Post-lung transplant patient - NYSORA

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Post-lung transplant patient

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

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:

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.

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