Anesthesia in transplantation

What are the challenges of anesthesia to achieve organ transplantation ? 

 

Anesthesiologists in the case of organ transplantation are involved from the preoperative period to the first few days after the operation to assess the patient, perform the anesthesia during surgery and to manage postoperative pain or surgical complications. 

In the preoperative phase, the different aims of the visit are to assess the patient’s major vital functions (mainly cardiac and respiratory), to optimize some patient’s frailties in collaboration with other specialists (management of anemia, of pain, of sarcopenia, and improvement in the capacity for physical effort) and to determine the best strategy of analgesia and anesthesia during surgery. Detailed and personalized information is delivered to the patient according to the aforementioned data and the anesthesiologist determines the best way to manage anxiety in collaboration with the department’s psychologists. We take part in the final multi-disciplinary decision of inscription or not to the waiting list of organs. 

On the day of the transplant, we proceed to a final assessment before welcoming the patient to the operating room. Time of anesthesia starts quickly. In most situations of transplant (lung, kidney, and uterine transplants), general anesthesia is combined with regional anesthesia. General anesthesia consists of : 

  • the induction of a loss of consciousness known as sedation, using drugs to reduce brain activity, 
  • the control and the inhibition of any nociceptive stimulus (unconscious pain mechanisms) using morphine-derived drugs and local anesthetics
  • the complete immobilization of the patient with reversible drugs to ensure maximum comfort for the surgeon 

Anesthesia is adapted all along the procedure according to the information provided by multimodal monitoring, especially monitoring of the depth of sedation or monitoring of the organ perfusion. At the end of the procedure, if the major vital functions are controlled and if the surgery is uneventful, we stop the administration of anesthetics to clear them. Therefore, the patient wakes up spontaneously and comfortably. Regional anesthesia consists of the transient interruption of the nerve transmission through the administration of a local anesthetic in contact with the nerve. The concentration of local anesthetic in contact with the nerve and the characteristics of the nerve (large or small, myelinated or not) will result in the absence of pain, fine sensitivity, or motor skills. The other actions during surgey includes tha optimization of ventilatory settings, transfusion, administration of immunosuppresive drugs and close monitoring of the cardiac function and of the coagulation. 

In the early postoperative period, the anesthesiologists’ missions focus on pain management and on the assessment of the function of the new organ. Pain management remains an essential part of the activity. We monitor the patient’s progress daily, adapting our therapeutic strategy with medication. Moreover, local anesthesia, and some complementary techniques such as TENS (transelectrical nerve stimulation), hypnosis, and auriculotherapy can be prescribed to improve the patients’ experience and to avoid chronic postoperative pain. 

Dr Morgan Le Guen

Morgan Le Guen M.D. PhD. Is the Professor and Chair of Department since 2021, following Pr. Marc Fischler who gave a strong impulsion towards research in anesthesia for organs transplantation. His main expertise is about diaphragm and bronchial function in different conditions (senescence, diabetes, deafferentation). The experimental area is now devoted to the study of negative pressure ventilation on the lung and crossed circulation on the lung preservation. The holistic approach of anesthesia in such a major surgery remains a cornerstone in daily clinical practice. 

