1. ANESTHESIA CONSIDERATIONS FOR LUNG
TRANSPLANT
DR. ABHIJIT S. NAIR
Consultant Anesthesiologist

2. Is anesthesia management related to
cardiac anesthesia or OLV as in
non
cardiac thoracic surgeries?

3. “ ITS CARDIAC ANESTHESIA WITH
OLV ( DLT
OR BLOCKER) EITHER BEATING HEART
OR
CPB WITHOUT CARDIOPLEGIA ”

4. DONORS
 Brain dead/ trauma victims
 Compatible
 P/F ratio > 300
 Less than 60 years
 Preferably non- smokers
 Acceptable bronchoscopy findings

5. INDICATIONS
“ End stage lung disease “
 Suppurative
 Restrictive
 Obstructive
 Pulmonary vascular

6. SINGLE LUNG TRANSPLANT
 Emphysema
 Pulmonary fibrosis
 Pulmonary Hypertension
 Connective tissue disorders
 ILD
 Bronchoalveolar carcinoma?

7. DOUBLE LUNG TRANSPLANT
 Suppurative lung disease
 Emphysema
 PH

8. ABSOLUTE CONTRAINDICATIONS
 Ventilatory cripple
 Metastatic cancer
 Serious, multiple co-morbidities
 Psychosocial issues
 Serious chest wall deformity
 Viral markers positive

9. CONT
 Age ( > 60y for DLT, > 65y for SLT )
 Previous thoracic surgery
 Peripheral vascular disease
 Corticosteroid dependence

10.  INDICATION
 ENTITIES
 ISSUES

11. OBSTRUCTIVE LUNG DISEASE
 COPD
 α 1 anti-trypsin deficiency
 Bronchiolitis obliterans
syndrome

12. ISSUES
 Cor pulmonale, RHF
 CAD
 Pneumothorax during intubation, CVC
insertion
 Ventilatory strategies?

13. RESTRICTIVE LUNG DISEASE:
 Idiopathic pulmonary fibrosis
 Connective tissue disorders
 Drug or radiation induced disease

14. ISSUES
 Difficult ventilation
 Needs high inflating pressures ( 40 cm H2O )
 Pressure controlled ventilation with PEEP
 ICU ventilator

15. SUPPURATIVE LUNG DISEASE
 Cystic fibrosis
 Non CF bronchiectasis
 Single lung transplant: contraindicated

16. ISSUES
 OLV mandatory
 Needs frequent intra operative toileting
 High inflation pressure
 Difficult ventilation
 High end antibiotics
 Povidone iodine irrigation after pneumonectomy
 Burkholderia cepacia on BAL:
CONTRAINDICATION

17. PULMONARY VASCULAR DISEASES
 Idiopathic
 Secondary to COPD, pulmonary fibrosis
 Connective tissue disorders
 Intracardiac shunting due to Eisenmenger’s
syndrome

18. ISSUES
 Can crash on induction
 Lines under local, including femoral arterial
line
 Surgeon and CPB machine ready prior to
induction

19. RELEVANT INVESTIGATIONS
 Blood picture
 PFT
 DLCO
 Lung perfusion scan
 2D ECHO, DSE, Perfusion scan
 Cardiac catheterization
 HLA typing

20. THORACIC EPIDURAL ANALGESIA
 Excellent analgesia
 Use of CPB : a hurdle
 Can be placed previous night
 Useful in bilateral lung transplants
 Paravertebral catheters for unilateral
surgeries

21. MONITORING
 Standard including ETCO2
 Temperature
 RGM
 Spirometry

22. CONT
 TOF
 ABP, CVP
 PCWP
 Cardiac output

23. VASCULAR ACCESS
 Large bore peripheral lines
 Arterial line
 Central venous line/ AVA
 PAC
STRICT ASEPSIS

24. TEE
 Improves standard of care
 Lot of information
 ACC/AHA/ASE: Class 2 b
indication

25. INDICATIONS OF TEE
 Pulmonary hypertension
 Right ventricular dysfunction
 Suspicion of a patent foramen
ovale

26. INFORMATION PROVIDED BY TEE
 Left and right sided preload
 Left and right ventricular function
 Regional wall motion abnormalities
 Intracardiac air
 Detects intra cardiac thrombus
 Detects shunting: unexplained hypoxemia

27. INDUCTION
 Avoid myocardial depression
 Avoid hyperinflation of lung
 Avoid increase in RV afterload

28. CHOICE OF ETT
 Left DLT ideal
 Lot of advantages of DLT over regular ETT
 DLT to ETT at the end with tube exchanger
 Bronchial blocker can be used for single lung
transplants

29. CPB IN LUNG TRANSPLANT
 Pulmonary hypertension
 Simultaneous cardiac surgery
 Patients requiring plasma
pheresis for HLA mismatch
 HLA antibodies against donors

30. CONT
 Not tolerating OLV
 Not tolerating PA clamping ( RVF )
 Hemodynamic instability
 If PA pressure don’t reduce after perfusing
first lung
 ECMO dependent patient

31. CPB?
 Beating heart CPB
 Cardioplegia used in simultaneous cardiac
surgeries

32. ADVANTAGES OF CPB
 Hemodynamic stability
 Controlled reperfusion of grafts

33. DISADVANTAGES OF CPB
 Hemolysis
 AKI
 ALI
 TRALI
 Mechanical ventilation
 Pulmonary edema

34. RV FAILURE
 At induction
 OLV
 Hilum manipulation
 PA clamp
 After reperfusion
 Severe early graft dysfunction

35. RV AFTERLOAD REDUCTION
 Correct parameters
 Milrinone, Noradrenaline, adrenaline
 Pulmonary vasodilatation: 100% O2, NO
 PGI2
 Inhaled milrinone ??

36. POST OPERATIVE MANAGEMENT
 Extubation after SLT
 Pain management
 Bronchodilators
 NIV
 Chest PT
 DVT prophylaxis

37. VENTILATION
 Use of CPB
 Core hypothermia
 Unstable patient
 Bilateral lung transplant

38. IMMEDIATE POST OP ISSUES
 Luxury perfusion
 Anastomotic dehiscence
 Stenosis
 Hyperinflation of native lung
 Infectious complications
 PRIMARY GRAFT DYSFUNCTION

39. SUMMARY
 Application of cardiac & thoracic anesthesia
 Multidisciplinary approach
 Rigorous evaluation
 Hemodynamic management
 Evidence based practice