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Early Trends in the PaO₂/FIO₂ Ratio Predict Outcome in Lung Transplant Recipients with Severe Primary Graft Dysfunction

¹University of Minnesota, Minneapolis, MN, Division of Cardiovascular and Thoracic Surgery ²Division of Pulmonary, Allergy, and Critical Care Medicine

dahlb002{at}umn.edu

Abstract

BackgroundThe development of severe primary graft dysfunction (PGD) is a risk factor for perioperative death following lung transplantation. Our goal is to improve the predictive value of the earliest PaO₂/FIO₂ (P/F) measurements, which gauge PGD severity.

MethodsWe identified 96 patients with severe PGD (P/F <200) at ICU arrival through a retrospective review of 431 lung transplants performed at our institution from 1992 to 2005. The P/F trend, represented as quartiles of the twelve-hour percentage change in P/F, was analyzed using multivariate logistic regression. Study outcomes were 90-day death and long-term survival.

ResultsThe median percentage change in P/F over twelve hours was +52% (interquartile range, +20-90%). We observed the highest early mortality among those in the lowest quartile of the P/F trend (an increase of 20% in P/F). Ninety-day death rates decreased across the quartiles (low quartile, 32%; low-mid, 9%; high-mid, 5%; high quartile, 5%; test for trend, p = 0.007). After adjustment for the use of cardiopulmonary bypass, those in the lowest quartile of P/F trend had 6.8 times the odds of early death versus patients with a more favorable trend (OR 6.80, 95% CI 1.73-30.51, p = 0.007). In the first five years post-transplant, there were significantly more deaths within the low quartile group versus those with a more rapidly increasing P/F trend (log-rank test, p = 0.01).

ConclusionsAmong lung recipients with severe PGD at ICU arrival, an improvement in P/F of 20% in the first twelve hours portends a poor outcome.

Key Words: acute lung injury • lung transplantation • reperfusion injury • treatment outcome • trends.