Perioperative Care of the Patient With a Lung Transplant
The curriculum asks us to explain 'the anaesthetic management of patients with transplanted organs for non-transplant surgery ', without specifying which organs in particular.
The page is included because the lung transplant recipient seems a plausible candidate for a question based on the above, although there hasn't been a BJA Education article on the topic.
There is a separate page on anaesthesia for lung transplant surgery .
Transplanted lung physiology
Denervation leads to:
Loss of cough reflex
Loss of neurally-mediated changes in bronchomotor tone
Reduced mucociliary clearance and thus higher risk of post-operative pulmonary infection
The donor bronchial vessels aren't anastomosed
Oxygenation comes from:
Hypoxic (venous) pulmonary arterial blood
Oxygen diffusion
Formation of de novo collaterals post-transplant
The ischaemic period prior to collateral growth can lead to bronchial stenosis, bronchiomalacia and anastamotic dehiscence
There is interrupted lymphatic drainage in the transplanted lung
Reperfusion injury following transplant can impair capillary integrity
Patients may be at higher risk of fluid overload due to renal failure e.g. from immunosuppression
This renders the lung highly susceptible to pulmonary oedema
Control of breathing preserved
Little or no change in breathing pattern
Normal ventilatory response to changes in CO2
Mechanisms governing pulmonary vascular resistance
Hypoxic pulmonary vasoconstriction is intact
Perioperative management of the patient with a lung transplant
Pre-operative
Early and continuous liaison with the patient's transplant team will be imperative for optimising peri-operative care
Elucidate primary pathology as patients may have ongoing extra-pulmonary disease features, such as those from sarcoidosis or cystic fibrosis
There may be lasting RV failure due to historical pulmonary hypertension
Establish:
Immunosuppressive regimen
Prior complications e.g. autograft rejection, GVHD, vascular complications, anastamotic complications
Bloods to check for immunosuppression-induced renal (U&E), hepatic (LFTs) or bone marrow (FBC) failure
Pulmonary function tests
Intra-operative
Neuraxial and/or regional techniques are preferential to avoid airway instrumentation
If a GA is required:
SAD may be preferential to ETT
Employ a lung protective ventilatory strategy to avoid volu- or baro-trauma to the transplanted lung(s)
May have to provide differential lung ventilation for single lung transplant patients
Strict asepsis during procedures
Antibiotic prophylaxis
Judicious fluid use to reduce risk of pulmonary oedema
Full reversal of NMBA as may have steroid-induced muscle weakness
Steroid replacement as per guidelines
Post-operative
Incentive spirometry
Early, aggressive chest physiotherapy
Multi-modal analgesia
Multi-modal anti-emetics to facilitate early return to normal immunosuppressive regimen
Appropriate VTE prophylaxis