Publications about organ transplantation

  1. Fessler J. & al. Anesthetic considerations for perioperative ECMO in lung transplantation, Best Practice & Research Clinical Anaesthesiology, Volume 38, Issue 1, 2024, Pages 58–63, ISSN 1521–6896, https://doi.org/10.1016/j.bpa.2024.03.002
  2. Messika J. & Investigators from the ECMOToP Study group (2024). Protocol for venoarterial ExtraCorporeal Membrane Oxygenation to reduce morbidity and mortality following bilateral lung TransPlantation : the ECMOToP randomised controlled trial. BMJ open, 14(3), e077770. PMID : 38448059
  3. Bottiger B. & al. (2024). Examining Bleeding Risk, Transfusion-related Complications, and Strategies to Reduce Transfusions in Lung Transplantation. Anesthesiology, 10.1097/ALN.0000000000004829 PMID : 38345894
  4. Fessler J. & al. (2024). Bleeding risks in preoperative plasmapheresis. The Journal of heart and lung transplantation, S1053-2498(24)00011–1. PMID : 38220123
  5. Pascreau T. & al. 2024). Interest in the new thromboelastometry device, Clot Pro®, for predicting thrombocytopenia and hypofibrinogenemia during lung transplantation. Thrombosis research, 233, 203–211 PMID : 38128338
  6. De Wolf J. & al. Prolonged dialysis during ex vivo lung perfusion promotes inflammatory responses. Front Immunol. 2024 Mar 22;15:1365964. PMID : 38585271 ;
  7. Gouin C. & al. Cell type- and time-dependent biological responses in ex vivo perfused lung grafts. Front Immunol. 2023 Jul 3;14:1142228. PMID : 37465668 ;
  8. Martin AK. & al. How We Would Treat Our Own Lung Transplantation : A Multidisciplinary and International Perspective. Journal of Cardiothoracic and Vascular Anesthesia. PMID : 37635039
  9. Fessler J. & al. From a good idea to the best practice ! Journal of Heart and Lung Transplantation, (2023) S1053-2498(23)01958–7 PMID : 37532085
  10. Glorion M. & al. Results of Lung Transplantation for Cystic Fibrosis With Selected Donors Over 65 Years Old. Transpl Int. 2023 Jun 12;36:11180. PMID : 37404718
  11. Glorion M. & al. A cross-circulatory platform for monitoring innate allo-responses in lung grafts. PLoS One. 2023 May 30;18(5):e0285724. PMID : 37253049 ;
  12. Fessler J. & al. Perioperative Outcomes During Double-Lung Transplantation and Retransplantation in Cystic Fibrosis Patients : A Monocentric Cohort Study. J Cardiothorac Vasc Anesth. 2023 Feb 23 : S1053-0770 (23) 00114–3. PMID : 36964081
  13. Michel-Cherqui M. & al. Complementary Therapy Learning in the Setting of Lung Transplantation : A Single-Center Observational Study of Appropriation and Efficacy. Journal of Clinical Medicine. 2023 ; 12(5):1722. PMID : 36902509
  14. Roux A. & al. First use of imlifidase desensitization in a highly sensitized lung transplant candidate : a case report. Am J Transplant. 2023 Feb;23(2):294–297. PMID : 36695676
  15. Le Pavec J. & al. 2022 Update of indications and contraindications for lung transplantation in France. Respir Med Res. 2023 Jun;83:100981. PMID : 36565563
  16. Fessler J. & al. New Aspects of Lung Transplantation : A Narrative Overview Covering Important Aspects of Perioperative Management Life (Basel). 2022 Dec 28;13(1):92. PMID : 36676041
  17. Michel-Cherqui M. & al. Feasibility and Usefulness of Self-Hypnosis in Patients Undergoing Double-Lung Transplantation During the Pre- and Postoperative Periods : A Randomized Study. J Cardiothorac Vasc Anesth . 2022 Aug;36(8 Pt A):2490–2499. PMID : 35181234
  18. Fessler J. & al. Blood lactate during double-lung transplantation : a predictor of grade‑3 primary graft dysfunction. J Cardiothorac Vasc Anesth. 2021 Nov 3;S1053-0770 (21) 00962–9. PMID : 34879926
  19. Marchiset A. & Foch Lung Transplant Group. High-Emergency Lung Transplantation for Interstitial Lung Disease Associated With Anti-MDA5 Dermatomyositis : A Case Report. Transplant Proc. 2021 Oct;53(8):2613–2615. PMID : 34511249.
  20. Laurent Q. & al. Prevalence, Characteristics and Preoperative Predictors of Chronic Pain After Double Lung Transplantation : A Prospective Cohort Study. J Cardiothorac Vasc Anesth. 2021 Jul 30;S1053-0770 (21) 00622–4. PMID : 34479783
  21. De Wolf J & al. Challenging the Ex Vivo Lung Perfusion Procedure With Continuous Dialysis in a Pig Model. Transplantation. 2022 May 1;106(5):979–987. PMID : 34468431
  22. Parquin F. & al. A virtual crossmatch-based strategy for perioperative desensitisation in lung transplant recipients with performed donor-specific antibodies : 3‑year outcome. Eur Respir J. 2021 May 20:2004090. PMID : 34016620
  23. Fessler J. & al. Operating Room Extubation : A Predictive Factor For One-Year Survival After Double-Lung Transplantation. The Journal of Heart and Lung Transplantation. 2021 Feb 6 ; May;40 (5): 334–342. PMID : 33632637
  24. Fessler J. & al. Is Extracorporeal Membrane Oxygenation Withdrawal a Safe Option After Double-Lung Transplantation ? Ann Thorac Surg. 2020 Oct;110 (4): 1167–1174. PMID : 32380057
  25. Fessler J. & al. Intraoperative Implications of the Recipients’ Disease for Double-Lung Transplantation. J Cardiothorac Vasc Anesth. 2020 Jul 17:S1053-0770 (20) 30710–2. PMID : 32741611
  26. Carbonnel M & al. Uterus Transplantation with Live Donors : Screening Candidates in One French Center. J Clin Med. 2020 Jun 25;9(6):2001. PMID : 32630524 ;
