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ANESTHESIA FOR LUNG TRANSPLANtaTION

GKK. ANESTHESIA FOR LUNG TRANSPLANtaTION. KAPLAN’S CARDIAC ANESTHESIA 5 TH EDITION 26/845-865. FACTS. Lung transplants annual frequency-500 {UNOS} Mortality -13.6% DLT/12.6% SLT {1991} 3 year survival rate – 60% {1995}

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ANESTHESIA FOR LUNG TRANSPLANtaTION

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  1. GKK ANESTHESIA FOR LUNG TRANSPLANtaTION gkk

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

  3. 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

  4. 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

  5. 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

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

  7. 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

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

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

  10. 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} gkk

  11. 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 gkk

  12. 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

  13. 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

  14. THANK YOU gkk

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