**4. Post-operative management**

Patient undergoing lung transplantation requires a team of caregivers who are committed, familiar with the protocols and able to ensure ongoing communication between members of the team. The team members include, transplant coordinators, transplant pulmonologist, transplant surgeon, anesthesiologist, pain management team, critical care specialist, ICU nurses, Infectious disease specialist, pharmacologist, physical and occupational therapist, nutritionist and social worker. Clinical pathways are developed addressing complete patient care with incorporation of immunosuppressive and infection prophylaxis protocols (14). Despite clinical pathways, regular team meeting discussing daily care of patient facilitate efficient and timely interventions and improve post-operative care.

#### **5. Respiratory management**

Despite advances in the donor management and preservation of lung, primary graft dysfunction is not uncommon following lung transplantation (15). In the majority however the degree of dysfunction is minor to moderate and reversible, therefore does not progress to graft failure. The incidence of primary graft dysfunction has been reported between 11-57

Lung Transplantation 301

operative use of inhaled NO or other pulmonary vasodilator pharmacotherapy is not uncommon and certainly useful to reduce post-operative pulmonary hypertension and the

The most common hemodynamic disturbance following lung transplantation is hypotension and supra-ventricular tachyarrhythmia. The principle of keeping these patients in a relative hypovolemic status, make them susceptible to hypotension, if there is any degree of vasodilation. It is important to maintain adequate intravascular volume to maintain adequate cardiac output as well as urine output. The fluid therapy is aimed at maintaining low or low normal cardiac filling pressures. It is however not necessary to monitor pulmonary artery wedge pressures in all patients and monitoring of right atrial filling pressures are most often adequate. The fact that the lymphatic drainage is interrupted from the lung allograft following transplantation, any capillary leak in to the lung parenchyma will be cleared less efficiently. It had been shown that fluid restriction in patients with lung injury promotes early recovery (21). This may be an important factor to consider during the post operative period, due to the fact that majority of the lung grafts suffer some degree of reperfusion injury. Systemic vasodilation whether it is produced by medications or sympathetic blockade due to epidural or release of cytokines, best treated with vasoconstriction using intravenous short acting alpha-blockers than by volume. Neosynephrine is the drug of choice in the treatment of systemic vasodilation in these patients. Vasopressin is an effective systemic vasoconstricor but also appears to cause profound bronchial vasoconstriction and may cause bronchial ischemia in these patients and

The incidence of supraventricular arrhythmias are not uncommon following lung transplantation (22). The commonest arrhythmias are supraventricular tachycardia and atrial fibrillation. Many programs take preventive measures for atrial fibrillation in the postoperative period which can reduce the incidence of this complication but unlikely to prevent it completely. The effects and complication due to atrial fibrillation are systemic hypotension and systemic embolization, perhaps made worse by fresh suture line on the left atrium. Although amiodarone is generally avoided due to its effects on the lung, we have used amidarone in patients who are resistant or unsuitable for treatment with calcium channel blockers or beta blockers. Anticoagulation will be necessary as in other patients with atrial fibrillation and the biopsy schedules needed to be considered and preferentially treated with short acting agents in the post operative period. It will be prudent to check clotting studies prior to transbronchial biopsy or endobronchial intervention as

The major surgical complications are bleeding, anastomotic complications and mal-rotation of the graft (24). The latter two are rare with current understanding and experience. Bleeding is less common and is due to refinement in surgical techniques, judicious use of pharmacological agents and blood products. The patients at high risk are the ones with extensive pleural adhesions, large and extensive mediastinal collateral vessels and patients with connective tissue disorders with secondary pulmonary hypertension. Patients with right heart failure and congested liver or patients on chronic anticoagulation or anti-platelet therapy are particularly susceptible and correction of coagulation defect is mandatory in these patients. If a patient persists with significant blood loss (>100 cc/hr), for 4-6 hours, the

fluctuations in pressures and reduce the hemodynamic instability.

may affect bronchial anastomotic healing, therefore its use is avoided.

uncontrollable bronchial hemorrhage is invariably fatal.

**7. Diagnosis and management of early surgical complication** 

% (16). When there is primary graft failure, extra corporeal membrane oxygenation (ECMO) may be required. Early institution of ECMO had been shown to be more successful than late (17-19). When the graft dysfunction is mild to moderate, management strategies are employed as used in patients with significant lung injury.

