Transcript ANESTHESIA FOR LUNG TRANSPLANTION

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KAPLAN’S 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 <
30% of a lobe
 CT, X’ray, 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 >2 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
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Single lung transplantation-mostly
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Double lung transplantation-cystic
fibrosis,Ch bronchiectasis
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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
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Avoid myocardial depression
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Avoid RV afterload increase
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Avoid lung hyperinflation
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ANESTHETIC MANAGEMENT
MAINTENANCE
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One lung Ventilation
Pneumothorax –Detection & Management
Trail PA ligation
CPB prior to PA ligation in severe PHT
RVF managementAvoid increase in intra thoracic pressure,
Increase in preload,
Inodilators-Dobutamine,milrinone
α agonists to maintain RV coronary perfusion pr,
Pulmonary vasodilatorsPg E1 {0.05- 0.15µg/kg/min},NO {20-40ppm}
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ANESTHETIC MANAGEMENT
MAINTENANCE
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CPB indicationCI< 2L, SvO2<60%, MAP<60mmHg
SaO2<85%, pH<7
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After transplantNative lung add dead space ventilation
Exaggerated broncho constriction response
Impairment of mucocilliary function
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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
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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
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