further 58 donor lungs for transplantation. 3EXTENDED DONOR CRITERIAThis group of patients is increasingly being explored as a donor pool. Marginal or extended criteria patients arethose with one or more donor criteria, most commonly PaO2:FiO2 ratio, age, smoking history or CXR abnormalityoutside the ideal range. The current basis of donor assessment is continually questioned in an attempt to explorefurther means of increasing donor numbers. 6EX VIVO LUNG PERFUSIONEx-vivo lung perfusion (EVLP) and reconditioning is an emerging technology first used in Sweden in 2001 by StigSteen et al. 24 This technique involves explant of donor lungs followed by ex-vivo perfusion and ventilation. Donorsmay be DBD with marginal or poor gas exchange or DCD donors whose lungs require further assessment. The lungblock is perfused via a pulmonary artery cannula and a flange sutured to the donor left atrium. The perfusate is anacellular or low (10%) haematocrit heparinised buffered crystalloid solution containing albumin and dextran withoptimised colloid osmotic pressure, Steen Solution (Vitrolife, Göteborg Sweden). This is delivered by a centrifugalpump via a gas exchanger under pressure, flow and temperature controls. The lungs’ trachea is intubated andventilated with a protective lung ventilation strategy including regular recruitment and bronchial toilet. The gasexchange membrane (effectively a de-oxygenator) is adjusted to provide oxygen and carbon dioxide partial pressuresmimicking mixed venous blood in the delivery limb of the circuit. The perfusate is sampled on the pulmonary venousside of the circuit so that the gas exchange capability of the lungs is assessable. The temperature of the circuit iscontrolled to minimise warm ischaemia. Keshavjee et al in Toronto have shown in a prospective non-randomisedtrial that this technique has the capacity to increase donor numbers by nearly 20%. They demonstrated that lungsfrom 20 donors with “high risk” profiles (PaO2:FiO2