Evaluation of Donor Lungs for Transplantation: The Efficacy of Screening Bronchoscopy for Detecting Donor Aspiration and Its Relationship to the Resulting Allograft Function in Corresponding Recipients.

BACKGROUND: Potential organ donors often have suffered anoxic and/or traumatic brain injury during which they may have experienced aspiration of gastric material (AGM). Evaluation of such donors typically includes a screening bronchoscopic examination during which determinations of aspiration are made. The efficacy of this visual screening and its relationship to post-transplant allograft function are unknown. METHODS: Before procurement, bronchoscopy was performed on donors in which both bronchoalveolar lavage fluid (BALF) was collected and a visual inspection made. As a marker of AGM, BALF specimens were analyzed for the presence of bile salts. Data collected on the corresponding recipients included primary graft dysfunction (PGD) score, post-transplant spirometry, acute rejection scores (ARS), and overall survival. RESULTS: Of 31 donors evaluated, bronchoscopies revealed only 2 with visual evidence of AGM, whereas BALF analysis for bile salts indicated AGM in 14. As such, screening bronchoscopy had a sensitivity of only 7.1%. Visual detection of AGM via bronchoscopy was not associated with any resulting grade of PGD (χ2 = 2.96, P = .23); however, AGM defined by detection of bile salts was associated (χ2 = 7.56, P = .02). Over the first post-transplant year, the corresponding recipients experienced a similar improvement in allograft function (χ2 = 1.63, P = .69), ARS (P = .69), and survival (P = .24). CONCLUSION: Visual inspection during a single bronchoscopic examination of lung donors underestimates the prevalence of AGM. The detection of bile salts in donor BALF is associated with early allograft dysfunction in the corresponding recipients but not with later allograft proficiency, acute rejection responses, or 1-year post-transplant survival.

Gastrointestinal Dysfunction and Feeding Intolerance in Critical Illness: Do We Need an Objective Scoring System?

PURPOSE OF REVIEW: Efforts to provide early enteral nutrition in critical illness are thwarted by gastrointestinal dysfunction and feeding intolerance. While many of the signs and symptoms of this dysfunction reflect gastroparesis and intestinal dysmotility, other symptoms which may or may not be related are often included such as diarrhea, bleeding, and intra-abdominal hypertension. This paper discusses the need to monitor tolerance of nutritional therapy in the critical care setting and reviews the results of those clinical trials which have helped establish objective measures, define feeding intolerance, and provide a tool to guide continued delivery of the enteral regimen. RECENT FINDINGS: While definitions vary, the presence of gastrointestinal dysfunction and feeding intolerance correlates with adverse clinical outcomes, including prolonged duration of mechanical ventilation, greater length of stay in the intensive care unit, and increased mortality. Despite their prognostic value, it is not clear to what extent these scoring systems should direct nutritional therapy. The clinician should be astute in the careful selection of monitors, in identifying and addressing signs and symptoms of intolerance, and by responding appropriately with feeding strategies that are effective and safe. Early enteral feeding in critical illness has been shown to be optimized by following protocols which allow monitoring patient tolerance while providing individualized care.