Lung transplant - Revision history

Jchen900 at 16:49, 1 October 2023

2023-10-01T16:49:08Z

@@ Line 118: / Line 118: @@
 * Parenteral narcotics
-=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
+== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ==
-* RV dysfunction/failure
+=== Primary Graft Dysfunction (PGD)<ref>{{Cite journal|last=Potestio|first=Christopher|last2=Jordan|first2=Desmond|last3=Kachulis|first3=Bessie|date=2017-06|title=Acute postoperative management after lung transplantation|url=http://dx.doi.org/10.1016/j.bpa.2017.07.004|journal=Best Practice &amp; Research Clinical Anaesthesiology|volume=31|issue=2|pages=273–284|doi=10.1016/j.bpa.2017.07.004|issn=1521-6896}}</ref> ===
-* Rejection
+Primary graft dysfunction (PGD) is a form of acute lung injury that occurs in the immediate postoperative period. It is associated with 30% of all deaths in the immediate postoperative period. The characteristics of PGD are similar to ARDS and as follows:
-* Infection
-* Pulmonary edema
+* Hypoxemia with pulmonary infiltrates in absence of left heart failure
 == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Jchen900 at 20:03, 4 September 2023

2023-09-04T20:03:45Z

← Older revision		Revision as of 13:03, 4 September 2023
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	\|		\|
	* May be on high oxygen/ventilatory requirement prior to procedure.		* May be on high oxygen/ventilatory requirement prior to procedure.
			*6 minute walk test can be another useful tool to assess disease severity
	\|-		\|-
	\|Gastrointestinal		\|Gastrointestinal
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	* Presence of renal dysfunction is a determinant of post-transplant survival.		* Presence of renal dysfunction is a determinant of post-transplant survival.
	\|-		\|-
	\|~~Endocrine~~		\| colspan="2" \|
	\|
	\|-
	~~\|Other~~
	\|
	\|}		\|}

Jchen900 at 01:21, 31 August 2023

2023-08-31T01:21:48Z

← Older revision		Revision as of 18:21, 30 August 2023
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	== Preoperative management ==		== Preoperative management ==

	=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===		=== Patient evaluation<ref>{{Cite journal\|last=Murray\|first=Andrew W.\|last2=Boisen\|first2=Michael L.\|last3=Fritz\|first3=Ashley\|last4=Renew\|first4=J. Ross\|last5=Martin\|first5=Archer Kilbourne\|date=2021-11\|title=Anesthetic considerations in lung transplantation: past, present and future\|url=https://pubmed.ncbi.nlm.nih.gov/34992834\|journal=Journal of Thoracic Disease\|volume=13\|issue=11\|pages=6550–6563\|doi=10.21037/jtd-2021-10\|issn=2072-1439\|pmc=8662503\|pmid=34992834}}</ref><ref name=":0" /><!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->===
	{\| class="wikitable"		{\| class="wikitable"
	\|+		\|+
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	\|		\|
	* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.		* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
	** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref>{{Cite book\|last=Jaffe\|first=Richard\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2009\|isbn=978-1-4511-7660-5}}</ref>		** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref name=":0">{{Cite book\|last=Jaffe\|first=Richard\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2009\|isbn=978-1-4511-7660-5}}</ref>
	* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.		* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
	\|-		\|-
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	\|Gastrointestinal		\|Gastrointestinal
	\|		\|
			* Obesity is a contraindication for transplantation (Class II-III obesity is considered to be absolute contraindication).
			* Many patients are underweight and present with sarcopenia.
	\|-		\|-
	\|Hematologic		\|Hematologic
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	\|Renal		\|Renal
	\|		\|
			* Renal dysfunction is prevalent. Preoperative etiologies include hypotension, decreased cardiac output, hypoxemia, and nephrotoxic medications (antibiotics, calcinurin inhibitors).
			* Presence of renal dysfunction is a determinant of post-transplant survival.
	\|-		\|-
	\|Endocrine		\|Endocrine
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	* TIVA setup after transition to ICU ventilator		* TIVA setup after transition to ICU ventilator
	* Crossmatched blood products		* Crossmatched blood products
			*Heparin, TXA, and protamine (if going on pump)

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

Jchen900 at 21:36, 16 August 2023

2023-08-16T21:36:49Z

← Older revision		Revision as of 14:36, 16 August 2023
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	\| airway = DLT, left sided		\| airway = DLT, left sided
	\| lines_access = large bore IVs, central access (volume and infusion lines)		\| lines_access = large bore IVs, central access (volume and infusion lines)
	\| monitors = Standard, arterial line, CVP, +/- PA cath~~, TEE, neurooximetry~~		\| monitors = Standard, arterial line, CVP, TEE, neurooximetry, +/- PA cath
	\| considerations_preoperative = Usually significant oxygen requirement, possible RH disease		\| considerations_preoperative = Usually significant oxygen requirement, possible RH disease
	\| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)		\| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)

Jchen900: Made fairly significant changes to all sections.

2023-08-16T20:30:08Z

Made fairly significant changes to all sections.