The ventilatory management would be influenced, if the patient received a single or bilateral lung transplant. In patients with bilateral lung transplant it would be aimed at minimizing barotraumas by using low inflation volumes and moderate levels of positive end expiratory pressure (PEEP, less than 10 cm water). In patients with single lung transplant the pathophysiology of the remaining native lung will influence ventilatory strategy. Significant air trapping and auto PEEP is not uncommon in patients with emphysema. Low ventilatory volumes, adequate expiratory time and avoidance of excessive PEEP will help to prevent air trapping and significant hemodynamic instability in these patients. Positioning patients with the allograft side up and bronchodilator therapy are useful strategies in patients with single lung transplant. Very rarely isolated lung ventilation with double lumen tube is necessary to effectively ventilate when there is significant graft dysfunction.

Inhaled Nitric Oxide (NO) through the ventilator has been shown to reduce reperfusion injury in experimental models and clinical transplantation, when used as prophylaxis. It's usefulness in established graft dysfunction is controversial. Selective use of inhaled NO in peri-operative period in patients with pre-existing pulmonary hypertension is not an uncommon practice. The aim of the inhaled NO use is to reduce pulmonary artery pressures during the operation and immediately afterwards thereby assisting the right ventricular function.

As a rule aggressive weaning off the ventilator is practiced following lung transplantation to prevent nosocomial infection and promote early rehabilitation. Sedation should be carefully monitored and sparingly used. It is advisable to use short acting agents while patient is intubated. Majority of the patients are extubated within the first 24 hours after transplantation. After extubation we advocate use of epidural analgesia and avoidance of narcotics and benzodiazepines. Aggressive bronchial hygiene is mandatory to prevent collapse and development of pneumonia. While patients are intubated using soft suction catheters to clear secretion should be performed routinely. Once the patient is extubated incentive spirometry, chest physiotherapy and ambulation are necessary to promote clearance of bronchial secretions. In patients who are debilitated and have retention of secretion we have employed 'mini-tracheostomy' to facilitate removal of the secretion with a soft tip 10 french catheter. Alternatively patients will require repeat bronchoscopic suction of secretions. When a patient fails trial extubation, early tracheostomy facilitates rapid weaning of ventilation, assist in effective management of secretions and promote early physical rehabilitation.

## **6. Hemodynamic management**

Patients selected for lung transplant undergo a detailed cardiac evaluation. Isolated single vessel coronary artery disease alone is not a contra-indication for lung transplantation. These patients would be candidates for pre-transplantation, percutaneous revascularization or would be candidates for simultaneous surgical re-vascularization (19,20). Correctable cardiac lesions such as ASD or simple VSD they are repaired during lung transplantation. Patients with primary or secondary pulmonary hypertension will have varying degrees of right ventricular dysfunction but this improves with successful lung transplantation. Peri-

% (16). When there is primary graft failure, extra corporeal membrane oxygenation (ECMO) may be required. Early institution of ECMO had been shown to be more successful than late (17-19). When the graft dysfunction is mild to moderate, management strategies are

The ventilatory management would be influenced, if the patient received a single or bilateral lung transplant. In patients with bilateral lung transplant it would be aimed at minimizing barotraumas by using low inflation volumes and moderate levels of positive end expiratory pressure (PEEP, less than 10 cm water). In patients with single lung transplant the pathophysiology of the remaining native lung will influence ventilatory strategy. Significant air trapping and auto PEEP is not uncommon in patients with emphysema. Low ventilatory volumes, adequate expiratory time and avoidance of excessive PEEP will help to prevent air trapping and significant hemodynamic instability in these patients. Positioning patients with the allograft side up and bronchodilator therapy are useful strategies in patients with single lung transplant. Very rarely isolated lung ventilation with double lumen tube is necessary to

Inhaled Nitric Oxide (NO) through the ventilator has been shown to reduce reperfusion injury in experimental models and clinical transplantation, when used as prophylaxis. It's usefulness in established graft dysfunction is controversial. Selective use of inhaled NO in peri-operative period in patients with pre-existing pulmonary hypertension is not an uncommon practice. The aim of the inhaled NO use is to reduce pulmonary artery pressures during the operation and immediately afterwards thereby assisting the right ventricular

