Difference between revisions of "Lung transplant"

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(Made fairly significant changes to all sections.)
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Line 3: Line 3:
| 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)

Revision as of 14:36, 16 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

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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.[1]
  • 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
Hematologic
  • Polycythemia in setting of chronic hypoxia.
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
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. Jaffe, Richard (2009). Anesthesiologist's Manual of Surgical Procedures. Wolters Kluwer. ISBN 978-1-4511-7660-5.