Lung transplant
From WikiAnesthesia
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, +/- PA cath, TEE, neurooximetry |
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 | |
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
System | Considerations |
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Neurologic |
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Cardiovascular |
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Pulmonary |
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Gastrointestinal | |
Hematologic |
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Renal | |
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
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 | |
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Unique considerations | ||
Position | ||
Surgical time | ||
EBL | ||
Postoperative disposition | ||
Pain management | ||
Potential complications |
References
- ↑ 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