In lung transplant candidates with severe hypoxemia, pulmonary hypertension, or right ventricular (RV) dysfunction, induction of anesthesia poses significant risk. In extreme cases, pre-induction central lines or ECMO cannulation can offer additional cardiopulmonary support. Induction strategies should maintain RV perfusion, avoid hypoxia, hypercapnia, and acidosis, and tailor ventilation to underlying physiology. The anesthesiologist must always be prepared for cardiac arrest on induction, which requires rapid correction of physiological derangements, tailored ACLS, and early extracorporeal support.