Lung transplant: balance between sparing lungs and administering fluid.

[sleepyrasrn]

Just curious what the concensus is out there with thoracic transplant nurses. I am relatively new to the thoracic specialty (8 mos thoracic, but RN for 5 years with Neuro ICU background prior) and I haven't figured out the balance between tolerating a low MAP and CI versus giving fluid to bolster the index of a lung transplant pt. I know giving fluid potentially sacrifices the health of the new lungs even when it improves numbers.

I have a pt who was transplanted a week ago (relatively healthy young pt in 30's) and got a large pair of lungs...so large that they opened the pt back up for several days to allow the inflammatory process to ease before closing the chest again (after repeat periods of SVT 170's and CI

[ShyViolet]

I have seen both heart and lung transplants kept fairly dry for the most part, with inotropic support for MAP and CI. Our surgeons' drug of choice for this is usually either epi or milrinone or some combination thereof.

[ghillbert, MSN, NP]

My surgeon loves to run his lung tx's DRYYYYYYYYYY. Woe betide the foolish nurse who overloads the patient.

Now, I'm biased because I work mostly with heart failure and mechanical support devices BUT.....

OP, your patient sounds like he has cardiac failure. He needs inotropes +/- mechanical support. If he had a healthy heart, he wouldn't be unable to maintain perfusion with normal filling pressures. How are the lungs? PVR? Perhaps despite NO you have high PAPs and the RV is failing from high afterload and unable to get blood across to the LV. Epi would help there, although it's going to compromise your HR.

You do have to give 'enough' fluid and perhaps your patient needs more. But really I would want to know pulmonary pressures and resistance, as well as echo visualization of the heart so I could tell how much is cardiac and how much is respiratory failure.

In any case, your patient is in extremis. MAPs of 50 and CI 1.6 in new postop, young patient? Very much not good. What happens with a fluid challenge? Does it improve the index? Poor man's method of checking - raise legs and see if your CI improves. If it does, he needs volume. If it doesn't, he needs inotropic support.

In terms of the balance between sparing lungs and fluid - alive and perfused wins over lung condition in my book. No point having lovely lungs and being brain injured or chronically nephropathic.

Please let us know.