DK2985_C000 1..28 - AlSharqia Echo Club

Lung Transplantation 487(A)EKG 121Pa 103/62[78]Ppa 29/19[23]CO2 26Sat 99Resp 370(B)EKG 121Pa 103/61[77]Paop [13]CO2 25Sat 99Resp 370(C)(D)LVESCOFigure 21.9 Hemodynamic instability following single lung transplantation in a 53-year-old woman with end-stage emphysema.(A, B) Invasive hemodynamic monitoring shows a heart rate of 121 beats/min, an arterial blood pressure (Pa) of 103/62 mmHg, a pulmonaryartery pressure (Ppa) of 29/19 mmHg with a pulmonary artery occluded (wedge) pressure (Paop) of 13 mmHg. The centralvenous pressure was 14 mmHg (not shown). The capnographic waveform (CO 2 ) is typical of a single lung transplant with the initialnormal waveform from the transplanted lung followed by the ascending phase III typical of obstructive disease. Respiratory variationof the saturation (Sat) signal from the pulse oximeter is seen. (C, D) Despite relatively normal filling pressures, left ventricular endsystoliccavity obliteration (LVESCO) is found on the transgastric mid-papillary view at 08. The patient improved with intravenousfluid administration (EKG, electrocardiogram; Resp, respiration).postoperatively. We believe that careful tailoring of the vascularstructures on both the recipient and donor side as wellas a meticulous surgical technique with the use of intraoperativeTEE may account for these excellent results.IV.ROLE OF TEE AFTER LUNG TRANSPLANTIN THE INTENSIVE CARE UNITTransesophageal echocardiography also plays an essentialrole in the postoperative care of lung transplant recipientsin the ICU. The early post-operative course of thesepatients is frequently characterized by hemodynamic,radiographic and gas exchange abnormalities. Despiteimproved preservation techniques in recent years, severeischemia–reperfusion injury (IRI) is still prevalent in10% of patients following transplantation (Fig. 21.8).This injury is usually associated with abundant frothysputum from the endotracheal tube, a PaO 2 /FiO 2ratio , 100, diffuse alveolar infiltrates on the side of thegraft and hemodynamic instability. The differential diagnosisincludes acute allograft rejection, cardiogenic pulmonaryedema, noncardiogenic pulmonary edema otherthan IRI, sepsis and vascular anastomotic complications.Transesophageal echocardiography in this setting isuseful in excluding the etiologies listed earlier and inconfirming the diagnosis of IRI suggested by the clinicalhistory and the hemodynamic profile obtained from a PAcatheter. More interestingly, continuous TEE monitoringhelps to assess the response to therapy (Fig. 21.9) anddetermine the need for more invasive support such asextra-corporeal membrane oxygenation (ECMO).During ECMO, based on the American Society ofAnesthesiology–Society of Cardiovascular Anesthesiology(ASA–SCA) guidelines (1), TEE is considered a categoryI indication (see Chapter 14). Transesophagealechocardiography can help to evaluate ventricular recovery,assist in cannula positioning and exclude the presenceof intracardiac clot before initiating the weaning processEKG 111Pa 105/60[69]Ppa 45/26 [35]CO 2 28Sat 90Figure 21.10 Hemodynamic instability in a 65-year-old womanfollowing single lung transplantation. Fluctuation of the arterialpressure (Pa) or pulsus paradoxus coincident with the pulseoximetry signal (Sat), followed later by the pulmonary artery(Ppa) signal suggests tamponade. (CO 2 , end-tidal CO 2 ;EKG,electrocardiogram).[With permission of Denault et al. (25).]