Liver transplant - Revision history

Asdoyal at 15:24, 12 November 2024

2024-11-12T15:24:58Z

← Older revision		Revision as of 08:24, 12 November 2024
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	Hypo/hyperglycemia		Hypo/hyperglycemia
	\| considerations_postoperative = Hemorrhage		\| considerations_postoperative = Hemorrhage
	}}A '''liver transplant''' is performed in adult or pediatric patients with end-stage liver disease.		}}A '''liver transplant''' is performed in adult or pediatric patients with end-stage liver disease (ESLD).

	For living donor hepatic resection, see [https://wikianesthesia.org/wiki/Hepatic_resection#Hepatectomy_for_living_donor_liver_transplant Hepatectomy for living donor liver transplant]		For living donor hepatic resection, see [https://wikianesthesia.org/wiki/Hepatic_resection#Hepatectomy_for_living_donor_liver_transplant Hepatectomy for living donor liver transplant]

			Liver transplantation at its core, this surgery is a "big-belly" case that requires management of severe physiologic derangements (such large fluid/volume changes, temperature changes, coagulopathy, cardiovascular issues, and pulmonary issues), and the secondary effects of ESLD (such as portal HTN, portopulmonary HTN, hepatopulmonary syndrome, hepatorenal syndrome, cirrhotic cardiomyopathy, coagulopathies, electrolyte disturbances ascites, varices, and encephalopathy). The key portions of the transplant surgery include the 1. hepatic dissection/resection, 2. major vascular/IVC clamping, 3. portal vein and IVC unclamping/liver reperfusion, and 4. hepatic artery & bile duct reconstruction.

	==Overview==		==Overview==
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	Liver transplantation is a complex surgical procedure that can be separated into three distinct phases <ref>{{Cite web\|title=Anesthesiologist's Manual of Surgical Procedures\|url=https://www.wolterskluwer.com/en/solutions/ovid/anesthesiologists-manual-of-surgical-procedures-5433\|access-date=2021-11-22\|website=www.wolterskluwer.com\|language=en}}</ref><ref>{{Cite journal\|last=Brezeanu\|first=Lavinia Nicoleta\|last2=Brezeanu\|first2=Radu Constantin\|last3=Diculescu\|first3=Mircea\|last4=Droc\|first4=Gabriela\|date=2020-05-06\|title=Anaesthesia for Liver Transplantation: An Update\|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216023/\|journal=The Journal of Critical Care Medicine\|volume=6\|issue=2\|pages=91–100\|doi=10.2478/jccm-2020-0011\|issn=2393-1809\|pmc=7216023\|pmid=32426515}}</ref>:		Liver transplantation is a complex surgical procedure that can be separated into three distinct phases <ref>{{Cite web\|title=Anesthesiologist's Manual of Surgical Procedures\|url=https://www.wolterskluwer.com/en/solutions/ovid/anesthesiologists-manual-of-surgical-procedures-5433\|access-date=2021-11-22\|website=www.wolterskluwer.com\|language=en}}</ref><ref>{{Cite journal\|last=Brezeanu\|first=Lavinia Nicoleta\|last2=Brezeanu\|first2=Radu Constantin\|last3=Diculescu\|first3=Mircea\|last4=Droc\|first4=Gabriela\|date=2020-05-06\|title=Anaesthesia for Liver Transplantation: An Update\|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216023/\|journal=The Journal of Critical Care Medicine\|volume=6\|issue=2\|pages=91–100\|doi=10.2478/jccm-2020-0011\|issn=2393-1809\|pmc=7216023\|pmid=32426515}}</ref>:

