Postop Management of Lung Transplant Recipients in the ICU

Abstract and Introduction

Abstract

The number of lung transplantations is progressively increasing worldwide, providing new challenges to interprofessional teams and the intensive care units. The outcome of lung transplantation recipients is critically affected by a complex interplay of particular pathophysiologic conditions and risk factors, knowledge of which is fundamental to appropriately manage these patients during the early postoperative course. As high-grade evidence-based guidelines are not available, the authors aimed to provide an updated review of the postoperative management of lung transplantation recipients in the intensive care unit, which addresses six main areas: (1) management of mechanical ventilation, (2) fluid and hemodynamic management, (3) immunosuppressive therapies, (4) prevention and management of neurologic complications, (5) antimicrobial therapy, and (6) management of nutritional support and abdominal complications. The integrated care provided by a dedicated multidisciplinary team is key to optimize the complex postoperative management of lung transplantation recipients in the intensive care unit.

Introduction

Lung transplantation is a complex treatment for select patients with a diverse array of end-stage pulmonary diseases. The number of lung transplantations is progressively increasing worldwide, and in the last 5 yr, more than 4,000 were performed annually.^[1] Improvements in donor management, organ preservation, recipient selection, antimicrobial prophylaxis, and immunosuppressive medications have resulted in durable and steady improvements in lung transplant outcomes. Survival of lung transplantation recipients, although lower than in other solid organ transplants, is currently at 60% at 5 yr.^[2]

The expansion of lung transplantation provides new challenges in the perioperative management of the recipients in the intensive care unit (ICU). First, the number of lung transplantation centers and the number of admissions to the ICU posttransplant is increasing. Second, the increase of older lung transplantation recipients and those with associated comorbidities will undoubtedly increase the perioperative risk.^[3] Third, severe primary graft dysfunction still occurs in up to 20 to 30% of the lung transplantation recipients, affecting outcome.^[2,4,5] A complex interplay of unique pathophysiologic conditions and risk factors attributable to the characteristics of the donor, the recipient, and the interaction between them (Figure 1) affects the perioperative outcome of the lung transplantation. Thus, knowledge of these specific issues is fundamental to properly care for these patients, especially for those who require prolonged life support.

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Figure 1.

Donor, recipient, and donor–recipient interaction—associated risk factors for primary graft dysfunction (adapted from Diamond et al. ⁴).

Table 1. Postoperative Acute Critical Complications Associated with Lung Transplantation
Respiratory Failure	Shock	Others
• Primary graft dysfunction² • Primary graft dysfunction 0: no edema on chest X-ray with any Pao₂/FIO₂ • Primary graft dysfunction 1: edema on chest X-ray with Pao₂/FIO₂ > 300 • Primary graft dysfunction 2: edema on chest X-ray with Pao₂/FIO₂ 200–300* • Primary graft dysfunction 3: edema on chest X-ray with Pao₂/FIO₂ < 200† • Donor-associated pneumonia • Ventilator-associated pneumonia • Acute rejection • Bronchial anastomotic complications (dehiscence) • Cardiogenic pulmonary edema • Pulmonary vein anastomotic obstruction • Pulmonary embolism • Hemothorax • Whole lung or lobar torsion • Phrenic nerve injury	• Hemorrhagic • Distributive (septic) • Cardiogenic (right ventricular failure, left ventricular failure) • Obstructive (tamponade, pulmonary embolism)	• Infection • Arrhythmias • Postoperative pericarditis • Gastroesophageal reflux • Bowel obstruction, perforation, ischemia • Immunosuppression side effects • CNS complications • ICU acquired weakness

Primary graft dysfunction is graded at four timepoints, every 24 h, over the first 72 h after transplantation (0, 24, 48, and 72 h). Primary graft dysfunction in recipients treated with noninvasive ventilation should be graded according to Pao₂/FIO₂ ratio as for invasive mechanical ventilation.
*If Pao₂/FIO₂ ratio is not available, oxygen saturation/FIO₂ ratio 235 to 315 is used instead of Pao₂/FIO₂ ratio 200 to 300. †Use of extracorporeal membrane oxygenation with pulmonary edema is graded as primary graft dysfunction 3. Extracorporeal membrane oxygenation for cardiac indication (without pulmonary edema) is ungradable.
CNS, central nervous system; FIO₂, inspired oxygen fraction; ICU, intensive care unit.

Table 3. Donor and Recipient Preoperative and Postoperative Infective Risk Factors
Donor Factors	Recipient Factors: Preoperative	Recipient Factors: Postoperative
• Bacterial or fungal allograft colonization • Allograft latent infection (toxoplasma, cytomegalovirus, other viruses, endemic mycosis, tuberculosis)	• Age • Diabetes • Hypogammaglobulinemia • Renal failure • No immunity against cytomegalovirus, toxoplasmosis, rubeola virus, varicella zoster virus • Latent infection tuberculosis, cytomegalovirus, herpes simplex virus, varicella zoster virus, Epstein–Barr virus, endemic mycosis • Colonization with multidrug-resistant microorganisms • Immunosuppressive therapy • Rejection • Environmental exposure (gardener, animals, caves, travel) • Native lung colonization	• Allograft injury (ischemia, preservation, reperfusion) • Complexity and length of surgery • Postsurgical care (mechanical ventilation, intravenous catheters, drains, bladder catheter, extracorporeal membrane oxygenation) • Transfusion • Intensive care stay

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Postoperative Management of Lung Transplant Recipients in the Intensive Care Unit

Abstract and Introduction

Abstract

Introduction

Tables

Tables

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Authors and Disclosures

Authors and Disclosures

Figure 1.

Figure 1.

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