  27. Parquin F & FOCH Lung Transplant group. C1-esterase inhibitor treatment for antibody-mediated rejection after lung transplantation : two case reports. Eur Respir J. 2020 Apr 16;55(4):1902027. PMID : 32079639.
  28. Fessler J. & al. Inhaled nitric oxide dependency at the end of double-lung transplantation : A boosted propensity score cohort analysis. Transpl Int. 2019 Mar ; 32 (3): 244–256. PMID : 30449027
  29. Fessler J. & al. Prognostic value of the PaO2/FiO2 ratio determined at the end-surgery stage of a double-lung transplantation. Clin Transplant. 2019 Jan 22 ; e 13484. PMID : 30667566
  30. Trebbia G & Foch Lung Transplant Group. Assessment of lung edema during ex-vivo lung perfusion by single transpulmonary thermodilution : A preliminary study in humans. J Heart Lung Transplant. 2019 Jan;38(1):83–91. PMID : 30391201.
  31. Assenzo V & al. The feasibility of extubation in the operating room after bilateral lung transplantation in adult emphysema patients : an observational retrospective study. Eur J Cardiothorac Surg. 2018 Dec 1;54(6):1128–1133. PMID : 29800126.
  32. Roux A & al. Donor-specific HLA antibody-mediated complement activation is a significant indicator of antibody-mediated rejection and poor long-term graft outcome during lung transplantation : a single center cohort study. Transpl Int. 2018 Jul;31(7):761–772. PMID : 29537702
  33. Roux A & al. Characteristics of Donor-Specific Antibodies Associated With Antibody-Mediated Rejection in Lung Transplantation. Front Med (Lausanne). 2017 Oct 11;4:155. PMID : 29075627
  34. Kupersztych-Hagege E & al. Epidural Hematoma and Abscess Related to Thoracic Epidural Analgesia : A Single-Center Study of 2,907 Patients Who Underwent Lung Surgery. J Cardiothorac Vasc Anesth. 2017 Apr;31(2):446–452 PMID : 27720493
  35. De Wolf J & al. Logistic ex Vivo Lung Perfusion for Hyperimmunized Patients. Ann Thorac Surg. 2016 Sep;102(3):e205-e206. PMID : 27549543
  36. Restoux A & al. Pilot study of closed-loop anaesthesia for liver transplantation. Br J Anaesth. 2016 Sep;117(3):332–40. PMID : 27543528.
  37. Roux A & FOCH Lung Transplant Group. High Emergency Lung Transplantation : dramatic decrease of waiting list death rate without relevant higher post-transplant mortality. Transpl Int. 2015 Sep;28(9):1092–101. PMID : 25959679.
  38. Michel-Cherqui M. & al. Prevalence and characteristics of pain in patients awaiting lung transplantation. J Pain Symptom Manage. 2015 Mar;49(3):548–54. PMID : 25150816.
  39. Sage E. & Foch Lung Transplant Group. Lung transplantation from initially rejected donors after ex vivo lung reconditioning : the French experience. Eur J Cardiothorac Surg. 2014 Nov;46(5):794–9. PMID : 25061219.
  40. Pons A & al. An unidentified endobronchial object in a newly transplanted lung. A A Case Rep. 2014 Aug 15;3(4):43–4. PMID : 25611220.
  41. Mitilian D. & Foch Lung Transplant Group. Techniques and results of lobar lung transplantations. Eur J Cardiothorac Surg. 2014 Feb;45(2):365–9 ; discussion 369–70. PMID : 23900745.
  42. Felten ML. & al. nsplantation. Interact Cardiovasc Thorac Surg. 2013 Jun;16(6):929–31. PMID : 23439442
  43. Le Guen M & al. Intraoperative cerebral air embolism during lung transplantation : treatment with early hyperbaric oxygen therapy. J Cardiothorac Vasc Anesth. 2012 Dec;26(6):1077–9. PMID : 21924628
  44. Felten ML. & al. Transesophageal and contact ultrasound echographic assessments of pulmonary vessels in bilateral lung transplantation. Ann Thorac Surg. 2012 Apr;93(4):1094–100. PMID : 22387146.
  45. Felten ML. & al. Factors associated with early graft dysfunction in cystic fibrosis patients receiving primary bilateral lung transplantation. Eur J Cardiothorac Surg. 2012 Mar;41(3):686–90. PMID : 22345188.
  46. Michel-Cherqui M. & al. Management of takotsubo cardiomyopathy in a lung transplant recipient. Transplantation. 2010 Sep 27;90(6):692–4. PMID : 20847635.
  47. Liu N & Foch Lung Transplant Group. Closed-loop control of consciousness during lung transplantation : an observational study. J Cardiothorac Vasc Anesth. 2008 Aug;22(4):611–5. PMID : 18662642.
  48. Dalibon N. & al. Use of cardiopulmonary bypass for lung transplantation : a 10-year experience. J Cardiothorac Vasc Anesth. 2006 Oct;20(5):668–72. PMID : 17023286.

Works in progress

  1. NCT05798286 Quantra® System With the QPlus® Cartridge in Double-lung Transplantation
  2. NCT04165161 Performance Diagnosis of a Patent Foramen Ovale During Lung Transplantation Using Transesophageal Echocardiography

Grants

  • Search for a predictive survival score for lung transplant patients based on pre- and intraoperative data and specificities of cystic fibrosis patients
  • Association Vaincre la Mucoviscidose [RC20190502424]
  • Does bedside ultrasound clot elasticity measurement reduce intraoperative transfusion during double-lung transplantation ? NCT : 2021-A00842-39
  • Association chirurgicale pour le développement et l’amélioration des techniques de dépistage et de traitement des maladies cardio-vasculaires
  • Association Recherche Transfusion

Conflict of interest

  • None
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