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first 24 to 48 hours. Fluid management is facilitated by determination of pulmonary diastolic pressure or capillary wedge pressure and daily weight. Overly aggressive diuresis resulting in hypotension and prerenal azotemia should be avoided.

Pulmonary hypertension and elevated pulmonary vascular resistance can be controlled with prostaglandin E1 infusion 10-100 ng/kg/min. Nitric oxide (at 20-60 parts per million) has also been found to be useful in decreasing pulmonary artery pressures and in improving oxygenation.31

Pain Control

Pain relief is effectively achieved with the use of an epidural catheter. This is placed pre-operatively in virtually all patients, except those who are anticoagu-lated, or in patients with pulmonary vascular disease, in whom systemic heparin-ization and cardiopulmonary bypass is needed. In these cases, when the epidural catheter is not placed pre-operatively, it is placed as soon after the transplant as possible. After several days the epidural catheter is removed, and patient controlled analgesia (PCA) is initiated as soon as the patient can cooperate.

Postural Drainage and Physiotherapy

Optimization of pulmonary toilet expedites weaning and extubation. SLT recipients are maintained in a lateral position with the allograft side "up" for the first 24 hours to enhance ventilation and adequate drainage of the allograft. BLT recipients are maintained supine as much as possible for the first 12 hours, then rotated from side to side as tolerated. Physiotherapy consists of vigorous chest percussion and postural drainage, and includes early mobilization of the patient after extubation. These aggressive maneuvers are withheld for the first 36 hours in SLT recipients for PPH to avoid the occurrence of pulmonary hypertensive crisis.

Bronchoscopy

Bronchoscopy is useful for clearance of airway secretions, inspection of the integrity of the anastomosis, and obtaining washings to guide antimicrobial therapy. Bronchoscopy is performed in the operating room at the end of the transplantation, then on the first post-operative day and again immediately prior to extuba-tion, and also whenever indicated by the clinical situation.

Pleural Drainage

Two thoracostomy tubes are inserted into the pleural space at the time of the transplantation. They are removed as soon as there are no air leaks and drainage is minimal (<200 ml per 24 hours). Pleural space complications after lung transplantation have been reviewed in a previous report.33

Nutrition

Intravenous alimentation is started within 24 hours of transplantation. In most patients, an oral diet is started within 3-7 days of the procedure, but if prolonged ventilatory support is required, a feeding tube is placed to provide enteral nutrition. Optimization of the nutritional state in these frequently malnourished patients is encouraged.34

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