Aspects of Anesthesia for Lung Transplantation

Abstract

Anesthesia for lung transplantation is both a demanding and rewarding experience. Success requires teamwork, experience, knowledge of cardiorespiratory pathophysiology and its anesthetic implications, appropriate use of noninvasive and invasive monitoring, and the ability to respond quickly and effectively to lifethreatening perioperative events. Specific issues include management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation, perioperative respiratory failure, pulmonary hypertension, and acute right ventricular failure. Recent advances include greater understanding of dynamic hyperinflation ("gas-trapping") during mechanical ventilation, perioperative use of inhaled nitric oxide and treatment of acute right ventricular failure. Successful anesthetic management leads to greater hemodynamic stability, improvement in gas exchange and a reduction in need for cardiopulmonary bypass, all of which should lead to improved patient outcome.Copyright@ 1998 by IIV. B. Saunders Company.Anesthesia for lung transplantation is one of the most complicated and demanding procedures that anesthesiologists are confronted with in their practice. Issues that arise include management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation (OLV), perioperative respiratory failure, pulmonary hypertension and right ventricular (RV) failure, pathophysiology of cardiopulmonary bypass (CPB), coagulopathy and multiple blood product transfusion, maintenance of other vital organ function (especially brain and kidneys), and postoperative pain management.1&dquo;21 Critical incidents during the procedure are common and often life-threateningB-11 ,14,19,20; they demand rapid assessment and intervention. This can be compromised by anesthesiologist fatigue because most lung transplantation procedures take 6 to 10 hours and usually occur at night, often after a busy cardiothoracic operating scheduse.1,2,4 Successful management demands both knowledge and experience, and this is best optimized by concentrating clinical exposure to lung transplantation among a small number of dedicated anesthesiologists at any one institution. Although this increases individual work load, it does enhance expertise and consistency of practice. Work schedules the day after transplantation can be reorganized, and this is most efficiently achieved with a cohesive cardiothoracic anesthetic team. As with other types of specialized surgery, 22 outcome after lung transplantation may be affected by caseload, with larger units having more favorable results.5 Accumulating experience within an institution is also associated with improved outcome'5 ; at the author's institution, a 50% reduction from 20% to 10% in early (<90 days) postoperative mortality rate over the first 7 years of the program (G. Snell, personal communication, May 20, 1997) has been observed.Ideally, clinical practice should be evidencebased, guided by clinical trials showing superiority of one treatment over another.23,24 However, i...

Preoperative Hypercapnia as a Predictor of Hypotension During Anesthetic Induction in Lung Transplant Recipients

“…5,14 A narcotic-based "cardiac anesthetic" with slow titration of the induction agent may provide improved hemodynamic stability. 4,10 However, slow titration of the induction agent may increase the risk of hypoventilation and oxygen desaturation during induction because it takes more time to induce anesthesia and secure the airway. Consequently, rapid induction with propofol or midazolam tends to be preferred for lung transplant recipients.…”

“…1 Lung transplant recipients are at a risk of severe hypotension and even cardiac arrest during the induction period, and most authorities recommend close hemodynamic monitoring. 2,3,4 It would be useful to predict those patients at a risk of severe hypotension during this period because anesthesiologists may be distracted immediately after induction by several tasks such as airway management, ventilator adjustments, and the placement of pulmonary artery catheters. However, the hemodynamic responses or the predisposing factors associated with hypotension during the anesthetic induction in lung transplant recipients are not completely understood.…”

Anesthesia for Lung Transplantation

“…Anesthetic evaluation should include such routine details as fasting status, previous response to anesthesia, cardiopulmonary assessment, and airway examination. 5 A discussion about anesthetic management and risks, including death and intraoperative recall, is appropriate. Many centers use thoracic epidural analgesia for lung transplant cases.…”

“…Many centers use thoracic epidural analgesia for lung transplant cases. 2,[5][6][7][8][9] Immunosuppressive induction may be started preoperatively, with the patient receiving the first dose of immunosuppressive agents orally. 1 Preoperative sedatives should be used sparingly, because benzodiazepines and narcotics may exacerbate preexisting hypercarbia and hypoxia, particularly in the patient with COPD.…”

“…Once anesthesia has been induced, rapid control of the airway should be accomplished by using either succinylcholine or rocuronium. 5 Whether a double-lumen endotracheal tube or a single-lumen tube with an endobronchial blocker is used is based on individual institutional practices. Patients who undergo lung transplantation in which cardiopulmonary bypass is used can be managed with a standard single-lumen endotracheal tube.…”