**3. Perioperative care of the lung transplant recipient**

#### **3.1 Intraoperative management**

Preemptive management strategies that include meticulous and continuous cardiorespiratory monitoring, prompt initiation of vasoactive pharmacotherapy, volume administration, and institution of extracorporeal support are of critical importance during specific phases of intraoperative care. During these intraoperative phases of care (described below), there is a high risk of hemodynamic instability, lung derecruitment, worsening ventilation/perfusion mismatch, and alveolar hypoventilation leading to hypoxemia and hypercarbia in varying degrees of severity. The goals of perioperative ventilator support in lung transplantation rely on providing adequate minute ventilation while preventing oxygen toxicity, barotrauma, and volutrauma.

Specific problems that may occur during various intraoperative phases, and the recommended management strategies, are highlighted below:

#### *3.1.1 Induction of anesthesia*

Specific problems: acute RV decompensation due to (i) volume overload, (ii) decreased right ventricular (RV) preload and low cardiac output especially in the hypovolemic patient caused by increased intrathoracic pressure on

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) or severe new-onset PHTN.

Management strategies:


**99**

*3.1.3 Preimplantation*

Management strategies:

*Induction therapy: Alemtuzumab (Campath).*

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

eral veno-venous ECMO, veno-arterial ECMO, or CPB.

measurement of a thermodilution cardiac output.

venous blood gas (SvO2) from the PA port of the Swan-Ganz catheter, and

x.Inhaled pulmonary vasodilator therapy, e.g., inhaled nitric oxide (INO) at 20 ppm, is used for all lung transplants at the authors' institution and is started

xi.The surgical team as well as the perfusionist should be present in the room during anesthetic induction and be prepared to rapidly institute resuscitative measures that include emergent extracorporeal life support, such as periph-

i.If the decision is made to use CPB or ECMO, a 70 mg/kg IV bolus of aminocaproic acid followed by an IV infusion at 30 mg/kg/h is given to minimize

ii.The induction immunotherapy protocols are detailed in Section 3.4.1 and

iii.Perioperative antibiotics: protocol details are provided in Section 3.5 below.

iv.For patients with a recent (<7 days) history of Coumadin administration, an IV infusion of vitamin K 10 mg diluted in 100 mL of normal saline is admin-

A.Induction (intraoperative): begin induction when final decision is made by the surgeons to accept the

3.Methylprednisolone (Solu-Medrol): additional dose of 250 mg IV prior to reperfusion of each lung

1.Prednisone 5 mg orally or feeding tube daily; 10 mg if on chronic prednisone therapy preoperatively

2.Standard tacrolimus and mycophenolate mofetil/MMF (Cellcept) schedule

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

i.An early trial of one-lung ventilation is advisable to see if acceptable gas exchange (pO2, pCO2, pH) and cardiac function can be maintained.

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

following intubation.

Management strategies:

fibrinolysis.

Appendices (**Table 1**).

istered over 15 min.

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

B.Postoperative Immunosuppression (Campath):

*3.1.2 Preincision*

lungs

POD#1

**Table 1.**

venous blood gas (SvO2) from the PA port of the Swan-Ganz catheter, and measurement of a thermodilution cardiac output.

