Postoperative Management

Because reperfusion of the transplanted lungs rapidly leads to pulmonary edema, perioperative fluid restriction is essential. Following lung implantation but prior to cessation of cardiopulmonary bypass, the bypass circuit should be utilized to remove as much fluid as possible via ultrafiltration. Postoperatively, administration of intravenous fluids must be minimized and the patient should be aggressively diuresed with furosemide. If intravascular volume is needed, colloid rather than crystalloid should be administered. Such diuresis typically leads to a contraction alkalosis, and a base excess of 8-10 is acceptable.

To control the mechanics of ventilation and to optimize efforts to eliminate pulmonary edema, it is advisable to keep the child pharmacologically paralyzed, sedated and mechanically ventilated for 24-48 hours postoperatively. The F1O2 should be weaned to achieve a paO2 of at least 70 mm Hg. Prior to extubation, fiberoptic bronchoscopy should be performed to suction retained secretions.

Prophylactic antibiotics (vancomycin and aztreonam) should be given for 48 hours, by which time the culture results of the donor's sputum culture should be known. Posttransplant, patients should continue to receive all antibiotics which were being administered preoperatively, especially in patients with cystic fibrosis. Bacteria grown from the donor's sputum may cause an infection in the recipient, no matter how innocuous the organism may seem; the recipient should receive antibiotics which will specifically cover such bacteria. Lung transplant recipients should receive a 6-week course of intravenous ganciclovir as prophylaxis against CMV infection. For most children, an indwelling silastic venous catheter is necessary for blood sampling and intravenous drug administration.

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