Post-lung transplant patient

Learning objectives

A post-lung transplant patient may have one or both lungs may be replaced by a donor’s lung, sometimes along with a donor’s heart
A lung transplant is a surgical procedure to replace a diseased or failing lung with a healthy lung from a deceased donor
It usually takes at least 3-6 months to fully recover from transplant surgery
Consider an increased risk of infection or rejection of the transplanted lungs

If possible, continue immunosuppressants until the day of surgery
Be cautious with anxiolytics as they may lead to hypercarbia
Administer:
- Immunosuppressants IV if oral agents are precluded
- Prophylactic antibiotics to avoid infection
Perform standard monitoring
Avoid:
- Femoral lines → increased risk of infection
- Nasal intubation → increased risk of infection
- Invasive monitoring if not required → risk of infection or pneumothorax
Place a central line in the antecubital fossa or internal jugular vein → a lower risk of pneumothorax than in the subclavian approach

Local, regional, or general anesthesia are all considered safe to use, however, do not perform a block above T10
Propofol is the anesthetic of choice
Etomidate is preferred when there is a risk of hemodynamic instability
Volatile anesthetics are also well tolerated
Use short-acting relaxants (mivacurium) or intermediate-acting agents independent of kidney and liver function (cisatracurium, atracurium)
Consider that vecuronium, rocuronium, and pancuronium can have prolonged effects with hepatic or renal insufficiency
Note that immunosuppressive agents may interact with neuromuscular blocking agents
Avoid:
- Succinylcholine because of the possibility of hyperkalemia
- Long-acting agents such as pancuronium or doxacurium

Aim for early extubation to minimize the risk of infection
The Trendelenberg position may further compromise pulmonary function and increase the work of breathing
Place the endotracheal cuff just beyond the vocal cords to avoid trauma to the trachea or bronchial anastomosis
Consider using a fibreoptic laryngoscope
Positive pressure ventilation is complicated in single lung transplant recipients
Consider differences in lung compliance between the native and transplanted lungs and consequently, two ventilator machines may be required with different ventilator settings
Avoid:
- Benzodiazepines
- Nitrous oxide
- Positive end-expiratory pressures
Consider cardiac denervation in patients who have undergone double lung transplantation with tracheal anastomosis
- These patients are sensitive to hypovolemia
- Intraoperative bradycardia does not respond to atropine and direct agents such as epinephrine should be used

Monitor central venous pressure, pulmonary artery pressure, and urine output
Maintain a careful fluid balance
Consider that altered lymphatic drainage in the transplanted lung may cause interstitial fluid accumulation
- Treat these patients with diuretics and limited crystalloid infusion

Transfer the patient to the ICU
Monitor oxygen saturation
Administer adequate analgesia:
- Parenteral paracetamol is an effective analgesic agent
- Be cautious with the use of opioids as they can mediate CNS and respiratory depression
- Transdermal buprenorphine and methadone appear to be safe to use even in patients with renal dysfunction
- Avoid NSAIDs because of the risk of adverse reactions
Seek and treat infection or rejection
Continue immunosuppressive therapy