ANAESTHESIOLOGIC MANAGEMENT OF COMBINED L UNG AND LIVER-TRANSPLANTATION

A 53-year-old man with alpha-1-antitrypsin deficiency had an 8-year hi story of progressive dyspnoea and two episodes of bleeding oesophageal varices with liver decompensation. After the diagnosis of terminal pu lmonary emphysema (Fig. 1) and liver cirrhosis with progressive liver failure was made, he was accepted for combined lung and liver transpla ntation. Methods. Anaesthesia was induced with thiopentone and fentany l and maintained with fentanyl, midazolam, and isoflurane. After relax ation with succinylcholine, the patient's trachea was intubated with a left endobronchial double-lumen tube. Haemodynamic monitoring include d arterial, central-venous, pulmonary-artery, and capillary-wedge pres sures and cardiac output measurement. Ventilatory monitoring consisted of pulse oximetry, sidestream spirometry, and continuous measurement of arterial and mixed-venous blood oxygen saturation with fibreoptic c atheters. A left single-lung transplantation was performed under one-l ung ventilation without cardiopulmonary bypass. Prostacyclin was infus ed to reduce pulmonary vascular resistance. The transplant was ventila ted separately with 50% oxygen and positive end-expiratory pressure of 8-10 cm H2O, and then liver transplantation was carried out. The inst itution of veno-venous bypass during the anhepatic phase failed becaus e of portal-vein and axillary-vein thrombi.Results. Total operation ti me was 6 h 10 min Clamping of the left pulmonary artery lasted 45 min 2nd the duration of the anhepatic phase was 92 min. Ventilation and ox ygenation during lung transplantation caused no problems (Table 1). Cl amping of the left pulmonary artery caused a slight increase in pulmon ary vascular resistance (104 to 124 dyn . s . cm-5) and mean pulmonary artery pressure (25 to 27 mm Hg) without a decrease in cardiac index (Table 2). During the anhepatic phase with exclusion of the portal vei n and inferior vena cava, a marked decrease in cardiac index (-27,2%) was seen (Table 4). The operation required substitution with 10 units packed red blood cells, 12 units fresh frozen plasma, and 5 platelet c oncentrates. The post-operative course showed normal liver graft funct ion (Table 5). Acute pulmonary rejection on the 7th day was treated su ccessfully with methylprednisolone. The patient's trachea has extubate d 10 days after transplantation and he was discharged from the intensi ve care unit 2 weeks later. Conclusion. The management of this combine d lung and liver transplantation was performed according to the experi ence with isolated lung and liver transplants in our hospital. Aggress ive haemodynamic and ventilatory monitoring, including systemic and pu lmonary arterial fibreoptic catheters, seems of particular importance in such high-risk procedures.