Alpha 1-antitrypsin deficiency: circulatory arrest following induction of anaesthesia

Aspects of Anesthesia for Lung Transplantation

Anesthesia for lung transplantation is both a demand ing and rewarding experience. Success requires team- work, experience, knowledge of cardiorespiratory patho physiology and its anesthetic implications, appropriate use of noninvasive and invasive monitoring, and the ability to respond quickly and effectively to life- threatening perioperative events. Specific issues in clude management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation, perioperative respiratory failure, pulmonary hyperten sion, and acute right ventricular failure. Recent ad vances include greater understanding of dynamic hyper inflation ("gas-trapping") during mechanical ventilation, perioperative use of inhaled nitric oxide and treatment of acute right ventricular failure. Successful anesthetic management leads to greater hemodynamic stability, improvement in gas exchange and a reduction in need for cardiopulmonary bypass, all of which should lead to improved patient outcome.

Lessons from lung transplantation for everyday thoracic anesthesia

Patients with end-stage lung disease are at significant risk of hypoxia and dynamic hyperinflation during mechanical ventilation, particularly during one-lung ventilation. This article describes aspects of care such as patients, including acceptance of permissive hypercapnia, adjustment of ventilator settings, and methods to optimize recovery from anesthesia.

Anaesthesia for patients with a transplanted organ

Increasing numbers of individuals leading normal lives have transplanted organs. They may appear in any hospital for treatment of trauma or general diseases. Common anaesthesia methods can be used for these patients, but safe conduct of anaesthesia requires knowledge of the immunosuppression, risk factors, and altered physiology or drug actions. This article reviews the anaesthesia-related literature on patients with transplanted organs.

Anesthesia for heart or single or double lung transplantation in the adult patient

Providing an anesthetic for patients undergoing heart or a single or double lung transplantation may represent a challenge even to the most experienced anesthesiologist. Patients with end-stage cardiac dysfunction have an impaired response to beta-agonist due to receptor downregulation. These patient will have isolated left ventricular dysfunction secondary to ischemic heart disease or present with biventricular failure with or without significant pulmonary hypertension. Increasingly, more patients have undergone prior major cardiac procedures and are at risk for significant perioperative bleeding. Patients undergoing single or double lung are particularly challenging because most of these procedures are performed without the aid of cardiopulmonary bypass. The anesthesiologist must be proficient at the management of one-lung ventilation techniques and have a rational physiologic approach to the management of intraoperative hypoxemia and auto-PEEP.

Continuous arterial blood gas monitoring during bilateral sequential lung transplantation

OBJECTIVE

To determine the accuracy and clinical utility of a continuous arterial blood gas (ABG) monitor during lung transplantation.

DESIGN

Prospective, observational cohort study.

SETTING

University hospital.

PARTICIPANTS

Eleven patients undergoing bilateral sequential lung transplantation (BSLTx).

INTERVENTIONS

Repeated ABG sampling.

MEASUREMENTS AND MAIN RESULTS

Agreement was measured by the bias (limits of agreement): pH, 0.006 (-0.10 to 0.10); PaO2, -22 mmHg (-130 to 86 mmHg); and PaCO2, -1.6 mmHg (-13.4 to 10.2 mmHg). Sensitivity and specificity of the Paratrend 7 (Biomedical Sensors, Ltd, Malvern, PA) PaO2 measurements (to detect PaO2 < 100 mmHg) were 84.6% and 97.6%, respectively.

CONCLUSION

Continuous ABG monitoring with the Paratrend 7 shows sufficiently good agreement with laboratory blood gas analysis during BSLTx and thus is a convenient alternative to intermittent laboratory blood gas measurement. Because of the potential for significant (and sometimes rapid) acid-base disturbances, continuous ABG monitoring may have a role during most lung transplantation procedures.

Dynamic hyperinflation: comparison of jet ventilation versus conventional ventilation in patients with severe end-stage obstructive lung disease

Positive pressure ventilation in patients with obstructive lung disease may result in over-inflation of the relatively compliant lungs, resulting in dynamic hyperinflation (DHI). Using a crossover trial design, we compared high-frequency jet ventilation (HFJV) versus "optimal" intermittent positive pressure ventilation (IPPV) in ten patients undergoing lung transplantation for severe, end-stage obstructive lung disease. We measured haemodynamics and the degree of DHI after both modes of ventilation. There were no significant differences between IPPV and HFJV, with respect to efficiency of ventilation (PaCO2), haemodynamic effects (stroke volume, blood pressure and cardiac output), or lung hyperinflation (trapped gas volume). This study suggests that HFJV, when compared with optimal IPPV, is no better at minimizing DHI in patients with severe, end-stage obstructive lung disease.

Anesthesia for bilateral sequential lung transplantation: experience of 64 cases

OBJECTIVES

To review the experience of anesthesia for bilateral sequential lung transplantation (BSLTx) and describe factors associated with outcome.

DESIGN

Case series.

SETTING

University hospital.

PARTICIPANTS

Sixty-four adult patients undergoing BSLTx.

INTERVENTIONS

Descriptive and inferential statistical analysis.

MEASUREMENTS AND MAIN RESULTS

Details of anesthetic technique, patient, and perioperative characteristics are presented. Mean (SD) lung allograft ischemic times were 320 (81) minutes for the first lung and 446 (93) minutes for the second lung. Mean (SD) duration of surgery was 8.5(2) hours, and median time to extubation was 28 hours. There was a reduction in the use of cardiopulmonary bypass, from 10 of 19 (53%) in 1992 to 1993 to 10 of 45 (22%) in 1994 to 1996, p = 0.016. There was an association between time to extubation and duration of surgery (Spearman rank correlation, p = 0.33, p = 0.008), but no association with intraoperative fluid administration (p = 0.18, p = 0.16), or inotrope requirements (p = 0.06, p = 0.65). Predictors of in-hospital mortality were preoperative renal impairment (p = 0.034), early reoperation (p = 0.005), and delay in extubation (p = 0.013); and for 12-month mortality was patient age (p = 0.01). The actuarial survival rates were 90%, 73%, and 58% at 30 days, 1 year, and 2 years, respectively.

CONCLUSIONS

Anesthesia for BSLTx is a most challenging procedure, for which maintenance of tissue oxygenation and right ventricular perfusion are essential. Recent advances include use of inhaled nitric oxide, ventilator management that reduces dynamic hyperinflation, and permissive hypercapnia. Analysis of outcome from a large case series such as this enables the anesthesiologist to be more aware of the important features of anesthesia for BSLTx, as well as identify potential areas of improvement.

Techniques and results in bilateral sequential single lung transplantation. The National Heart & Lung Replacement Service

Lung transplantation continues to evolve as a therapeutic option for patients with end-stage lung disease. Bilateral sequential single lung transplantation (BSSLTx) is a recent addition to the lung transplant surgeon's armamentarium that incorporates the benefits of single lung transplantation in patients who require double lung replacement while avoiding the morbidity inherent in the en bloc double lung transplant procedure. Between November 1992 and October 1993, 17 recipients underwent 18 bilateral BSSLTx procedures for a variety of indications. In 53% of patients, the procedure was completed without the requirement for cardiopulmonary bypass. Telescoping of the bronchial anastomosis has proved satisfactory. Induction cytolytic therapy has not been utilized. Patients received methyl prednisolone from day 1 and as maintenance prednisolone therapy. Actuarial 1-year survival is 87%; 12 of the 15 survivors are in Functional Class I. BSSLTx is an evolving transplant option for patients who require double lung replacement. Definitive clinical diffusion of the procedure will depend upon intermediate and long-term outcomes for specific recipient pathologies.