*3.1.2 Preincision*

*Perioperative Care for Organ Transplant Recipient*

deteriorate rapidly in these patients.

the pulmonary artery catheter.

PEEP especially in COPD patients.

due to the risk of allosensitization.

management, especially in high-risk patients.

the guidance of the attending anesthesiologist.

decompensation.

or severe new-onset PHTN. Management strategies:

commencement of positive pressure ventilation, (iii) Trendelenburg positioning, and (iv) medication-induced hypercarbia, hypoxia, and systemic hypotension leading to an acute exacerbation of preexisting pulmonary hypertension (PHTN)

i.Invasive arterial blood pressure monitoring is required as hemodynamics can

ii.Temperature monitoring is mandatory as hypothermia exaggerates pulmonary vascular resistance (PVR) [13]. Core temperature can be measured with

iii.Following induction, orotracheal intubation options for selective lung ventilation include a double-lumen endotracheal tube or a single-lumen tube with a bronchial blocker, if a double-lumen tube cannot be passed successfully. The appropriate intubation strategy depends on laterality in cases of single-lung transplantation and surgical technique in particular whether the procedure will be performed using cardiopulmonary bypass (CPB) support. The intubation strategy should be discussed with the surgical team prior to induction.

iv.Initial ventilator parameters are adjusted according to the arterial blood gas (ABG) to maintain low arterial CO2 tension and prevent hypoxemia. Suggested parameters include tidal volume 6–7 cc/kg body weight, a positive end-expiratory pressure (PEEP) of 5 cm H2O, respiratory rate 14/min, inspired oxygen concentration (FiO2) to maintain arterial oxygen saturation above 95%, and inspiration to expiration ratio (I:E) of 1:2 to prevent auto-

v.Volume resuscitation is achieved with leukocyte-depleted packed red blood cells if the hemoglobin is <10 g/dL or colloid (albumin 5%) rather than crystalloid if the hemoglobin is >10 g/dL. Blood transfusion is minimized to

vi.Sedative agents should be administered with caution before induction as even minor respiratory depression may lead to increased PVR and acute RV

vii.Pulmonary artery (PA) pressure monitoring via either a Swan-Ganz catheter or transesophageal echocardiography (TEE) is employed to guide anesthetic

patients at the authors' institution to evaluate ventricular filling, ventricular function, and patent foramen ovale (PFO) status and to ensure correct Swan-Ganz catheter tip position in the main PA to prevent inadvertent catheter entrapment on clamping either branch PA. The probe is placed under

ix.Hemodynamic goals include avoidance of hypotension, bradycardia/tachycardia and exacerbation of PHTN. Heart rate and mean arterial pressure (MAP) goals are 60–100/min and 70–75 mmHg, respectively. An epinephrine infusion (2–4 μm/min) should be prepared and started in those patients with a preoperative history of, or evident, pulmonary hypertension or RV dysfunction. Baseline physiological assessment includes an ABG, a mixed

viii.TEE monitoring is routinely performed (unless contraindicated) in all

**98**

Management strategies:


Protocol for all patients except CMV mismatch, HBV/HCV/HIV infection, or history of malignancy

	- 1.Premedication (30 min prior to alemtuzumab)
		- i. Methylprednisolone (Solu-Medrol): 1 g IV
		- ii. Acetaminophen (Tylenol): 650 mg PO/feeding tube
		- iii. Diphenhydramine (Benadryl): 50 mg IV
		- iv. Famotidine (Pepcid): 20 mg IV
	- 2.Alemtuzumab (Campath) 30 mg IV over 2 h
