Difference between revisions of "Lung transplant"

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{{Infobox surgical procedure
| anesthesia_type = GA +/- epidural
| airway = DLT, left sided
| lines_access = large bore IVs, central access (volume and infusion lines)
| monitors = Standard, arterial line, CVP, TEE, neurooximetry, +/- PA cath
| 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_postoperative = ICU, generally remain intubated
}}


A '''lung transplant''', or '''bilateral orthotopic lung transplantation (BOLT)''', is a surgical procedure performed for patients with end stage pulmonary disease.
== Preoperative management ==
=== 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"
|+
!System
!Considerations
|-
|Neurologic
|
* Right to left intracardiac shunting can cause strokes.
|-
|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 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.
|-
|Pulmonary
|
* May be on high oxygen/ventilatory requirement prior to procedure.
*6 minute walk test can be another useful tool to assess disease severity
|-
|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
|
* Polycythemia in setting of chronic hypoxia.
|-
|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.
|-
| colspan="2" |
|}
=== 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. --> ===
* 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
*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. --> ===
* 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. --> ===
== Intraoperative management ==
=== 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. --> ===
* 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. --> ===
* 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. --> ===
* 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. --> ===
Transported to ICU intubated.
== Postoperative management ==
=== 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. --> ===
* Thoracic epidural catheter
* Parenteral narcotics
== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ==
=== 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> ===
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:
* Hypoxemia with pulmonary infiltrates in absence of left heart failure
* New diagnosis of pulmonary hypertension in immediate postoperative period
* Otherwise unexplained respiratory failure
There are many independent risk factors for PGD including (many of these are modifiable risk factors):
* Overweight and obesity
* Preoperative pulmonary hypertension or sarcoidosis
* Use of cardiopulmonary bypass
* Single lung transplantation
* Increased FiO2 during allograft reperfusion
* Blood products administered during surgery
* Donor age less than 21 or greater than 45 years old, female gender, smoker, and African American in origin
Treatment for PGD consists of lung protective ventilation, similar to ARDS. Pulmonary vasodilators such as iNO and Iloprost have been used. Severe cases may require ECMO support.
=== Atrial Arrhythmias ===
=== Gastroesophageal Reflux ===
=== Acute Renal Insufficiency ===
=== Infection ===
=== Thromboembolic Events ===
=== Surgical Nerve Injury ===
=== Acute Allograft Rejection ===
== 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). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!On Pump BOLT
!Off Pump BOLT
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}
== References ==
[[Category:Surgical procedures]]

Latest revision as of 08:49, 1 October 2023

Lung transplant
Anesthesia type

GA +/- epidural

Airway

DLT, left sided

Lines and access

large bore IVs, central access (volume and infusion lines)

Monitors

Standard, arterial line, CVP, TEE, neurooximetry, +/- PA cath

Primary anesthetic considerations
Preoperative

Usually significant oxygen requirement, possible RH disease

Intraoperative

Thoracic epidural, 1 lung ventilation w/ DLT (may require ECMO or bypass if not tolerated)

Postoperative

ICU, generally remain intubated

Article quality
Editor rating
In development
User likes
0

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

Preoperative management

Patient evaluation[1][2]

System Considerations
Neurologic
  • Right to left intracardiac shunting can cause strokes.
Cardiovascular
  • Pulmonary hypertension causing elevated RV pressures and tricuspid regurgitation.
    • RV failure can occur when pulmonary pressures is 2/3 of systemic arterial pressure.[2]
  • Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
Pulmonary
  • May be on high oxygen/ventilatory requirement prior to procedure.
  • 6 minute walk test can be another useful tool to assess disease severity
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
  • Polycythemia in setting of chronic hypoxia.
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.

Labs and studies

  • 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

  • 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
  • Heparin, TXA, and protamine (if going on pump)

Patient preparation and premedication

  • 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

Intraoperative management

Monitoring and 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

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

Positioning

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

Maintenance and surgical considerations

  • 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

Transported to ICU intubated.

Postoperative management

Disposition

Transported to ICU intubated.

Pain management

  • Thoracic epidural catheter
  • Parenteral narcotics

Potential complications

Primary Graft Dysfunction (PGD)[3]

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:

  • Hypoxemia with pulmonary infiltrates in absence of left heart failure
  • New diagnosis of pulmonary hypertension in immediate postoperative period
  • Otherwise unexplained respiratory failure


There are many independent risk factors for PGD including (many of these are modifiable risk factors):

  • Overweight and obesity
  • Preoperative pulmonary hypertension or sarcoidosis
  • Use of cardiopulmonary bypass
  • Single lung transplantation
  • Increased FiO2 during allograft reperfusion
  • Blood products administered during surgery
  • Donor age less than 21 or greater than 45 years old, female gender, smoker, and African American in origin


Treatment for PGD consists of lung protective ventilation, similar to ARDS. Pulmonary vasodilators such as iNO and Iloprost have been used. Severe cases may require ECMO support.

Atrial Arrhythmias

Gastroesophageal Reflux

Acute Renal Insufficiency

Infection

Thromboembolic Events

Surgical Nerve Injury

Acute Allograft Rejection

Procedure variants

On Pump BOLT Off Pump BOLT
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. ↑ Murray, Andrew W.; Boisen, Michael L.; Fritz, Ashley; Renew, J. Ross; Martin, Archer Kilbourne (2021-11). "Anesthetic considerations in lung transplantation: past, present and future". Journal of Thoracic Disease. 13 (11): 6550–6563. doi:10.21037/jtd-2021-10. ISSN 2072-1439. PMC 8662503 Check |pmc= value (help). PMID 34992834 Check |pmid= value (help). Check date values in: |date= (help)
  2. ↑ 2.0 2.1 Jaffe, Richard (2009). Anesthesiologist's Manual of Surgical Procedures. Wolters Kluwer. ISBN 978-1-4511-7660-5.
  3. ↑ Potestio, Christopher; Jordan, Desmond; Kachulis, Bessie (2017-06). "Acute postoperative management after lung transplantation". Best Practice & Research Clinical Anaesthesiology. 31 (2): 273–284. doi:10.1016/j.bpa.2017.07.004. ISSN 1521-6896. Check date values in: |date= (help)

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