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pulmonary vasodilators in these circumstances is frequently not very effective. It is important to maintain coronary perfusion pressure in order to preserve the oxygen supply to the right ventricle.

Sudden reductions in oxygen saturation and hypotension can be the result of tension pneumothorax, especially in patients with bullous disease or fibrotic lungs.

After reperfusion, the transplanted lung may dysfunction, or the native lung may not tolerate PEEP or develop air trapping; this situation requires differential lung ventilation. However, if the transplanted lung functions well, the double lumen endotracheal tube is replaced by a single lumen tube at the end of the procedure.

Coagulopathy

Coagulopathy may be induced by cardiopulmonary bypass, although lung transplantation by itself may be associated with activation of the coagulation and fi-brinolytic systems. Thus, double lung transplantation and use of cardiopulmonary bypass is associated with more significant bleeding, and frequently requires platelet administration. Aprotinin, epsilon-aminocaproic acid, tranexamic acid, and DDAVP have all been used in lung transplantation.

Lung Reperfusion

Some degree of pulmonary edema is common in the transplanted lung after reperfusion. Significant edema requires the use of high levels of PEEP, diuresis, and volume restriction. Severe pulmonary edema requires differential lung ventilation, or in the case of double lung transplantation, the use of extracorporeal membrane oxygenation.

Postoperative Analgesia

A thoracic epidural catheter may be placed preoperatively in patients with a very low chance for cardiopulmonary bypass. However, more frequently, the epidural catheter is placed early postoperatively after correction of any persisting coagulopathy.

Selected Readings

1. Haluszka J, Chartrand DA, Grassino AE et al. Intrinsic PEEP and arterial PCO2 in stable patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1990; 141:1194-1197.

2. Quinlan JJ, Buffington CW. Deliberate hypoventilation in a patient with air trapping during lung transplantation. Anesthesiology 1993; 78:1177-1181.

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