As a rule aggressive weaning off the ventilator is practiced following lung transplantation to prevent nosocomial infection and promote early rehabilitation. Sedation should be carefully monitored and sparingly used. It is advisable to use short acting agents while patient is intubated. Majority of the patients are extubated within the first 24 hours after transplantation. After extubation we advocate use of epidural analgesia and avoidance of narcotics and benzodiazepines. Aggressive bronchial hygiene is mandatory to prevent collapse and development of pneumonia. While patients are intubated using soft suction catheters to clear secretion should be performed routinely. Once the patient is extubated incentive spirometry, chest physiotherapy and ambulation are necessary to promote clearance of bronchial secretions. In patients who are debilitated and have retention of secretion we have employed 'mini-tracheostomy' to facilitate removal of the secretion with a soft tip 10 french catheter. Alternatively patients will require repeat bronchoscopic suction of secretions. When a patient fails trial extubation, early tracheostomy facilitates rapid weaning of ventilation, assist in effective management of secretions and promote early

Patients selected for lung transplant undergo a detailed cardiac evaluation. Isolated single vessel coronary artery disease alone is not a contra-indication for lung transplantation. These patients would be candidates for pre-transplantation, percutaneous revascularization or would be candidates for simultaneous surgical re-vascularization (19,20). Correctable cardiac lesions such as ASD or simple VSD they are repaired during lung transplantation. Patients with primary or secondary pulmonary hypertension will have varying degrees of right ventricular dysfunction but this improves with successful lung transplantation. Peri-

employed as used in patients with significant lung injury.

effectively ventilate when there is significant graft dysfunction.

function.

physical rehabilitation.

**6. Hemodynamic management** 

operative use of inhaled NO or other pulmonary vasodilator pharmacotherapy is not uncommon and certainly useful to reduce post-operative pulmonary hypertension and the fluctuations in pressures and reduce the hemodynamic instability.

The most common hemodynamic disturbance following lung transplantation is hypotension and supra-ventricular tachyarrhythmia. The principle of keeping these patients in a relative hypovolemic status, make them susceptible to hypotension, if there is any degree of vasodilation. It is important to maintain adequate intravascular volume to maintain adequate cardiac output as well as urine output. The fluid therapy is aimed at maintaining low or low normal cardiac filling pressures. It is however not necessary to monitor pulmonary artery wedge pressures in all patients and monitoring of right atrial filling pressures are most often adequate. The fact that the lymphatic drainage is interrupted from the lung allograft following transplantation, any capillary leak in to the lung parenchyma will be cleared less efficiently. It had been shown that fluid restriction in patients with lung injury promotes early recovery (21). This may be an important factor to consider during the post operative period, due to the fact that majority of the lung grafts suffer some degree of reperfusion injury. Systemic vasodilation whether it is produced by medications or sympathetic blockade due to epidural or release of cytokines, best treated with vasoconstriction using intravenous short acting alpha-blockers than by volume. Neosynephrine is the drug of choice in the treatment of systemic vasodilation in these patients. Vasopressin is an effective systemic vasoconstricor but also appears to cause profound bronchial vasoconstriction and may cause bronchial ischemia in these patients and may affect bronchial anastomotic healing, therefore its use is avoided.

The incidence of supraventricular arrhythmias are not uncommon following lung transplantation (22). The commonest arrhythmias are supraventricular tachycardia and atrial fibrillation. Many programs take preventive measures for atrial fibrillation in the postoperative period which can reduce the incidence of this complication but unlikely to prevent it completely. The effects and complication due to atrial fibrillation are systemic hypotension and systemic embolization, perhaps made worse by fresh suture line on the left atrium. Although amiodarone is generally avoided due to its effects on the lung, we have used amidarone in patients who are resistant or unsuitable for treatment with calcium channel blockers or beta blockers. Anticoagulation will be necessary as in other patients with atrial fibrillation and the biopsy schedules needed to be considered and preferentially treated with short acting agents in the post operative period. It will be prudent to check clotting studies prior to transbronchial biopsy or endobronchial intervention as uncontrollable bronchial hemorrhage is invariably fatal.
