Postoperative Management of Lung Transplant Recipients in the Intensive Care Unit

Matteo Di Nardo, M.D.; Jussi Tikkanen, M.D.; Shahid Husain, M.D.; Lianne G. Singer, M.D.; Marcelo Cypel, M.D.; Niall D. Ferguson, M.D.; Shaf Keshavjee, M.D.; Lorenzo Del Sorbo, M.D.


Anesthesiology. 2022;136(3):482-499. 

In This Article

Abstract and Introduction


The number of lung transplantations is progressively increasing worldwide, providing new challenges to interprofessional teams and the intensive care units. The outcome of lung transplantation recipients is critically affected by a complex interplay of particular pathophysiologic conditions and risk factors, knowledge of which is fundamental to appropriately manage these patients during the early postoperative course. As high-grade evidence-based guidelines are not available, the authors aimed to provide an updated review of the postoperative management of lung transplantation recipients in the intensive care unit, which addresses six main areas: (1) management of mechanical ventilation, (2) fluid and hemodynamic management, (3) immunosuppressive therapies, (4) prevention and management of neurologic complications, (5) antimicrobial therapy, and (6) management of nutritional support and abdominal complications. The integrated care provided by a dedicated multidisciplinary team is key to optimize the complex postoperative management of lung transplantation recipients in the intensive care unit.


Lung transplantation is a complex treatment for select patients with a diverse array of end-stage pulmonary diseases. The number of lung transplantations is progressively increasing worldwide, and in the last 5 yr, more than 4,000 were performed annually.[1] Improvements in donor management, organ preservation, recipient selection, antimicrobial prophylaxis, and immunosuppressive medications have resulted in durable and steady improvements in lung transplant outcomes. Survival of lung transplantation recipients, although lower than in other solid organ transplants, is currently at 60% at 5 yr.[2]

The expansion of lung transplantation provides new challenges in the perioperative management of the recipients in the intensive care unit (ICU). First, the number of lung transplantation centers and the number of admissions to the ICU posttransplant is increasing. Second, the increase of older lung transplantation recipients and those with associated comorbidities will undoubtedly increase the perioperative risk.[3] Third, severe primary graft dysfunction still occurs in up to 20 to 30% of the lung transplantation recipients, affecting outcome.[2,4,5] A complex interplay of unique pathophysiologic conditions and risk factors attributable to the characteristics of the donor, the recipient, and the interaction between them (Figure 1) affects the perioperative outcome of the lung transplantation. Thus, knowledge of these specific issues is fundamental to properly care for these patients, especially for those who require prolonged life support.

Figure 1.

Donor, recipient, and donor–recipient interaction—associated risk factors for primary graft dysfunction (adapted from Diamond et al. 4).