Mod13: Lung & Corneal Transplantations

Question 1

_{Lung Transplantation - Overview}

What are common indications for Lung Transplantation?

Answer 1

End-stage Parenchymal disease

Severe Pulmonary hypertension

Question 2

_{Lung Transplantation - Overview}

Candidates for lung Tpx have a poor prognosis. What are they functionally incapacitate by?

Answer 2

Dyspnea

Question 3

_{Lung Transplantation - Overview}

Which factor is responsible for varying management criteria in lung transplantation?

Answer 3

Primary disease process

Question 4

_{Lung Transplantation - Overview}

General indications to having a lung Tpx from Barash anesthesia:

Answer 4

End-stage lung dz

Failed maximal medical treatment of lung dz

Age within limits for planned transplant

Life expectancy < 2-3 yrs

Ability to walk and undergo rehabilitation

Sound nutritional status (70%-130% of IBW)

Stable psychosocial profile

No significant comorbid disease

Question 5

_{Lung Transplantation - Overview}

From Barrish, what are COPD-specific indications for lung Tpx?

Answer 5

FEV1 < 25% of predicted value after bronchodilators and/or

PaCO2 = 55 mmHg and/or

Pulmonary Hypertension (especially with Cor Pulmonale)

Chronic O2 therapy

Question 6

_{Lung Transplantation - Overview}

From Barrish, what are Cystic Fibrosis-specific indications for lung Tpx?

Answer 6

FEV1 < 30% of predicted

Hypoxemia, hypercarbia, or rapidly declining lung function

Weight loss and hemoptyis

Frequent exacerbations, especially young females

Absence of antibiotic-resistant organisms

Question 7

_{Lung Transplantation - Overview}

From Barrish, what are Idiopathic pulmonary fibrosis-specific indications for lung Tpx?

Answer 7

Vital capacity <60%-65% of predicted

Resting hypoxemia

Progression of disease despite therapy (steroids)

Question 8

_{Lung Transplantation - Overview}

From Barrish, what are Pulmonary-hypertension-specific indications for lung Tpx?

Answer 8

NYHA functional status class III or IV,

despite Prostacyclin therapy

Mean right atrial pressure < 15 mmHg

Mean pulmonary artery pressure < 55 mmHg

Cardiac Index < 2L/min/m2

Question 9

_{Lung Transplantation - Overview}

From Barrish, what are Einsenmenger-syndrome-specific indications for lung Tpx?

Answer 9

NYHA class III or IV, despite optimal therapy

Question 10

_{Lung Transplantation - Overview}

From Barrish, what are Pediatric-specific indications for lung Tpx?

Answer 10

NYHA class III or IV

Disease unresponsive to maximal therapy

Cor pulmonale, cyanosis, low CO

Question 11

_{Single vs. Double Lung Transplant}

Single-lung transplantation may be performed for selected patients with which medical condition?

Answer 11

COPD

Chronic obstructive pulmonary disease

Question 12

_{Single vs. Double Lung Transplant}

Double-lung transplantation is typically performed for patients with which medical conditions?

Answer 12

Cystic fibrosis

Bullous emphysema

Vascular diseases

Question 13

_{Single vs. Double Lung Transplant}

Why are younger patients more likely to receive bilateral lung transplants?

Answer 13

Disease process tyically involve full lungs

Question 14

_{Single Lung Transplantation}

Why is Single Lung Transplantation often attempted without CPB?

Answer 14

Can ventilate the other lung (down lung) that is not being transplanted

Double-lumen tube must be used for one-lung (down lung) ventilation

Question 15

_{Single Lung Transplantation}

Which type of incision is used for Single Lung Transplantation?

Answer 15

Posterior thoracotomy

Question 16

_{Single Lung Transplantation}

Which clinical signs would indicate the need for CPB during transplantation of one lung?

Answer 16

Arterial hypoxemia (spO2 <88%)

Sudden increase in PA pressures

Question 17

_{CPB for One Lung Transplantation}

When CPB is necessary, where would pt be cannulated during a Left thoracotomy?

