title: Combined lung and liver transplantation in a girl with cystic fibrosis.
abstract: OBJECTIVE
  To describe the anesthetic considerations of a combined lung and liver transplant in a 14-yr-old girl with cystic fibrosis.
  
  
  METHODS
  A 14 yr-old girl with cystic fibrosis presented for combined liver and lung transplantation. Anesthetic management was complex in that the pulmonary, hemodynamic, and hematological changes after cardiopulmonary bypass and lung transplantation made the management of the subsequent liver transplant unique. We used a moderate dose fentanyl and isoflurane anesthetic with invasive monitoring including a pulmonary artery catheter. Upon reperfusion of the new liver our patient exhibited severe pulmonary hypertension that was associated with a decrease in cardiac output and systemic hypotension. Utilizing a pulmonary artery catheter, this episode was treated with an increase of prostaglandin E1 (PGE1) infusion to 0.025 microg x kg(-1) x min(-1) and the initiation of 3 microg x kg(-1) x min(-1) dobutamine. The pulmonary hypertension resolved and the cardiac output and blood pressure returned to baseline levels.
  
  
  CONCLUSIONS
  The anesthetic considerations for a combined lung and liver transplant are complex because of the interactions and alterations in cardiovascular, pulmonary and hemostatic systems. The use of a pulmonary artery catheter was critical to the management of our patient because it allowed us to accurately treat an episode of hypotension occurring during liver transplantation. This episode was secondary to acute pulmonary hypertension which is common after pulmonary transplantation but unusual during liver transplantation. It is also critical that a team approach is used to consider all of the concerns of the multiple services managing these complex patients.
authors.affiliation: Department of Anesthesiology, Washington University School of Medicine and St. Louis Children's Hospital, Missouri, USA. azimme@chmc.org
authors.forename: A A
authors.initials: AA
authors.lastname: Zimmerman
authors.forename: T K
authors.initials: TK
authors.lastname: Howard
authors.forename: C B
authors.initials: CB
authors.lastname: Huddleston
mesh_terms: D000293:Adolescent; D000527:Alprostadil / Q000627:therapeutic use; D000768:Anesthesia, General / Q000379:methods; D018685:Anesthetics, Inhalation / Q000008:administration & dosage; D018686:Anesthetics, Intravenous / Q000008:administration & dosage; D002303:Cardiac Output, Low / Q000188:drug therapy / Q000209:etiology; D002315:Cardiopulmonary Bypass; D002316:Cardiotonic Agents / Q000627:therapeutic use; D002407:Catheterization, Swan-Ganz; D003550:Cystic Fibrosis / Q000601:surgery*; D004280:Dobutamine / Q000627:therapeutic use; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage; D006488:Hemostasis, Surgical; D006801:Humans; D006976:Hypertension, Pulmonary / Q000188:drug therapy / Q000209:etiology; D007022:Hypotension / Q000188:drug therapy / Q000209:etiology; D007431:Intraoperative Complications / Q000188:drug therapy; D007530:Isoflurane / Q000008:administration & dosage; D016031:Liver Transplantation / Q000379:methods / Q000502:physiology; D016040:Lung Transplantation / Q000379:methods / Q000502:physiology; D016343:Monitoring, Intraoperative; D010348:Patient Care Team; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D018685:Anesthetics, Inhalation; D018686:Anesthetics, Intravenous; D002316:Cardiotonic Agents; D014665:Vasodilator Agents; D004280:Dobutamine; D007530:Isoflurane; D000527:Alprostadil; D005283:Fentanyl