Anesthesia for Lung Transplantation

Abstract

Lung transplantation is the only therapeutic option for more than 3,000 individuals in the United States with end-stage lung disease. Innovations in anesthetic and surgical techniques have expanded the indications for lung transplantation. Presently, the major limiting factor in the number of lung transplantations that are performed is the availability of suitable donor organs. Lung transplantation includes a number of surgical procedures, including single-lung, double-lung, bilateral-sequential-single-lung, heart-lung, and lobar transplantation. Patients undergoing lung transplantation present a variety of challenges to the anesthesia team. Critical periods include induction of anesthesia, initiation of positive pressure ventilation, establishment and maintenance of one-lung ventilation, pulmonary artery clamping, pulmonary artery unclamping, and reperfusion of the transplanted lung. Pharmacologic advances have been an important factor in the continued development and success of lung transplantation. Newer immunosuppressive agents have improved the prevention and management of post-transplant rejection. Selective pulmonary vasodilators that are administered via inhalation affect the anesthetic management during the surgical procedure. Technologic advances in monitoring have also been valuable in lung transplantation. Transesophageal echocardiography is commonly used to evaluate intraoperative ventricular function. Continuous cardiac output, mixed venous oxygen saturation, continuous arterial blood gas monitoring, and the bispectral index have also been used to monitor the patient during lung transplantation. Anesthetic management of lung transplantation requires a thorough understanding of end-stage lung disease and pharmacologic and technical considerations that may not be applicable in any other part of anesthetic practice.

Intra‐operative protective mechanical ventilation in lung transplantation: a randomised, controlled trial

“…There were no significant differences between control and alveolar recruitment groups in median (IQR [range]) ICU length of stay (6 (3–23 [2–124]) days vs. 4 (2–8 ) days, p = 0.46) or hospital length of stay (28 (21–37 [16–128]) days vs. 21 (14–24 [13–65] days), p = 0.26). All of the patients involved in the study survived at least 30 days.…”

“…No standardised approach to ventilatory management exists in lung transplantation . Recent reviews have suggested that some protective benefit may be realised from low tidal volume ventilation, possibly with pressure‐controlled ventilator modes, higher positive end‐expiratory pressure (PEEP) and step‐wise alveolar recruitment manoeuvres .…”

Anesthetic management in lung transplantation: Our single-center experience

“…Previous studies have suggested that femoral cannulation may be beneficial in high-risk patients during the induction of anesthesia. [ 7 ] We also performed femoral artery and vein catheterization for guiding purposes for possible V-A ECMO support after the induction.…”

Preoperative Hypercapnia as a Predictor of Hypotension During Anesthetic Induction in Lung Transplant Recipients

“…Patients with end-stage lung disease are generally at least moderately hypovolemic due to diuretic use or increased insensible losses from work of breathing. 10 Most lung transplant recipients have pulmonary hypertension and right ventricular dysfunction to some extent, 11 and they often have pulmonary vascular medial wall hypertrophy, which increases the potential for sudden increases in pulmonary vascular resistance and right heart failure. 12,13 These factors may exaggerate the myocardial depressant or vasodilatory effects of anesthetic agents and lead to significant hemodynamic instability.…”

“…5,14 A narcotic-based "cardiac anesthetic" with slow titration of the induction agent may provide improved hemodynamic stability. 4,10 However, slow titration of the induction agent may increase the risk of hypoventilation and oxygen desaturation during induction because it takes more time to induce anesthesia and secure the airway. Consequently, rapid induction with propofol or midazolam tends to be preferred for lung transplant recipients.…”