Answer 17

Femoral-vein-to-Femoral-artery bypass

Question 18

_{CPB for One Lung Transplantation}

When CPB is necessary, where would pt be cannulated during a Right thoracotomy?

Answer 18

Right-atrium-to-Aorta bypass

This is the typical approach for open heart surgery

Question 19

_{Double-Lung Transplantation}

Which type of incision is used for Double-Lung Transplantation?

Answer 19

“Clamshell” transverse sternotomy

Question 20

_{Double-Lung Transplantation}

True or False: Double-Lung Transplantation is occasionally performed with normothermic CPB

Answer 20

True

As opposed to traditional hypothermic CPB

Question 21

_{Double-Lung Transplantation}

Why is Sequential bilateral thoracotomies for double-lung transplantation now the preferred approach over the sequential unilateral (one lung at the time) approach?

Answer 21

Sequential bilateral thoracotomies associated with:

Decrease bleeding

Decrease need for tracheal anastomosis

Question 22

_{Double-Lung Transplantation}

What’s a disadvantage of sequential bilateral thoracotomies

Answer 22

One-lung ventilation not feasable

Henced the need for CPB

Question 23

_{Lung Transplantation - Induction of Anesthesia}

Which induction technique is appropriate for lung Tpx?

Answer 23

RSI with aspiration prophylaxis

Question 24

_{Lung Transplantation - Induction of Anesthesia}

Which induction technique would you employ to avoid precipitous drops in blood pressure?

Answer 24

Slow induction with:

Ketamine - Etomidate - Opioids

Question 25

_{Lung Transplantation - Induction of Anesthesia} Which muscle relaxant will you use to facilitate laryngoscopy?

Answer 25

Succinylcholine or a nondepolarizing NMBA

Question 26

_{Lung Transplantation - Induction of Anesthesia} Which must be avoided to prevent further increases in pulmonary artery pressure?

Answer 26

**Hypoxemia** and **Hypercarbia**

Question 27

_{Lung Transplantation - Induction of Anesthesia} Why should you treat hypotension with pressors rather than fluid?

Answer 27

Fluid will cause further increase in PA pressures

Question 28

_{Lung Transplantation - Post-transplantation Management} True or False: After anastomosis ventilation to both lungs is delayed to allow the anastomosis to heal.

Answer 28

**False** After anastomosis _ventilation to both lungs is resumed_

Question 29

_{Lung Transplantation - Post-transplantation Management} Why should you keep Peak inspiratory pressures as low as possible?

Answer 29

To maintained minimum pressure compatible with good lung expansion Avoid placing any additional stress and pressure on the anastamosis

Question 30

_{Lung Transplantation - Post-transplantation Management} Why must you maintain inspired oxygen concentration close to room air?

Answer 30

To keep **PaO2 \>60 mm Hg** May go up on your FiO2 if PaO2 is inadequate

Question 31

_{Lung Transplantation - Post-transplantation Management} Why are **Methylprednisolone** and **mannitol** usually given prior to release of vascular clamps?

Answer 31

Must anticipate the fact that the tpx will _interupt neural innervation_ Will affect _lymphatic drainage_, and bronchial circulation Respiratory patterns once the pt is awake should go back to normal, but the **cough reflex** below the carina will be _abolished_ This will result in **bronchial hyperactivity** _Absence of lymphatic drainage_ will increase the risk of **pulmonary edema**_,_ **pneumonia** Another reason to be conservative with intraop fluid replacement

Question 32

_{Corneal Transplant} Corneal Transplant is the most common transplant. How many are done per year?

Answer 32

**\>40,000**

Question 33

_{Corneal Transplant} Which anesthetic techniques are appropriate for Corneal Transplant?

Answer 33

Local, MAC or general anesthesia appropriate Typically a combination of _Local + IV sedation_

Question 34

_{Corneal Transplant} If using General Anesthesia, why should Succinylcholine be avoided?

Answer 34

Succinylcholine will increase IOP The goal is to keep IOP low

Question 35

_{Corneal Transplant} True or False: Most recipients are elderly pts

Answer 35

True

Question 36

_{Corneal Transplant} What's the most common cause of graft loss in the 1st year

Answer 36

Rejection of allograft