ANESTHESIA FOR LUNG TRANSPLANTATION GKK gkk 1 KAPLANS

ANESTHESIA FOR LUNG TRANSPLANTATION GKK gkk 1

KAPLAN’S CARDIAC ANESTHESIA 5 TH EDITION 26/845 -865 gkk 2

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. gkk 3

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. gkk 4

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 gkk 5

Types of transplantations � Single lung transplantation-mostly � Double lung transplantation-cystic fibrosis, Ch bronchiectasis � Lobar transplantation-children & young adult with living related donors. gkk 6

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. gkk 7

PREOPERATIVE PREPARATION � Lung separation – DLT, Bronchial blocker � CPB Unit � Anesthesia ventilator + PCV � Deferential lung ventilation � PAC-to know RVEF � TEE gkk 8

ANESTHETIC MANAGEMENT INDUCTION � Avoid myocardial depression � Avoid RV afterload increase � Avoid lung hyperinflation gkk 9

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 E 1 {0. 05 - 0. 15µg/kg/min}, NO {20 -40 ppm} gkk 10

ANESTHETIC MANAGEMENT MAINTENANCE � CPB indication. CI< 2 L, Sv. O 2<60%, MAP<60 mm. Hg Sa. O 2<85%, p. H<7 � After transplant. Native lung add dead space ventilation Exaggerated broncho constriction response Impairment of mucocilliary function � ECMO gkk 11

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 gkk 12

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 � gkk 13

THANK gkk YOU 14