Combined lung and liver transplantation in a girl with cystic fibrosis

Purpose: To describe the anesthetic considerations of a combined lung and l iver transplant in a 14-yr-old girl with cystic fibrosis. Clinical features: A 14 yr-old girl with cystic fibrosis presented for comb ined liver and lung transplantation. Anesthetic management was complex: in that the pulmonary, hemodynamic, and hematological changes after cardiopulm onary bypass and lung transplantation made the management of the subsequent liver transplant unique. We used a moderate dose fentanyl and isoflurane a nesthetic with invasive monitoring including a pulmonary artery catheter. U pon reperfusion of the new liver our patient exhibited severe pulmonary hyp ertension that was associated with a decrease in cardiac output and systemi c hypotension, Utilizing a pulmonary artery catheter, this episode was trea ted with an increase of prostaglandin E-1 (PGE(1)) infusion to 0.025 mu g . kg(-1). min(-1) and the initiation of 3 mu g . kg(-1). min(-1) dobutamine. The pulmonary hypertension resolved and the cardiac output and blood press ure returned to baseline levels. Conclusion: The anesthetic considerations for a combined lung and liver tra nsplant are complex because of the interactions and alterations in cardiova scular, pulmonary and hemostatic systems. The use of a pulmonary artery cat heter was critical to the management of our patient because it allowed us t o accurately treat an episode of hypotension occurring during liver transpl antation. This episode was secondary to acute pulmonary hypertension which is common after pulmonary transplantation but unusual during liver transpla ntation. It is also critical that a team approach is used to consider all o f the concerns of the multiple services managing these complex patients.