Lung transplant process

You can call (352) 265-8940 to make a referral the to lung transplant program at the Shands Transplant Center at the University of Florida. In order to prepare the patient psychologically for the lung transplant, it is important to understand what can be expected. Being informed and prepared for the transplant can improve patient recovery.

Notification | CICU | Immune system | Infection | Complications

Notification
When a lung is identified for a specific patient, the lung transplant coordinator is responsible for notifying:

Patient to arrange a timely arrival at Shands at UF
Admitting office at Shands at UF
Emergency room where the patient will be received
Surgical resident on call
Cardiothoracic anesthesiologists
Cardiothoracic Intensive Care Unit (CICU) for bed availability
Operating room to schedule the procedure
Blood bank

The UF surgical resident on call will perform the admitting history and physical exam. The transplant coordinator on call initiates the preoperative orders. The UF cardiothoracic anesthesiologist performs a preoperative evaluation on the patient. A list of preoperative laboratory and other diagnostic tests is included in the admission orders. All orders and data are reviewed by the transplant surgeon, transplant pulmonologist and cardiothoracic anesthesiologists. The patient is then transported to the OR.

Return to top

Cardiovascular Intensive Care Unit
Recipients of lung allografts go from the OR to the Cardiovascular Intensive Care Unit (CICU). The transplant surgeon, transplant pulmonologist and anesthesiologist coordinate patient care. Ultimate responsibility for all patient management decisions while the patient is in the CICU remains with the surgical transplant staff.

Vital signs are recorded every 15 minutes until the patient is stable, then every hour. A complete hemodynamic profile is obtained on admission to the CICU and every four to six hours as clinically indicated. A chest radiograph is obtained to verify placement of the endotracheal tube following transfer from the OR to the CICU. Routine laboratory tests are performed. The patient is extubated and pulmonary and radial artery catheters are discontinued when clinically indicated.

When CICU care is no longer required, the patient is transferred to the transplant floor. Once the patient is transferred from the CICU, medical management is resumed by the transplant pulmonologist.

Return to top

Immune system
It is important to control the immune system immediately after a transplant. The body may want to reject the new lung and immunosuppressive therapy can help. Our current immunosuppressive strategy for lung transplant recipients is a triple drug regimen. A steroid bolus is given intraoperatively with subsequent tapering of the corticosteriod dose.

In the absence of renal failure, cyclosporine is started in the intensive care unit as a continuous infusion of 1.2 mg per kg per hour, adjusted for serum cyclosporine levels. Patients who may not tolerate cyclosporine (such as those with concomitant renal failure) are induced with equine Antithymocyte Globulin (ATG) rather than cyclosporine. Cyclosporine is instituted when renal function returns. Cyclosporine is adjusted to maintain serum trough levels between 300 to 350 nanograms per deciliter by the Abbot TDX Monoclonal Antibody FPIA (fluorescence polarization immunoassay technique).

Azathioprine is instituted at 2 mg per kg per day intravenously, adjusted for leukopenia. Patients are converted to oral cyclosporine, azathioprine and prednisone upon the return of normal gastrointestinal function. The regimen for pediatric patients is closely calculated on a per kilogram basis.

Rejection episodes are treated with intravenous pulse corticosteroid therapy. Recalcitrant rejection episodes are treated with ATG. When ATG is used, twice weekly flow cytometry for absolute CD3, CD4 and CD8 counts are used for monitoring purposes. Pre-medications (to ameliorate the first dose effects of ATG) routinely given include intravenous steroids, diphenhydramine and acetaminophen.

Return to top

Infection
Prophylaxis is given to prevent postoperative bacterial infections and to prevent opportunistic infections related to immunosuppression. Intravenous clindamycin and ceftazidime are used for the first five to 10 days post-operatively. Patients with cystic fibrosis or bronchiolitis receive an antibacterial regimen based on their preoperative sputum sensitivities.

