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Seven Critical Sins

ID Council Communications Co-Liaison

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When many of us begin working in the field of lung transplantation, it is recognized that surgical interventions and other invasive procedures place our patients at an increased risk for complications, more so than other patients not requiring transplantation or immunosuppressive drugs. Many lung recipients have an uneventful surgical intervention, but within a few minutes or hours after the intervention a rapid deterioration of their condition may be observed. This then may lead to re-intubation, ICU transfer and sometimes prolonged mechanical ventilation. The triggering event cannot always be determined, but fluid overload, attempts to normalize blood pressure and bleeding complications are seen on a regular basis. This could pose further risks and lead to a whole series of complications. Over the years we have learned that there were a number of "serious" errors committed in such context.

Over time we must be burdened with the task to admit to our own mistakes, determine those which are overt or covert and then prevent these errors by either preventing the procedure in the first place or by making sure that in preparing for the intervention, all possible outcomes and steps have been considered to best be prepared for even the rarest and seemingly most innocuous of complications.

At our program, it became obvious that we were always emphasizing the same things, but due to ever changing treatment teams and the "rarity" of interventions in our lung transplant recipients, the surgical and perioperative teams were unable to gain expertise and be aware of the potential dangers in our patients from the infrequent contact with lung recipients. As a result, we compiled a list of recommendations for the perioperative phase and gave it a catchy name, the "Seven Critical Sins". We instituted a protocol highlighting these "seven sins" list whenever we thought it may be necessary for our transplantation team which includes surgeons, anesthesiologists, intensivists and the respective ward physicians (Table 1). Strangely enough, this protocol was well received and was not misconstrued; in fact, extraordinary results with lung recipients were obtained through our heightened awareness regarding the care of these complex patients. The list has remained largely unchanged for a few years now and has been shared with the community.1 As time goes by we will improve its message but for the time being we just wanted to share this simple intervention to reduce emergent calls in the early postoperative phase of predominantly non-pulmonary surgical interventions.

The seven sins list reflects in a nutshell what we generally try to communicate to the perioperative team or try to achieve whenever we have a chance to be involved in the planning of a procedure. We take great strides in drawing attention to certain pitfalls and peculiarities in our patients always with the risk that we are considered "a pain ..." since fellow surgeons are by default optimistic and do not expect problems in healthy looking lung recipients. What are less visible at first sight are the polypharmacy and the vulnerability of their transplanted organ, also due to severe immunosuppression.

  1. Schuurmans MM, Tini GM, Zuercher A, Hofer M, Benden C, Boehler A. Practical approach to emergencies in lung transplant recipients: how we do it. Respiration. 2012;84(2):163-75. Epub 2012 Jul 20.

Disclosure Statement: No conflict of interest other than being the author of the main reference.

Table 1

'Seven Critical Sins' relating to invasive procedures in LTRs:

  1. Wrong indication or dismissal of conservative strategy. Invasive interventions in situations that may have possibly resolved with consequent conservative measures ('using standard indications for non-standard patients!').
  2. Lack of meticulous preparation of procedure involving all possible specialists that may be of relevance (including lung transplant specialist, anaesthetist, experienced surgeon familiar with high complication rate of this population, experienced intensivist for post-operative care).
  3. Lack of intravenous anti-infective treatment for at least 2-3 days before and after the surgical intervention (in collaboration with lung transplant specialist).
  4. Lack of early and consequent laxative treatment to prevent intestinal complications. Avoid opioids for this reason.
  5. Lack of cautious blood pressure control and fluid management; lack of experience with technicalities and pitfalls of blood pressure measurement and control in this population can severely complicate any intervention (arterial hypertension is highly prevalent among LTRs, and many require multiple anti-hypertensives for adequate blood pressure control). Fluid intake should not be restricted pre-operatively to avoid haemodynamic instability and renal dysfunction. Fluid overload should be avoided intraoperatively due to impaired lymphatic drainage.
  6. Lack of strict anti-reflux measures to prevent GOR and aspiration, such as positioning the patient in the 'tilt position' (reverse Trendelenburg position) at all times irrespective of circumstances, and no enteral feeds via the gastric tube (duodenal or jejunal tube feeding only).
  7. Non-anticipation of possible complications (kidney failure due to contrast agent or non-steroidal anti-rheumatics) and failure to implement preventive strategies including having an intensive care unit bed on 'stand-by' for all LTRs post-operatively.

Reproduced (without references) with permission from (1).