Double #lung #transplant

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I got the page at 1pm stating: “Double lung transplant. Booked for 1400 start.” I’ve never seen a lung transplant — which makes this all the more exciting! After getting to the hospital, I grab a quick reference to read over the details of the case. We see our pt: young, sickly, intubated on the ventilator. Parents were at the bedside…knowing this was their only chance for the patient’s survival. The patient had cystic fibrosis that was progressively suffocating this patient’s oxygenation capacity. A couple days prior to notification of a lung becoming available, the patient had acute desaturations from ongoing mucus plugging that became incredibly severe. The preop ABG: 7.18/PaO2 141/PaCO2 200 –>on 100% FiO2. I’ve never seen a PaCO2 that high! The sight of the nitric oxide machine brought me some relief, however, the situation was still tenuous. Looking through the chart, I wondered why ECMO wasn’t a possibility for this patient. One of the pulmonary fellow’s notes stated that the patient was not a candidate for ECMO. I’m still curious why.

We wheeled the patient back to the OR — lined the patient up, placed the echo. PA pressure was elevated (systolic PA was around 50-60s). Echo showed mild RV dilation, mild PA dilation. Otherwise, the patient’s heart was vigorous and actively pumping. This would be expected since the patient was otherwise healthy aside from the CF and the need for new lungs. The dissection began around the lungs to gain access to sites of attachments (airways, vessels, etc.). CPB was initiated and the old lungs were removed. The new lungs were placed — and they appeared nicely pink and much healthier than the old lungs. We opted to change out the patient’s endotracheal tube (ETT) over a tube exchanger as there was a kink in the old ETT. Prior to unclamping the PA, solumedrol was given. We also examined the patient’s airways after the anastamosis was complete. After a ton of suctioning, the airways appeared nice and patent. We changed our vent settings for the new lungs –> TV 550, RR 16, PIP 35, PEEP 8. Our base O2 sat after coming off CPB was pretty low — we hovered in the mid to low 80s for awhile, however, we were trying to avoid 100% FiO2 since it can cause a reperfusion injury with hyperoxia to the new lungs. Finally, we were happy with a O2 sat around 90s-95 on 60% FiO2. For drips, we had 5mcg/kg/min dopamine, 4U/hr vasopressin, 1g/hr amicar (carrier at 50ml/hr), 30mcg/kg/min propofol. We tucked her in to the ICU — 11 hrs after incision.

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