Learning objectives

• Pre- and perioperative management of a post-lung transplant patient

Definition and mechanisms

• A post-lung transplant patient may have one or both lungs may be replaced by a donor’s lung, sometimes along with a donor’s heart
• A lung transplant is a surgical procedure to replace a diseased or failing lung with a healthy lung from a deceased donor
• It usually takes at least 3-6 months to fully recover from transplant surgery
• Consider an increased risk of infection or rejection of the transplanted lungs

Indications for a lung transplantation

• Chronic obstructive pulmonary disease (COPD), including emphysema
• Pulmonary fibrosis
• Cystic fibrosis
• Pulmonary hypertension
• Alpha-1-antitrypsin

Symptoms of rejection

• Shortness of breath
• Fever
• Coughing
• Chest congestion

Management

Preoperative assessment

• Investigate:
  • The function of the transplanted lung
  • The possibility of rejection or infection of the transplanted lung
  • The effect of immunosuppressive therapy on other organs and the effect of organ dysfunction on the transplanted lung
  • Disease in the native lung
  • Indications for the surgical procedure and its effect on the lung
• Evaluate:
  • Need for supplemental oxygen
  • Pulmonary function tests
  • Arterial blood gas
  • Chest X-ray
  • CT
  • ECG
  • Echocardiogram
  • Complete blood count
  • Creatinine
  • BUN
  • Glucose
  • Electrolytes
  • Renal function tests
  • Liver function tests
  • Coagulation tests
  • Urinalysis
  • Exclude infections
• Take into account possible side effects of immunosuppressive therapy:
  • Hypertension
  • Renal failure
  • Hepatic dysfunction
  • Pancreatitis
  • Glucose intolerance or diabetes
  • Electrolyte abnormalities
  • Bone marrow depression

Perioperative management

General

• If possible, continue immunosuppressants until the day of surgery
• Be cautious with anxiolytics as they may lead to hypercarbia
• Administer:
  • Immunosuppressants IV if oral agents are precluded
  • Prophylactic antibiotics to avoid infection
• Perform standard monitoring
• Avoid:
  • Femoral lines → increased risk of infection
  • Nasal intubation → increased risk of infection
  • Invasive monitoring if not required → risk of infection or pneumothorax
• Place a central line in the antecubital fossa or internal jugular vein →  a lower risk of pneumothorax than in the subclavian approach

Anesthesia

• Local, regional, or general anesthesia are all considered safe to use, however, do not perform a block above T10
• Propofol is the anesthetic of choice
• Etomidate is preferred when there is a risk of hemodynamic instability
• Volatile anesthetics are also well tolerated
• Use short-acting relaxants (mivacurium) or intermediate-acting agents  independent of kidney and liver function (cisatracurium, atracurium)
• Consider that vecuronium, rocuronium, and pancuronium can have prolonged effects with hepatic or renal insufficiency
• Note that immunosuppressive agents may interact with neuromuscular blocking agents
• Avoid:
  • Succinylcholine because of the possibility of hyperkalemia
  • Long-acting agents such as pancuronium or doxacurium

Airway management

• Aim for early extubation to minimize the risk of infection
• The Trendelenberg position may further compromise pulmonary function and increase the work of breathing
• Place the endotracheal cuff just beyond the vocal cords to avoid trauma to the trachea or bronchial anastomosis
• Consider using a fibreoptic laryngoscope
• Positive pressure ventilation is complicated in single lung transplant recipients
• Consider differences in lung compliance between the native and transplanted lungs and consequently, two ventilator machines may be required with different ventilator settings
• Avoid:
  • Benzodiazepines
  • Nitrous oxide
  • Positive end-expiratory pressures
• Consider cardiac denervation in patients who have undergone double lung transplantation with tracheal anastomosis
  • These patients are sensitive to hypovolemia
  • Intraoperative bradycardia does not respond to atropine and direct agents such as epinephrine should be used

Fluid balance

• Monitor central venous pressure, pulmonary artery pressure, and urine output
• Maintain a careful fluid balance
• Consider that altered lymphatic drainage in the transplanted lung may cause interstitial fluid accumulation
  • Treat these patients with diuretics and limited crystalloid infusion

Postoperative care

• Transfer the patient to the ICU
• Monitor oxygen saturation
• Administer adequate analgesia:
  • Parenteral paracetamol is an effective analgesic agent
  • Be cautious with the use of opioids as they can mediate CNS and respiratory depression
  • Transdermal buprenorphine and methadone appear to be safe to use even in patients with renal dysfunction
  • Avoid NSAIDs because of the risk of adverse reactions
• Seek and treat infection or rejection
• Continue immunosuppressive therapy

Suggested reading

• Brusich, K.T., Acan, I., 2018. Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery. doi:10.5772/intechopen.74329
• Seo M, Kim WJ, Choi IC. Anesthesia for non-pulmonary surgical intervention following lung transplantation: two cases report. Korean J Anesthesiol. 2014;66(4):322-326.
• Haddow, G.R., 1997. Anaesthesia for patients after lung transplantation. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 44, 182–197.

Clinical updates

Azem et al. (Regional Anesthesia & Pain Medicine, 2025) report that adding superficial parasternal intercostal plane (sPIP) and serratus anterior plane (SAP) blocks to multimodal analgesia in lung transplantation reduces opioid consumption and increases early extubation rates, without added complications. These superficial chest wall blocks offer a safe alternative to thoracic epidural analgesia, particularly in anticoagulated or ECMO-supported patients, supporting enhanced recovery after lung transplantation.

• Read more about this study HERE.