All patients will receive lifelong prophylactic trimethoprim sulfa-methoxazole (monthly inhaled pentamidine or oral dapson may be substituted in patients allergic to sulfa) to prophylax against Pneumocystis carinii.

Prophylactic antiviral treatment for patients previously exposed to cytomegalovirus (CMV), or those receiving organs from CMV positive donors, are treated with intravenous ganciclovir. Patients seronegative for CMV and receiving CMV seronegative organs, but positive for Herpes simplex, are started on oral acyclovir for the first three months. Active CMV infections are treated with ganciclovir, with the use of CMV immune globulin if clinically indicated. Systemic opportunistic infections are also treated by appropriate reductions in immunosuppression.

Infection control policies at Shands at the University of Florida aim to restrict infection.

The policy indicates:

Recipients of lung transplants stay in private rooms with negative air flow
Direct-care staff must be free of known communicable disease
Visitors with obvious signs of upper respiratory tract infections can't visit
Strict immunocompromised host precautions are observed

Return to top

Complications
Early postoperative complications generally require urgent action. The patient's physical status and biochemical profile are closely monitored during the first 48 to 72 hours to assess for problems.

Reperfusion injury is low lung compliance and radiographically by pulmonary edema. Onset may occur in the first few hours after transplantation and may be accompanied by hypotension. Blood pressure is stabilized by intravenous inotropic and vasopressor agents, if indicated. Diuresis is initiated and maintained until the resolution of hypoxemia or a side effect of the diuresis occurs (systemic hypotension or early elevation in serum creatinine).

If significant hypoxemia persists after diuresis, then a stepwise work-up is performed to further evaluate other possible causes of hypoxemia. A transesophageal echocardiogram is performed to assess for the patency of pulmonary venous and arterial blood flow across the anastomosis. A perfusion scan may also be performed to assess differential pulmonary perfusion.

If a vascular anastomosis problem is identified, surgical reexploration will be performed to correct the problem. If no vascular anastomosis problem is identified, a bronchoscopy and transbronchial biopsy is performed in an effort to evaluate the pulmonary parenchyma for rejection or infection. Acute rejection and infection are treated with intravenous pulse steroids or antibiotics, respectively.

Patients that persist with severe hypoxemia after these therapy attempts and diagnosis are labeled as primary graft failure. This small sub-population will be considered for retransplantation.

Pulmonary vascular complications are usually present with severe and intractable pulmonary edema, hypoxemia or both. Once a vascular anastomosis complication is diagnosed, urgent surgical reexploration is performed to correct strictures or dehiscence.

Dehiscence of bronchial anastomosis is usually secondary to severe bronchial mucosal reperfusion injury or infections. Bronchial dehiscense usually presents as pneumomediastinum, pneumothorax or subcutaneous emphysema. Bronchoscopy and computerized tomography usually establish the diagnosis. Urgent surgical re-exploration is performed during which the leak is identified and pericardial or omental wrap is performed to seal the leak. Antibiotics will be maintained until healing occurs in an attempt to minimize mediastinal infections.

Acute rejection and infection occurs in 80 percent of this population in the first six months after transplantation. It is often difficult to differentiate acute rejection from infection, especially cytomegaloviral pneumonia. Bronchosopy and transbronchial biopsy are useful tools in differentiating between infections and rejection.

Statistics
Success rate and various other statistics regarding the Shands Transplant Center at UF are available from the Scientific Registry of Transplant Recipients at ustransplant.org.

Information
For more information about the Shands Transplant Center Lung Transplant Program, please call (352) 265-8940.

Related Links
CHF Patients

Transplant Navigation

Heart and Lung Transplant

Lung Transplant Navigation

Diseases of the lungs

Pediatric lung transplant

Process

Recovery

Referral

Make an Appointment

To make an appointment or find out more information about transplant services offered at Shands at the University of Florida, please call 352.265.8000 or toll-free 1.800.749.7424

You may also email our Consultation Center (consult@shands.ufl.edu) or use our secure online form.