ANESTHESIA CONSIDERATIONS FOR LUNG TRANSPLANT

DR. ABHIJIT S. NAIRConsultant Anesthesiologist

Is anesthesia management

related to

cardiac anesthesia or OLV as in non

cardiac thoracic surgeries?

“ ITS CARDIAC ANESTHESIA WITH OLV ( DLT

OR BLOCKER) EITHER BEATING HEART OR

CPB WITHOUT CARDIOPLEGIA ”

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

INDICATIONS

“ End stage lung disease “ Suppurative Restrictive Obstructive Pulmonary vascular

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

DOUBLE LUNG TRANSPLANT Suppurative lung disease Emphysema PH

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

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

INDICATION

ENTITIES

ISSUES

OBSTRUCTIVE LUNG DISEASE COPD α 1 anti-trypsin

deficiency Bronchiolitis obliterans

syndrome

ISSUES Cor pulmonale, RHF CAD Pneumothorax during intubation, CVC

insertion Ventilatory strategies?

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

ISSUES Difficult ventilation Needs high inflating pressures ( 40 cm

H2O ) Pressure controlled ventilation with

PEEP ICU ventilator

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

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

PULMONARY VASCULAR DISEASES Idiopathic Secondary to COPD, pulmonary fibrosis Connective tissue disorders Intracardiac shunting due to

Eisenmenger’s syndrome

ISSUES Can crash on induction Lines under local, including femoral

arterial line Surgeon and CPB machine ready prior

to induction

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

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

MONITORING Standard including ETCO2 Temperature RGM Spirometry

CONT TOF ABP, CVP PCWP Cardiac output

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

TEE Improves standard of care Lot of information ACC/AHA/ASE: Class 2 b

indication

INDICATIONS OF TEE Pulmonary hypertension Right ventricular dysfunction Suspicion of a patent foramen

ovale

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

INDUCTION Avoid myocardial depression Avoid hyperinflation of lung Avoid increase in RV afterload

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

CPB IN LUNG TRANSPLANT Pulmonary hypertension Simultaneous cardiac

surgery Patients requiring plasma

pheresis for HLA mismatch HLA antibodies against

donors

CONT Not tolerating OLV Not tolerating PA clamping ( RVF ) Hemodynamic instability If PA pressure don’t reduce after

perfusing first lung ECMO dependent patient

CPB? Beating heart CPB Cardioplegia used in simultaneous

cardiac surgeries

ADVANTAGES OF CPB Hemodynamic stability Controlled reperfusion of grafts

DISADVANTAGES OF CPB Hemolysis AKI ALI TRALI Mechanical ventilation Pulmonary edema

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

RV AFTERLOAD REDUCTION Correct parameters Milrinone, Noradrenaline, adrenaline Pulmonary vasodilatation: 100% O2,

NO PGI2 Inhaled milrinone ??

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

VENTILATION Use of CPB Core hypothermia Unstable patient Bilateral lung transplant

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

SUMMARY Application of cardiac & thoracic

anesthesia Multidisciplinary approach Rigorous evaluation Hemodynamic management Evidence based practice