	#Dissection (hepatectomy) phase		#'''Dissection (hepatectomy, pre-anhepatic) phase'''
	#*This encompasses everything from skin incision to clamping of the IVC, portal vein, and hepatic artery.		#*This encompasses everything from skin incision to clamping of the IVC, portal vein, and hepatic artery.
	#*The predominant portion of this case involves dissection of the recipient's native liver.		#*The predominant portion of this case involves dissection of the recipient's native liver.
	#*Blood loss during this phase of the surgery is significant and may be worse in patients with severe portal hypertension, coagulopathy, previous abdominal operations, recent recurrent or severe peritonitis, or history of upper abdominal radiation therapy.		#*Blood loss during this phase of the surgery is significant and may be worse in patients with severe portal hypertension, coagulopathy, previous abdominal operations, recent recurrent or severe peritonitis, or history of upper abdominal radiation therapy.
	#*Mobilization of the liver during dissection may partially or completely occlude the IVC causing a drop in blood pressure		#*Mobilization of the liver during dissection may partially or completely occlude the IVC causing a drop in blood pressure
	#Anhepatic phase		#'''Anhepatic phase'''
	#*This encompasses the time from clamping of hepatic venous inflow until the graft is portal venous reperfusion.		#*This encompasses the time from clamping of hepatic venous inflow until the graft is portal venous reperfusion.
	#*During this stage of the operation, the donor liver is implanted into the recipient.		#*During this stage of the operation, the donor liver is implanted into the recipient.
	#*The IVC may be completely or partially clamped during this phase of the operation, limiting venous return to the right atrium.		#*The IVC may be completely or partially clamped during this phase of the operation, limiting venous return to the right atrium.
	#*Hemodynamically unstable patients may benefit from ~~veno~~-veno bypass.		#*Hemodynamically unstable patients may benefit from
	#**Involves placement of cannulas in the femoral and portal veins that empty into the axillary or jugular vein, which maintains venous return.		#**Veno-veno bypass.
	#Post-revascularization (neo-hepatic) phase		#***Involves placement of cannulas in the femoral and portal veins that empty into the axillary or jugular vein, which maintains venous return.
			#**Surgical "piggyback" technique
			#***The recipient's IVC is preserved and the donor's IVC is anastomosed with the recipient's hepatic veins.
			#'''Post-revascularization (neo-hepatic) phase'''
	#*This phase begins with removal of the vascular clamps.		#*This phase begins with removal of the vascular clamps.
	#*Reperfusion of the liver may result in a temporarily hyperkalemia from liver cell lysis, and preservative solution.		#*Reperfusion of the liver may result in a temporarily hyperkalemia from liver cell lysis, and preservative solution.
	#*Massive air embolism is also a major immediate concern during reperfusion.		#*Massive air embolism is also a major immediate concern during reperfusion.
	#*This stage may rarely be complicated by severe ~~pHTN~~ resulting in right heart failure and low systemic pressures.		#*This stage may rarely be complicated by severe pulmonary HTN resulting in right heart failure and low systemic pressures.
	#*Reperfusion also frequently results in systemic hypotension likely from kinins, and cytokines from the liver allograft.		#*Reperfusion also frequently results in systemic hypotension likely from kinins, and cytokines from the liver allograft.
	#*Prior to reperfusion patients are given 250-1000mg of methylprednisolone or hydrocortisone that acts as an immunosuppressant and helps to blunt the effects of ischemia-reperfusion injury of the liver.		#*Prior to reperfusion patients are given 250-1000mg of methylprednisolone or hydrocortisone that acts as an immunosuppressant and helps to blunt the effects of ischemia-reperfusion injury of the liver.
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	* Full workup prior to transplant.		* Full workup prior to transplant.
	* CBC		** CBC
	* CMP		** CMP
	* Coagulation panel		**Coagulation panel
	* CXR		** CXR
	* EKG		** EKG
	* Cardiac evaluation possibly including stress test or TTE		** Cardiac evaluation possibly including stress test or TTE
			**Thromboelastogram/viscoelastogram (TEG, ROTEM, Hemosonics Quantra)

	===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===		===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===
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	*Alaris brain with multiple channels -- Possible infusions include: Vasopressin, Epinephrine, Norepinephrine, Insulin, Carrier fluid, Antibiotics, Calcium Chloride		*Alaris brain with multiple channels -- Possible infusions include: Vasopressin, Epinephrine, Norepinephrine, Insulin, Carrier fluid, Antibiotics, Calcium Chloride
	*Belmont or Level 1 Rapid Infuser for aggressive resuscitation		*Belmont or Level 1 Rapid Infuser for aggressive resuscitation
			*RBC salvage machine, Cellsaver

