*3.1.5 Chest closure*

*Perioperative Care for Organ Transplant Recipient*

dissection.

is unclamped.

hyperacute rejection.

Management strategies:

mized thereafter.

oxygen exchange.

high FiO2.

6 mL/kg (donor weight).

ii.To minimize a combustion hazard while using electrocautery:

catheter to entrain room air when the bronchus is divided.

ate), titrated to achieve a normal cardiac output and index.

request an additional bolus of methylprednisolone 250 mg IV.

*3.1.4 Postimplantation to lung allograft reperfusion/reexpansion*

iii.If a vasoconstrictor infusion is needed to maintain blood pressure, options include vasopressin 0.01–0.04 units/min (institutional preference), norepinephrine 2–30 mcg/min, and phenylephrine 50–300 mcg/min, titrated to effect.

iv.Inotropic support may be provided either with IV infusions of epinephrine 2–10 mcg/min or milrinone 0.1–0.5 mcg/kg/min (renally dosed as appropri-

v.Immediately prior to reperfusion of each transplanted lung, the surgeon will

vi.In preparation for reperfusion, the hemodynamic status should be optimized in anticipation of volume loss to the transplanted organ and peripheral vasodilation resulting from washout of vasoactive substances when the allograft

Specific problems: systemic vasodilatation and hypotension, reperfusion pulmonary edema (increased vascular permeability and loss of lymphatic drainage), and

i.On completion of the vascular anastomoses, a controlled reperfusion

prevent the development of allograft reperfusion pulmonary edema.

ii.Initial re-expansion of the donor lung is achieved with a sustained Valsalva maneuver to 30 cm H2O, and interruptions to ventilation should be mini-

iii.The ventilation strategy immediately posttransplant is intended to minimize injury to the donor lung from either mechanical factors or oxygen free radicals: typical settings will be FiO2 0.40, PEEP 10 cm H2O, rate 20/min, and TV

iv.Peripheral pulse oximeters are frequently inaccurate around the time of reperfusion, and the SvO2 may be used as an indirect measure of adequate

to 0.60 while communicating these changes with the surgeon.

v.If oxygenation is inadequate, FiO2 may be increased in a stepwise fashion up

vi.If graft performance is initially inadequate, consideration should be given to temporarily support gas exchange with ECMO rather than use a sustained

maneuver is performed by gradually releasing the pulmonary artery clamp to

• The FiO2 should be minimized as tolerated during lung and bronchial

• On isolation of the lung for explantation, the appropriate lumen of the double-lumen endotracheal tube is suctioned with a flexible suction

**100**

Specific problems: restrictive chest cavity dynamics caused by:


Management strategies include:


#### *3.1.6 Disruption to positive pressure ventilation*

This can occur during (i) ventilator disconnection prior to patient bed to bed transfer, (ii) switching to a single-lumen endotracheal tube to facilitate postprocedure bronchoscopy, (iii) airway dislodgement, and (iv) manual ventilation while

the patient is being transported. Gentle Valsalva maneuvers to 30 cm H2O are performed immediately after any disruptions to positive pressure ventilation.
