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Often performed in candidates with:

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  • Chronic pulmonary infections
  • Pulmonary hypertension
  • Congenital heart disease
  • Cystic fibrosis (absolute indication)

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Usually performed via clamshell incision (Figure 96-1) and sequentially rather than en bloc as

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  • Cardiopulmonary bypass can be avoided
  • Fewer complications with bronchial versus tracheal anastomoses

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Figure 96-1. Clamshell Incision
Graphic Jump Location

Reproduced from Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L. Adult Chest Surgery. Figure 137-10. Available at: www.accesssurgery.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

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Traditionally performed in candidates with

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  • COPD
  • IPF

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Poses challenges in postoperative ventilation and perfusion due to the discrepant compliance in the transplanted versus native lungs. Performed via thoracotomy in the fifth intercostal space.

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Consider thoracic epidural for postoperative pain management in patients with lower likelihood of needing cardiopulmonary bypass during the procedure

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Usually at least 6 hours notice prior to induction: patient NPO as for elective case

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Preinduction: A large bore IV and an arterial line.

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Induction

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  • Consider ‘gentle’ rapid sequence induction based on NPO status
  • Induction goals are to avoid increases in pulmonary vascular resistance and myocardial depression
  • Induction is usually performed with a combination of midazolam, fentanyl, and etomidate
  • PAC and TEE placed post-induction
  • A single lumen endotracheal tube should be placed to enable an initial bronchoscopy to clear secretions, which will facilitate single-lung ventilation
  • One-lung ventilation via a double lumen endotracheal tube

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Maintenance

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  • Maintenance is achieved with cautious titration of volatile anesthetics, opioids, and benzodiazepines
  • One-lung ventilation is needed to avoid cardiopulmonary bypass when performing sequential double-lung transplant or single-lung transplant
  • One-lung ventilation may result in hypoxemia, hypercarbia, acidosis, and subsequent pulmonary hypertension and right ventricular compromise
  • Clamping of the pulmonary artery, while improving oxygenation by decreasing shunt, may further increase pulmonary arterial pressures and compromise right ventricular function
  • Norepinephrine and vasopressin may be required to maintain systemic hemodynamics
  • In patients with pulmonary hypertension, milrinone (0.25–0.375 μg/kg/min) may be added to lower pulmonary vascular resistance and augment right ventricular function
  • In case milrinone is insufficient, inhaled nitric oxide (20 ppm) may be added. Inhaled nitric oxide also helps improve V/Q mismatch and may reduce hypoxemia during one-lung ventilation
  • Following pulmonary anastomosis, retrograde flow to wash out the pneumoplegia solution ensues, which may result in profound hypotension due to systemic vasodilation;
    • Vasoactive support is usually necessary
    • Avoid hypertension as it might result in pulmonary edema due to capillary leak
    • Blood transfusion is helpful in maintaining blood pressure. Maintain hematocrit around 30
  • Reinflation of the donor lung should be done manually on room air with low tidal volumes to minimize reperfusion injury and pulmonary edema
  • During one-lung ventilation, SpO2 >85% is tolerated to avoid cardiopulmonary bypass
  • Later FiO2 may ...

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