From 51 lung transplant recipients who required admission to the ICU at the Duke
University Medical Center, 53% required mechanical ventilation and 37% died (59% of those
requiring mechanical ventilation) (297). In other series, mortality of lung transplant recipients
requiring admission to a medical ICU was 37%. A preadmission diagnosis of bronchiolitis
obliterans syndrome, APACHE II score, nonpulmonary organ system dysfunction, initial
serum albumin level, and duration of mechanical ventilation are important prognostic factors
(30). Mortality of renal transplant recipients in the ICU was 11% in a recent series and infection
caused 6/7 deaths (298).
Prevention
Organ transplant patients admitted to the ICU should receive all measures available to prevent
nosocomial infection. The first one could be to avoid the admission to the unit itself, which has
been demonstrated to be a very stress-inducing situation for transplant recipients (299). In one
recent study, the proportion of liver transplant patients who could be extubated immediately
after surgery and transferred to the surgical ward without intervening ICU care was
determined. Of 147 patients, patients did not meet postsurgical criteria for early extubation
and 111 patients were successfully extubated. Eighty-three extubated patients were transferred
to the surgical ward after a routine admission to the postoperative care unit. Only three
patients who were transferred to the surgical ward experienced complications that required a
greater intensity of nursing care. A learning curve detected during the three-year study period
showed that attempts to extubate increased from 73% to 96% and triage to the surgical ward
increased from 52% to 82% without compromising patient safety. The protocol resulted in a
one-day reduction in ICU use in 75.5% of study subjects (300). The same approach can be
extended to the use of IV catheters or indwelling bladder catheters, which should be
withdrawn as soon as possible.
Other measures such as selective gastrointestinal decontamination (301), use of gowns, or
HEPA filters have not demonstrated so clearly an impact on the reduction of mortality or even
nosocomial infections.
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408 Mun ̃oz et al.