← Older revision		Revision as of 13:30, 16 August 2023
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	\|Neurologic		\|Neurologic
	\|		\|
			* Right to left intracardiac shunting can cause strokes.
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\|
			* Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
			** RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.<ref>{{Cite book\|last=Jaffe\|first=Richard\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2009\|isbn=978-1-4511-7660-5}}</ref>
			* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
	\|-		\|-
	\|Pulmonary		\|Pulmonary
	\|		\|
			* May be on high oxygen/ventilatory requirement prior to procedure.
	\|-		\|-
	\|Gastrointestinal		\|Gastrointestinal
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	\|Hematologic		\|Hematologic
	\|		\|
			* Polycythemia in setting of chronic hypoxia.
	\|-		\|-
	\|Renal		\|Renal
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	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

			* Cardiac studies: ECG, ECHO, RHC, LHC
			* Pulmonary studies: PFTs, CT Chest, V/Q scan
			* Labs: Type and screen, complete blood count, chemistry panel, coagulation panel, thromboelastography

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

			* Vasopressors/Inotropes Infusions: epinephrine, vasopressin, phenylephrine, norepinephrine
			* Additional infusions: insulin, +/- mannitol
			* Antibiotics (institutional specific): vancomycin (1gm, 1.5gm for >90kg), posaconazole 300mg, ceftazidime 1-2gm
			* Inhaled vasodilators: epoprostenol vs nitric oxide
			* ICU ventilator (may be required prior to transplant if concerns for high ventilator pressures)
			* TIVA setup after transition to ICU ventilator
			* Crossmatched blood products

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

			* Immunosuppressants (institutional specific): myophenolate 1000mg IV, azathioprine 2mg/kg IV, basilixamab 20mg IV, tacrolimus 1mg sublingual
			** Methylprednisolone 500mg IV usually given prior to reperfusion

	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
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	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

			* Cardiac monitoring: TEE, +/- continuous cardiac output monitoring
			* Neuromonitoring: +/- sedline, cerebral ox
			* Lines: large bore IVs, central lines x 1-2 (consider MAC or Cordis), +/- PA catheter, arterial line x 1-2, foley
			* Fiberoptic scope
			* Temperature probe: peripheral and central (both required if going on bypass)

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

			* ETT: left sided double lumen if off bypass, single lumen if on bypass

	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

			* For single lung: supine, lateral decubitus
			* For double lung: supine

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

			* Before reperfusion:
			** PA clamping: may increase PAP leading to RV dysfunction
			** May need to give methylprednisolone 500mg IV prior to reperfusion of each lung
			* Reperfusion:
			** Watch for hemodynamic instability. If off bypass, have low dose (10-16mcg/ml) and high dose (100mcg/ml) epinephrine ready.
			** Give mannitol 25mg
			** In line suction for new lung
			** Inflate lungs with Ambu during direct visualization

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
			Transported to ICU intubated.

	== Postoperative management ==		== Postoperative management ==

	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
			Transported to ICU intubated.

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

			* Thoracic epidural catheter
			* Parenteral narcotics

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

			* RV dysfunction/failure
			* Rejection
			* Infection
			* Pulmonary edema

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
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	\|+		\|+
	!		!
	!~~Variant 1~~		!On Pump BOLT
	!~~Variant 2~~		!Off Pump BOLT
	\|-		\|-
	\|Unique considerations		\|Unique considerations

Tony.Wang at 01:36, 8 January 2023

2023-01-08T01:36:19Z

← Older revision		Revision as of 18:36, 7 January 2023
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	}}		}}

	A '''lung transplant''', or '''bilateral orthotopic lung ~~transplanation~~ (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.		A '''lung transplant''', or '''bilateral orthotopic lung transplantation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.

	== Preoperative management ==		== Preoperative management ==

Tony.Wang at 10:35, 7 January 2023

2023-01-07T10:35:07Z

← Older revision		Revision as of 03:35, 7 January 2023
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = GA		\| anesthesia_type = GA +/- epidural
	\| airway = DLT, left sided		\| airway = DLT, left sided
	\| lines_access = large bore IVs, central access (volume and infusion lines)		\| lines_access = large bore IVs, central access (volume and infusion lines)

Tony.Wang at 10:28, 7 January 2023

2023-01-07T10:28:53Z

← Older revision		Revision as of 03:28, 7 January 2023
Line 2:		Line 2:
	\| anesthesia_type = GA		\| anesthesia_type = GA
	\| airway = DLT, left sided		\| airway = DLT, left sided
	\| lines_access = large bore IV, central access (volume and infusion lines)		\| lines_access = large bore IVs, central access (volume and infusion lines)
	\| monitors = Standard, arterial line, CVP, +/- PA cath, TEE, neurooximetry		\| monitors = Standard, arterial line, CVP, +/- PA cath, TEE, neurooximetry
	\| considerations_preoperative = Usually significant oxygen requirement		\| considerations_preoperative = Usually significant oxygen requirement, possible RH disease
	\| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)		\| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)
	\| considerations_postoperative =		\| considerations_postoperative = ICU, generally remain intubated
	}}		}}

Tony.Wang at 10:27, 7 January 2023

2023-01-07T10:27:26Z

← Older revision		Revision as of 03:27, 7 January 2023
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	}}		}}

	~~Provide~~ a ~~brief summary of this~~ surgical procedure ~~and its indications here~~.		A '''lung transplant''', or '''bilateral orthotopic lung transplanation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.

	== Preoperative management ==		== Preoperative management ==

Tony.Wang: info box update

2022-08-16T18:23:41Z

info box update

← Older revision		Revision as of 11:23, 16 August 2022
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type =		\| anesthesia_type = GA
	\| airway =		\| airway = DLT, left sided
	\| lines_access =		\| lines_access = large bore IV, central access (volume and infusion lines)
	\| monitors =		\| monitors = Standard, arterial line, CVP, +/- PA cath, TEE, neurooximetry
	\| considerations_preoperative =		\| considerations_preoperative = Usually significant oxygen requirement
	\| considerations_intraoperative =		\| considerations_intraoperative = Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)
	\| considerations_postoperative =		\| considerations_postoperative =
	}}		}}