Anesthesia for lung transplantation

Lung transplantation is the only therapeutic option for more than 3,000 individuals in the United States with end-stage lung disease. Innovations in anesthetic and surgical techniques have expanded the indications for lung transplantation. Presently, the major limiting factor in the number of lung transplantations that are performed is the availability of suitable donor organs. Lung transplantation includes a number of surgical procedures, including single-lung, double-lung, bilateral-sequential-single-lung, heart-lung, and lobar transplantation. Patients undergoing lung transplantation present a variety of challenges to the anesthesia team. Critical periods include induction of anesthesia, initiation of positive pressure ventilation, establishment and maintenance of one-lung ventilation, pulmonary artery clamping, pulmonary artery unclamping, and reperfusion of the transplanted lung. Pharmacologic advances have been an important factor in the continued development and success of lung transplantation. Newer immunosuppressive agents have improved the prevention and management of post-transplant rejection. Selective pulmonary vasodilators that are administered via inhalation affect the anesthetic management during the surgical procedure. Technologic advances in monitoring have also been valuable in lung transplantation. Transesophageal echocardiography is commonly used to evaluate intraoperative ventricular function. Continuous cardiac output, mixed venous oxygen saturation, continuous arterial blood gas monitoring, and the bispectral index have also been used to monitor the patient during lung transplantation. Anesthetic management of lung transplantation requires a thorough understanding of end-stage lung disease and pharmacologic and technical considerations that may not be applicable in any other part of anesthetic practice.