Difference between revisions of "Lung transplant"

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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. -->===
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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
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* Obesity is a contraindication for transplantation (Class II-III obesity is considered to be absolute contraindication).
* Many patients are underweight and present with sarcopenia.
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|Hematologic
|Hematologic
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|Renal
|Renal
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* 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.
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|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. --> ===

Revision as of 17:21, 30 August 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.
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.
Endocrine
Other

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

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

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.

Top contributors: Gang Chen, Mitchel DeVita, Tony Wang and Chris Rishel

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