Letters to the Editor: Letter to the Editor
To the Editor:
In their recently published article, Geube et al1 retrospectively analyzed perioperative data of 494 patients who had lung transplantation and, using partially adjusted multivariable logistic regression, concluded that intraoperative fluid volume is associated with grade-3 primary graft dysfunction (PGD).
The authors deserve our sincere appreciation for attempting to add new insights on intraoperative management of lung transplant recipients. We would like to share some thoughts.
First, the use of vasoconstrictor and inotropic agents was greater in grade-3 PGD patients than in low-grade PGD patients. Multivariable analysis was not adjusted for these variables: we do not know whether grade-3 PGD depends on fluid volume or vasoactive/inotropic dosage.
Second, the authors did not report preoperative cardiac function; we do not know anything about right ventricle function. Pulmonary hypertension and right heart dysfunction may require per se fluid administration and may be linked to PGD.
Third, the authors analyze volume of administered fluids, but they do not talk about fluid balance and hemodynamic status of the patients.
Infusions to replace blood loss and to correct hypovolemia are pathophysiologically different from infusions to augment arterial pressure in a failing heart or in a vasoplegic patient. In these different settings, fluids have different effects on the lung.2
Fourth, anesthesiologists handled patients without a hemodynamic-management protocol. It is well known that interphysician variability is very high in this setting.3
Fifth, fluid restriction may be protective against grade 3-PGD but at what cost? Just ask to the kidney and to the heart!
In conclusion, grade-3 PGD is a major cause of morbidity and mortality in patients who undergo lung transplantion.3 We know little about its etiology and pathophysiology. Perioperative management of the patient is a major determinant. Unfortunately, to date, no studies have prospectively investigated fluid administration and inotropic/vasoactive agents use in perioperative period.4 It is time to consider high-quality randomized clinical trials.
Jacopo Colombo, MD
Department of Pathophysiology and Transplantation
University of Milan
Angela Arena, MD
Daniela Codazzi, MD
Department of Anesthesia
Intensive Care and Palliative Care
Fondazione IRCCS Istituto Nazionale dei Tumori
1. Geube MA, Perez-Protto SE, McGrath TL, Yang D, Sessler DI, Budev MM, Kurz A, McCurry KR, Duncan AE. Increased intraoperative fluid administration is associated with severe primary graft dysfunction after lung transplantation. Anesth Analg 2016;122:1081–8.
2. Pilcher DV, Scheinkestel CD, Snell GI, Davey-Quinn A, Bailey MJ, Williams TJ. High central venous pressure is associated with prolonged mechanical ventilation and increased mortality after lung transplantation. J Thorac Cardiovasc Surg 2005;129:912–8.
3. Navarro LH, Bloomstone JA, Auler JO Jr, Cannesson M, Rocca GD, Gan TJ, Kinsky M, Magder S, Miller TE, Mythen M, Perel A, Reuter DA, Pinsky MR, Kramer GC. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond) 2015;4:3.
4. McIlroy DR, Pilcher DV, Snell GI. Does anaesthetic management affect early outcomes after lung transplant? An exploratory analysis. Br J Anaesth 2009;102:506–14.