Textbook outcome in lung transplantation: Planned venoarterial extracorporeal membrane oxygenation versus off-pump support for patients without pulmonary hypertension.

BACKGROUND: Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension. METHODS: Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression. RESULTS: Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p = 0.004). CONCLUSIONS: At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy.

Cross-border antibiotic resistance patterns in trauma patients.

BACKGROUND: Antibiotic resistance is a growing problem worldwide, with differences in regional resistance patterns driven by variance in antibiotic stewardship. Hospitals along the United States-Mexico border increasingly identify resistance, raising concern for transfer of drug-resistant organisms across the border. METHODS: This retrospective review evaluated trauma admissions between March 2011 and August 2015. Patients were included if cultures were obtained during the first 3 days of hospitalization to limit analysis of hospital-acquired bacteria. A matched Mexico and US cohort subanalysis was later compared to eliminate bias in time from injury to culture. RESULTS: Among 115 Mexico and 1,149 US patients, Mexico patients were younger (mean 44.3 vs 60.4 years), had a higher median injury severity score (21 vs 10), and longer hospital durations of stay (mean 11.6 vs 5.5 days). These differences resolved in the matched analysis. Infections were more common in Mexico than US patients in the matched cohort, and resistant infections including resistant gram-negative infections were more common in Mexico patients in both the matched and overall cohorts. The only resistant organism identified in matched US patients was methicillin-resistant Staphylococcus aureus. Extended-spectrum ß-lactamase Klebsiella was found only in patients from Mexico. Additional risk factors for resistance in the matched cohorts included injury in Mexico, ≥2 days from injury to admission, and tracheostomy placement in Mexico. CONCLUSION: Antibiotic resistance is more common in patients initially treated in Mexico healthcare facilities than those treated exclusively in the United States and may require alternative empiric treatment. Global initiatives to improve antibiotic stewardship will be critical to limit the continued rise in drug-resistant infections.