Lung transplantation
Stem
A 59-year-old woman, 64 kg, with idiopathic pulmonary fibrosis, is having a bilateral sequential lung transplant through a clamshell incision. She is on 6 L/min of oxygen with a resting SpO2 of 90%. Right heart catheterization showed a mean pulmonary artery pressure of 38 mmHg, and echo shows a mildly dilated right ventricle with preserved function. The donor lungs arrive in two hours.
Question
How will you anesthetize her, and when does she need extracorporeal support?
Ideal answer
HeadlineThe right ventricle is the weak link, so I protect it at induction and plan VA-ECMO with the surgeon and perfusionist before I start.
- Slow induction with pressors and milrinone ready: hypoxia and CO2 retention raise PA pressure in an already loaded RV.1
- Left DLT, arterial lines, left-sided PA catheter, TEE: radial and femoral lines; the right neck stays free for VV ECMO cannulation.1
- Test-clamp the pulmonary artery and watch the RV: clamping is where RV failure declares itself.1
- VA-ECMO, ready or elective: it needs less heparin than bypass, with an ACT around 200 seconds and less bleeding.1
- Protect each new lung at reperfusion: methylprednisolone 500 mg first, then controlled reperfusion,1 avoiding a high FiO2.2
Watch for: RV dilation on TEE, PA pressure rising as systemic pressure falls, and hypoxemia on one lung.
Breaking down the answer
- When to go on support — she cannot tolerate one-lung ventilation or the PA clamp, or the RV fails. ECMO also bridges to transplant and salvages severe graft dysfunction afterward.1 Changes if: she arrives bridged, and that circuit carries her through.
- VA or VV — VA unloads a failing RV and gives cardiorespiratory support; VV is for oxygenation alone, as in postoperative graft dysfunction.1 Peripheral femoral VA risks limb and spinal cord ischemia and watershed hypoxemia.1
- ECMO over bypass — a network meta-analysis found VA-ECMO beat bypass on plasma and platelet use, ventilation time, ICU stay, need for postoperative ECMO and mortality, though not red-cell use.3
- Pulmonary hypertension feeds graft injury — each 10 mmHg of mean PA pressure raises the odds of primary graft dysfunction about 1.3-fold.1
- Graft dysfunction risks I control — high FiO2 at reperfusion, use of bypass, and transfusion; donor age, smoking and ischemic time I cannot.2
- Analgesia — systemic anticoagulation for ECMO makes some centers avoid epidurals in favour of multimodal analgesia.1
Follow-up question
After the second lung is reperfused, she is off ECMO. Over 30 minutes her PaO2/FiO2 ratio falls to 120 and pink frothy fluid fills both lumens of the tube; the PA pressure rises to 45/24 mmHg. What is happening, and what do you do?
Follow-up answer
HeadlineThis is primary graft dysfunction grade 3; I ask for early ECMO now: VV, or VA if the RV is failing.
Graded on PaO2/FiO2 with infiltrates over the first 72 hours.2 I use lung-protective ventilation, keep fluids tight, and start inhaled nitric oxide 5–10 ppm, which lowers PA pressure and improves matching.1 I bronchoscope to exclude clot or an anastomotic problem. At grade 3, early VV ECMO beats delayed rescue;1 with the PA at 45/24 and a struggling RV on TEE, VA, which unloads it.1
Pitfalls that cost points
- Inducing a patient with severe pulmonary hypertension without the ECMO team in the room.
- Reperfusing the first graft on FiO2 1.0 and full flow by reflex.
Rapid-fire
Q: How common is primary graft dysfunction? A: About 10–25% of recipients, and it drives early mortality and later chronic graft dysfunction.2
Q: What rules out PGD regardless of oxygenation? A: A clear chest radiograph: no infiltrates is grade 0 whatever the PaO2/FiO2 ratio.2
Q: Why is mask ventilation hard at induction? A: High airway resistance in end-stage lung disease, while hypoxia and hypercarbia worsen PA pressure.1
Q: Which diseases get a single versus a double lung? A: Single is possible for COPD or fibrosis; bilateral is required for suppurative disease such as cystic fibrosis and for severe pulmonary hypertension,1 and is now the majority internationally.4
Numbers to know
| Item | Value |
|---|---|
| ACT on VA-ECMO | ~200 s1 |
| Methylprednisolone before reperfusion | 500 mg1 |
| Inhaled nitric oxide | 5–10 ppm1 |
| PGD window | First 72 h2 |
| PGD incidence | 10–25%2 |
| PGD risk per 10 mmHg mean PA pressure | OR ~1.31 |
Links
- Pulmonary hypertension and right ventricular failure, One-lung ventilation and hypoxemia, Double-lumen tubes and bronchial blockers, Temporary mechanical circulatory support: IABP, Impella and ECMO, ARDS and lung-protective ventilation
- Atlas: The 11 TEE views
- ISHLT primary graft dysfunction definition (2016 update)
Sources
- 1.Anesthesia for lung transplantation: A narrative review · Journal of Anaesthesiology Clinical Pharmacology (Khanna et al.), 2025 · ebi.ac.uk
- 2.Primary graft dysfunction in lung transplantation: still a thorn in the side of lung transplant · Journal of Thoracic Disease (Wong and Hsin), 2024 · ebi.ac.uk
- 3.Intraoperative extracorporeal support for lung transplant: a systematic review and network meta-analysis · Journal of Anesthesia, Analgesia and Critical Care (Pettenuzzo et al.), 2024 · ebi.ac.uk
- 4.Lung transplantation for interstitial lung disease · Breathe (Ronan, Helly, Murray; European Respiratory Society), 2025 · europepmc.orgInternationally a majority of lung transplants are now bilateral; single lung may be preferred in rapidly deteriorating or hard-to-match IPF candidates.
Facts on this page were checked against these sources on Oct 22, 2026. Guidelines change; confirm doses against current institutional protocols.