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Heart transplantation is considered emergency surgery, and there is often little time for extensive evaluation in the immediate preoperative period. This chapter covers the preoperative considerations and reviews the intraoperative management of heart transplant patients. Patients with severe heart failure are often on many drugs, including diuretics, angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists. Many of these drugs interact with anesthesia and should be taken into account. Following pre-anaesthetic assessment, induction of anesthesia should be performed after placement of essential monitoring. Initial pharmacological support is required during the period of weaning from cardiopulmonary bypass (CPB), and this initial management is described with ongoing support and choice of agent. After CPB, the transesophageal echocardiography (TEE) should focus on the ventricular function. Finally, there should be a careful and thorough handover to the team taking over the patient's care following transfer to the intensive care unit.
No procedure in medicine depends as much as lung transplantation does on a team approach from various disciplines including surgeons, respiratory physicians, microbiologists, physiotherapists and nurses if success is to be achieved. To minimize any confusion and optimize patient care it is essential to develop standard treatment protocols and to organize regular multidisciplinary ward rounds on a daily basis.
Although occasionally patients are extubated in the operating theatre, the majority of patients are extubated between 12 and 24 hours after surgery. They arrive in the intensive care unit mechanically ventilated and the approach to ventilation is to minimize the risk of trauma whilst ensuring adequate oxygenation on as low a fraction of inspired oxygen as possible. A low positive end-expiratory pressure of 5 cm H2O is usually employed. A degree of lung vascular injury resulting from factors in the donor lung, method of lung preservation and ischaemia–reperfusion injury occurs in all lungs but the severity varies considerably. Brain death itself induces systemic and local cytokine responses in the donor lungs. A severe injury is manifest by parenchymal infiltrates and significant hypoxaemia. This may require careful ventilatory management, diuresis and the use of inhaled nitric oxide. When diuretics are used it is important to ensure that the circulating blood volume is not reduced to a degree that impairs tissue perfusion. It is also important to avoid electrolyte abnormalities and uraemia. Chest drains are monitored for evidence of mediastinal or pleural haemorrhage and if this is persistent or massive, re-exploration is required. The frequency of surgical re-exploration for bleeding has decreased markedly over the years.
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