Perioperative anaesthetic considerations for patients undergoing lung transplantation

Abstract

Purpose: Five thousand, two hundred and eight lung transplants were performed worldwide before April, 1996. This review will discuss lung transplantation from an historical perspective, its indications, donor and recipient selection criteria, donor lung preparation, su~cal considerations, perioperative anaesthetic management, and associated morbidity and mortality. Source: Recent literature on perioperative anaesthetic management of lung transplantation and experience from international centres including the Toronto Lung Transplant Group and the St. Louis Lung Transplant Group. Principal fiadings: Lung transplantation comprises of a family of operations, including single lung transplant, bilateral single lung transplant, lobar transplant and block heart-lung transplant. Improved donor lung preservation techniques have increased the duration of cold ischaemic time. The advent of bilateral single lung transplant has decreased the requirement for cardiopulmonary bypass, and airway complications have been reduced by adoption of~e telescoping bronchial anastomoses. Advances in perioperative monitoring (including transoesophgeai echocardiography), pulmonary vasodilators (e.g., nitric oxide and prostaglandin El), carcliopulmonary bypass and ventilatory management, and a better understanding of the pathophysiological processes during the procedure have improved perioperative anaesthetic management. Also, advances in broad spectrum antibiotics and immunosuppressant drugs have improved the outcome by better management of the complications of infection and rejection. Conclusion: Lung transplantation improves the quality of life with marginal improvement in life expectancy of the recipients. It is an expensive procedure requiring continued resources for long term management of these patients.Objectif : jusqu'en avril 1996, cinq mille, deux cent huit transplantations de poumons avaient dEj,~ Et~ effectuL~,s ,~ travers le monde. Ce survol permettra de discuter de la transpl@~tion pulmonalre darts sa perspective historique, ses indications, les crit&es de s~lection du receveur et du donneur, la preparation du poumon du donneur, les consid&ations chirurgicales, la gestion p&iol~ratoire de ranesth~sie et la mortaiit~ et la morbidit~ assod~es. Source : Les publications r&entes traitant de la gestion p&iop&atoire de la transplantation pulmonaire et de l'exl:~rience acquise par des centres intemationaux dont le Toronto Lung Transplant Group et le St.Louis Lung Transplant Group. Princlpales r: la transplantation pulmonaire englobe une famille d'interventions dont la transplantation unipulmonaire, bilat&ale simple, Iobaire et coeur-poumons en bloc. I:am61ioration des techniques de pr6servation des poumons du donneur a permis ram~lioration de la durEe de risch6mie froide. I'av~nement de la transplantation bilat~rale simple a rEduit la n~cessitE de la circulation extracorporelle et rintroduction des anastomoses t~lescopiques a permis de r~duire les complications particuli&es aux voles a~dennes. Le perfectionnement du monitorage p~nop&a...

Mechanical ventilation for the lung transplant recipient

“…There are several unique aspects regarding the intra-operative period during LTx 49–53 . Adult LTx can be performed with or without the use of cardiopulmonary bypass in the absence of severe pulmonary hypertension.…”

Anaesthesia for patients with a transplanted organ

“…If necessary to administer intravenously, azathioprine dose needs no adjustment. Dose reduction or omittance has been recommended, if the white cell count is below 4–6 · 10 9 , or if the platelet count is below 40 · 10 9 ( 5, 8, 73). Elective surgery has been recommended to be postponed, if the leukocyte count is below 2000 cells/μl ( 15).…”

“…Peroral therapy should be used whenever possible. The drugs can also be administered via a nasogastric tube, if the use of suction can be avoided ( 73). It is suggested that the transplantation unit should recommend doses and routes of administration ( 118).…”

Anesthetic management of a patient with a double inferior vena cava and pulmonary alveolar proteinosis who underwent bilateral living-donor lobar lung transplantation

“…Pulmonary function tests performed just before the last WLL showed severe restrictive lung disease, i.e., forced vital capacity 0.87 L (28.2% predicted), forced expiratory volume at one second (FEV 1 …”

“…Some patients undergoing lung transplantation experience cardiac or respiratory instability during the procedure and require cardiopulmonary bypass (CPB) [1]. When the cardiopulmonary collapse occurs before thoracotomy incision, emergent establishment of extracorporeal circulation (ECC) through the femoral vessels is necessary [2,3].…”