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Canadian Journal of Anesthesia

, Volume 46, Issue 6, pp 571–575 | Cite as

Combined lung and liver transplantation in a girl with cystic fibrosis

  • A. Andrew Zimmerman
  • Todd K. Howard
  • Charles B. Huddleston
Clinical Report

Abstract

Purpose

To describe the anesthetic considerations of a combined lung and liver transplant in a 14-yr-old girl with cystic fibrosis.

Clinical features

A 14 yr-old girl with cystic fibrosis presented for combined liver and lung transplantation. Anesthetic management was complex in that the pulmonary, hemodynamic, and hematological changes after cardiopulmonary bypass and lung transplantation made the management of the subsequent liver transplant unique. We used a moderate dose fentanyl and isoflurane anesthetic with invasive monitoring including a pulmonary artery catheter. Upon reperfusion of the new liver our patient exhibited severe pulmonary hypertension that was associated with a decrease in cardiac output and systemic hypotension. Utilizing a pulmonary artery catheter, this episode was treated with an increase of prostaglandin E1 (PGE1) infusion to 0.025 μg · kg−1· min−1 and the initiation of 3 μg · kg−1 · min−1 dobutamine. The pulmonary hypertension resolved and the cardiac output and blood pressure returned to baseline levels.

Conclusion

The anesthetic considerations for a combined lung and liver transplant are complex because of the interactions and alterations in cardiovascular, pulmonary and hemostatic systems. The use of a pulmonary artery catheter was critical to the management of our patient because it allowed us to accurately treat an episode of hypotension occurring during liver transplantation. This episode was secondary to acute pulmonary hypertension which is common after pulmonary transplantation but unusual during liver transplantation. It is also critical that a team approach is used to consider all of the concerns of the multiple services managing these complex patients.

Keywords

Cystic Fibrosis Liver Transplantation Pulmonary Hypertension Dobutamine Fresh Freeze Plasma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Objectif

Décrire les composantes anesthésiques d’une greffe combinée du poumon et du foie chez une jeune fille de 14 ans atteinte de fibrose kystique.

Éléments cliniques

Une jeune fille de 14 ans atteinte de fibrose kystique devait subir une greffe combinée du foie et du poumon. L’anesthésie a été complexe, car les changements pulmonaires, hémodynamiques et hématologiques causés par la circulation extracorporelle et la transplantation du poumon ont influencé de façon unique la greffe du foie qui a suivi. On a utilisé une dose modérée de fentanyl et d’isoflurane et un monitorage effractif comprenant un cathéter de l’artère pulmonaire. À la reperfusion du nouveau foie, on a noté une hypertension pulmonaire sévère associée à une baisse du débit cardiaque et à une hypotension générale. Cet épisode a été traité avec une perfusion accrue de prostaglandine E1 (PGE1) jusqu’à 0,025 μg · kg−1 · min−1 et l’administration de 3 μg · kg−1· min−1 de dobutamine à l’aide du cathéter de l’artère pulmonaire. L’hypertension pulmonaire s’est résorbée et le débit cardiaque ainsi que la tension artérielle sont revenus à la normale.

Conclusion

La greffe combinée du poumon et du foie demande un aménagement anesthésique complexe à cause des changements cardio-vasculaire, pulmonaire et hémostatique et aux interactions entre ces systèmes. L’usage d’un cathéter de l’artère pulmonaire a été décisif, puisqu’il nous a permis de traiter efficacement l’hypotension survenue pendant la greffe du foie. Cet épisode était secondaire à l’hypertension pulmonaire aiguë, fréquente à la suite d’une greffe pulmonaire mais inhabituelle pendant la greffe du foie. Dans des situations cliniques d’une telle complexité, il est crucial de travailler en équipe afin de tenir compte de toutes les composantes des multiples services nécessaires.

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Copyright information

© Canadian Anesthesiologists 1999

Authors and Affiliations

  • A. Andrew Zimmerman
    • 1
  • Todd K. Howard
    • 2
  • Charles B. Huddleston
    • 2
  1. 1.Department of AnesthesiologyWashington University School of Medicine and St. Louis Children’s HospitalSt. LouisUSA
  2. 2.Department of SurgeryWashington University School of Medicine and St. Louis Children’s HospitalSt. LouisUSA

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