Post-double lung transplant, emergent cervical spine surgery, and COVID pandemic: A triple threat to perioperative management

Dear Editor, Recipients of double lung transplants (DLT) have multiple anesthetic considerations for future surgeries. These include, altered physiology (impaired cough and disrupted lymphatics), cor pulmonale, need for aseptic techniques, and multisystem dysfunction due to immunosuppressants.[1] An emergent cervical spine surgery in these patients potentiates further risks due to innate complexities related to positioning, unstable spine, bleeding, and extubation. We present a case of a middle-aged patient who underwent an emergent cervical spine surgery after a recent DLT. To make this more complicated, this case took place during the COVID-19 pandemic further multiplying these risks. A 56-year-old man was admitted for redo cervical spine decompression and fusion (C1-T2) due to progressively worsening cervical myelopathy. His past medical history included scleroderma, chronic kidney disease, thyroid goiter, and chronic pain. His scleroderma caused severely restrictive interstitial lung disease and pulmonary hypertension leading to DLT. A major challenge during this case was induction and intubation. Previous cervical spine fusion limited neck extension, while scleroderma increased aspiration risk. Gentle bronchoscopy while under deep anesthesia was the method of choice to avoid stimulation, to avoid exacerbation of pulmonary hypertension. This was made more difficult by tracheal deviation cause by his large goiter. We were further burdened by COVID-19 precautions. Double gloves made manipulation difficult, while face shields produced glare and obscured views of the screen. A second major challenge was preparing for any disruption in hemodynamic status and blood loss. His history of pulmonary hypertension made this a priority. Extensive bone manipulation often leads to severe bleeding, especially in redo spinal surgeries with hardware. Point-of-care tests, and diligent monitoring assessed need for transfusion to maintain spinal perfusion. In contrast, adequate depth using a total intravenous anesthetic was necessary to avoid sympathetic stimulation. This was vital as neuromonitoring prevented the use of volatile anesthetics and muscle relaxation. We thought this case was important to highlight, as there is a paucity of such cases in the literature. We conducted a literature search to identify case reports of lung transplant recipients undergoing spinal surgery and found only three articles of high relevance [Table 1].[234] This article outlines the risks of patients such as ours, and we hope that further documenting our care can lead to a better understanding of such challenges.Table 1: Summary of literature searchDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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