**3.2 Intensive care unit management**

Initial postoperative care for all lung transplant recipients is provided on the intensive care unit. Interventions specific to the care of the lung transplant patient will include, but are not limited to, the following:

	- A cardiac index of 2.2–2.5 is ideal—to minimize the risk of significant pulmonary edema. Specific hemodynamic optimization strategies are detailed in Section 3.1.3 above. Serial lactate levels and SvO2 are measured every 6 h or as needed depending on clinical status.

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*Perioperative Care for Lung Transplant Recipients: A Multidisciplinary Approach*

sion, hypotension, oversedation, and delayed extubation.

minimize residual pleural effusion collections.

ranted by the patient's condition.

Doppler studies are performed.

tion; early mobility is the goal.

*3.2.1 Primary graft dysfunction*

• Once clinically stable and not on high-dose pressors, aggressive diuresis as dictated by the patient's clinical status and radiographic findings is initiated with Lasix 20–40 mg IV every 8 h or a Lasix infusion 0.5–4 mg/min, titrated to achieve a negative intake/output balance (500 mL to 1 L) over

iv.Postoperative pain and sedation management: Important goals include use of the lowest effective dose and timely weaning of opioids such as fentanyl infusion 0.5–1.5 mcg/kg/h or 50–100 mcg IV boluses every 1–2 h (use renal dosing where applicable), sedatives such as Precedex 0.2–1.4 mcg/kg/h, and anxiolytics such as Versed 0.02–0.1 mg/kg/h to prevent respiratory depres-

v.*Flexible bronchoscopy* is performed on all patients prior to extubation to facilitate tracheobronchial toilet and to evaluate the integrity of the airways.

total serosanguineous drainage <200 mL/24 h, and/or <20 mL/h for the three consecutive hours prior to planned removal). Our institutional protocol involves removal of the posterior-dependent chest tube first, conversion of the anterior and middle chest tubes to H2O seal, and removal of the anterior and last the middle chest tube when the patient has been ambulant to

vi.*Chest tube removal* is started in POD#1 once criteria are met (no air leak,

vii.*Nutritional support*: While oral intake of all medications and nutrition is preferred, the patient will undergo a swallowing assessment 24–48 h following extubation and a nutritional assessment within 48 h after admission to the ICU. Until oral intake is established, for patients deemed at high risk of aspiration, a postpyloric naso-enteric feeding tube is placed immediately on extubation. In low-risk patients, orogastric tube feeds are started shortly after arrival to the ICU absent contraindications that include known severe gastroesophageal reflux disease, gastric distension, esophageal dysmotility syndromes, and high pressor requirements. The dietitian will make individualized recommendations for the patient's nutritional needs and will follow the patient throughout the hospitalization and make recommendations to the team accordingly. Gastroenterology consultation will be initiated as war-

viii.*DVT prophylaxis* will be initiated per hospital protocol (subcutaneous heparin 5000 units every 8 h). Weekly surveillance upper and lower extremity

ix.*Physical therapy consultation* will be completed within 48 h of transplanta-

PGD is an acute manifestation of ischemia-reperfusion injury associated with multiple risk factors (donor-derived and related to procurement/preservation and reperfusion) with a peak incidence within the first 72 h after lung transplantation [17, 18]. The severity of PGD is graded based on the presence or absence of diffuse opacities on chest radiograph and the ratio of arterial oxygen pressure to inspired oxygen concentration, i.e., the PaO2/FiO2 ratio. The severity ranges from

*DOI: http://dx.doi.org/10.5772/intechopen.85277*

the initial 24 h.

*Perioperative Care for Lung Transplant Recipients: A Multidisciplinary Approach DOI: http://dx.doi.org/10.5772/intechopen.85277*

