Lung transplant

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
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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

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. 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

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)

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.

Procedure variants

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