ANESTHESIA FOR LUNG TRANSPLANtaTION

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ANESTHESIA FOR LUNG TRANSPLANtaTION

• GKK

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• KAPLANS CARDIAC ANESTHESIA
• 5TH EDITION
• 26/845-865

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FACTS

• Lung transplants annual frequency-500 UNOS
• Mortality -13.6 DLT/12.6 SLT 1991
• 3 year survival rate 60 1995
• Post transplant factors - infection,
  bronchiolitis obliterans, immunosuppressive
  therapy.

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Donor selection

• Trauma victims with lung contusion lt 30 of a
  lobe
• CT, Xray, ABG, sputum stain
• Graft harvest- perfused with NTG,DNS,PGE
  inflated immersed in ice cold saline baggage.
• Lung preservation time 6-8 hrs.

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RECIPIENT SELECTION

• ESLD-End Stage Lung Disease life expectancy gt2
  years
• No extra pulmonary infections
• No serious medical illness
• Relative contra indications-previous thoracotomy,
  steroid dependence, advanced age.
• Cystic fibrosis-a challenge

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Types of transplantations

• Single lung transplantation-mostly
• Double lung transplantation-cystic fibrosis,Ch
  bronchiectasis
• Lobar transplantation-children young adult with
  living related donors.

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RECIPIENT PREPARATION

• Pre transplant evaluation-multi disciplinary
  assessment
• Investigations -Basics, CT lung, PFT, ECHO.
• Physical conditioning regimen-reverse muscle
  atropy,maintaining BMI 20
• Re evaluation present clinical status,
  biochemical,abg, echo.

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PREOPERATIVE PREPARATION

• Lung separation DLT,Bronchial blocker
• CPB Unit
• Anesthesia ventilator PCV
• Deferential lung ventilation
• PAC-to know RVEF
• TEE

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ANESTHETIC MANAGEMENT INDUCTION

• Avoid myocardial depression
• Avoid RV afterload increase
• Avoid lung hyperinflation

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ANESTHETIC MANAGEMENT MAINTENANCE

• One lung Ventilation
• Pneumothorax Detection Management
• Trail PA ligation
• CPB prior to PA ligation in severe PHT
• RVF management-
• Avoid increase in intra thoracic pressure,
• Increase in preload,
• Inodilators-Dobutamine,milrinone
• a agonists to maintain RV coronary perfusion
  pr,
• Pulmonary vasodilators-
• Pg E1 0.05- 0.15µg/kg/min,NO 20-40ppm

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ANESTHETIC MANAGEMENT MAINTENANCE

• CPB indication-
• CIlt 2L, SvO2lt60, MAPlt60mmHg
• SaO2lt85, pHlt7
• After transplant-
• Native lung add dead space ventilation
• Exaggerated broncho constriction response
• Impairment of mucocilliary function
• ECMO

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SURGICAL PROCEDURE

• Postrolateral / antrolateral thoracotomy
• Ipsilateral femoral for CPB
• Diseased lung removal
• Retaining long PA
• Allograft placement-Bronchial anastomosis,PA
  anastomosis, LA patching
• Pulmonoplegia, gluco corticoids
• Reperfusion of lung

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POSTOP MANAGEMENT

• Post Perfusion Pulmonary edema- strict fluid
  management, diuretics
• Pulmonary venous obstruction-TEE
• PA narrowing-TEE
• Pneumothorax-in native lung
• Hyper acute graft rejection- hypoxia, pulmonary
  infiltration, poor lung compliance, PHT, RVF.
• Infection
• Bronchiolitis obliterans

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THANK YOU