Difference between revisions of "Lung transplant"

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|Neurologic
|Neurologic
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* Right to left intracardiac shunting can cause strokes.
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|Cardiovascular
|Cardiovascular
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* 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>
* Right to left intracardiac shunting may be present in patients with history of ASD/VSD.
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|Pulmonary
|Pulmonary
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* May be on high oxygen/ventilatory requirement prior to procedure.
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|Gastrointestinal
|Gastrointestinal
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|Hematologic
|Hematologic
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* Polycythemia in setting of chronic hypoxia.
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|Renal
|Renal
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=== 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. --> ===
=== 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. --> ===
=== 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


=== 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. --> ===
* 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. --> ===
=== 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. --> ===
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=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== 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. --> ===
=== 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. --> ===
=== 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. --> ===
=== 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. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
Transported to ICU intubated.


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== 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. --> ===
=== 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. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* RV dysfunction/failure
* Rejection
* Infection
* Pulmonary edema


== 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). --> ==
== 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). --> ==
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!Variant 1
!On Pump BOLT
!Variant 2
!Off Pump BOLT
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|-
|Unique considerations
|Unique considerations

Revision as of 13:30, 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, +/- 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
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

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.

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

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