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Anesthetic Management

Preoperative sedation is minimal because these patients have limited cardiopulmonary reserve. Intravenous catheters are usually placed in upper extremities. However, in patients undergoing sequential double lung transplantation using the clamshell thoracosternotomy who will have both arms bent at the elbows and suspended from the ether screen, catheters in antecubital veins are avoided. After the recipient is transferred to the operating room, a right radial arterial catheter is placed. In patients who are likely to require cardiopulmonary bypass a femoral arterial catheter is also inserted. An oximetric pulmonary artery catheter is usually placed after induction of anesthesia. Standard non-invasive monitoring includes electrocardiography (lead II and V5), blood pressure cuff, pulse oximetry, and multigas analysis. TEE is very helpful in the evaluation of volume status and right ventricular function, and may help in the evaluation of the vascular anastomoses.

Anesthetic induction should keep the patient's recent oral intake into consideration. Because these procedures are done with little notice, cricoid pressure usually has to be applied. In patients with compromised right ventricular function, anesthetic agents that do not depress cardiac function are used (e.g., fentanyl, sufentanil, etomidate, muscle relaxants, benzodiazepines). In patients with preserved right ventricular function, low concentrations of inhaled anesthetics are usually well tolerated.

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