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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

Single lung transplantation-mostly

Double lung transplantation-cystic fibrosis,Ch bronchiectasis

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

Avoid myocardial depression

Avoid RV afterload increase

Avoid lung hyperinflation

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ANESTHETIC MANAGEMENT MAINTENANCE One lung Ventilation Pneumothorax –Detection & Management Trail PA ligation CPB prior to PA ligation in severe PHT RVF management- Avoid increase in intra thoracic pressure, Increase in preload, Inodilators-Dobutamine,milrinone α agonists to maintain RV coronary perfusion pr, Pulmonary vasodilators- Pg E1 {0.05- 0.15µg/kg/min},NO {20-40ppm}

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ANESTHETIC MANAGEMENT MAINTENANCE CPB indication- CI< 2L, SvO2<60%, MAP<60mmHg SaO2<85%, pH<7

After transplant- Native lung add dead space ventilation Exaggerated broncho constriction response Impairment of mucocilliary function

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 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 YOU

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