	===Patient preparation and premedication<!-- Generally sedative premedication is avoided due to patient susceptibility to exacerbation of underlying hepatic encephalopathy -->===		===Patient preparation and premedication<!-- Generally sedative premedication is avoided due to patient susceptibility to exacerbation of underlying hepatic encephalopathy -->===

Tony.Wang at 00:42, 20 August 2024

2024-08-20T00:42:05Z

← Older revision		Revision as of 17:42, 19 August 2024
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	Liver transplantation is a complex surgical procedure that can be separated into three distinct phases <ref>{{Cite web\|title=Anesthesiologist's Manual of Surgical Procedures\|url=https://www.wolterskluwer.com/en/solutions/ovid/anesthesiologists-manual-of-surgical-procedures-5433\|access-date=2021-11-22\|website=www.wolterskluwer.com\|language=en}}</ref><ref>{{Cite journal\|last=Brezeanu\|first=Lavinia Nicoleta\|last2=Brezeanu\|first2=Radu Constantin\|last3=Diculescu\|first3=Mircea\|last4=Droc\|first4=Gabriela\|date=2020-05-06\|title=Anaesthesia for Liver Transplantation: An Update\|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216023/\|journal=The Journal of Critical Care Medicine\|volume=6\|issue=2\|pages=91–100\|doi=10.2478/jccm-2020-0011\|issn=2393-1809\|pmc=7216023\|pmid=32426515}}</ref>:		Liver transplantation is a complex surgical procedure that can be separated into three distinct phases <ref>{{Cite web\|title=Anesthesiologist's Manual of Surgical Procedures\|url=https://www.wolterskluwer.com/en/solutions/ovid/anesthesiologists-manual-of-surgical-procedures-5433\|access-date=2021-11-22\|website=www.wolterskluwer.com\|language=en}}</ref><ref>{{Cite journal\|last=Brezeanu\|first=Lavinia Nicoleta\|last2=Brezeanu\|first2=Radu Constantin\|last3=Diculescu\|first3=Mircea\|last4=Droc\|first4=Gabriela\|date=2020-05-06\|title=Anaesthesia for Liver Transplantation: An Update\|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216023/\|journal=The Journal of Critical Care Medicine\|volume=6\|issue=2\|pages=91–100\|doi=10.2478/jccm-2020-0011\|issn=2393-1809\|pmc=7216023\|pmid=32426515}}</ref>:

	#~~Disection~~ (hepatectomy) phase		#Dissection (hepatectomy) phase
	#*This encompasses everything from skin incision to clamping of the IVC, portal vein, and hepatic artery.		#*This encompasses everything from skin incision to clamping of the IVC, portal vein, and hepatic artery.
	#*The predominant portion of this case involves dissection of the recipient's native liver.		#*The predominant portion of this case involves dissection of the recipient's native liver.

Chris.Rishel at 05:28, 15 January 2024

2024-01-15T05:28:20Z

← Older revision		Revision as of 22:28, 14 January 2024
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	#*During this stage of the operation, the donor liver is implanted into the recipient.		#*During this stage of the operation, the donor liver is implanted into the recipient.
	#*The IVC may be completely or partially clamped during this phase of the operation, limiting venous return to the right atrium.		#*The IVC may be completely or partially clamped during this phase of the operation, limiting venous return to the right atrium.
	#*Hemodynamically unstable patients may benefit from ~~venovenous~~ bypass.		#*Hemodynamically unstable patients may benefit from veno-veno bypass.
	#**Involves placement of cannulas in the femoral and portal veins that empty into the axillary or jugular vein, which maintains venous return.		#**Involves placement of cannulas in the femoral and portal veins that empty into the axillary or jugular vein, which maintains venous return.
	#Post-revascularization (neo-hepatic) phase		#Post-revascularization (neo-hepatic) phase

Chris.Rishel at 05:27, 15 January 2024

2024-01-15T05:27:05Z

← Older revision		Revision as of 22:27, 14 January 2024
Line 26:		Line 26:
	Hypo/hyperglycemia		Hypo/hyperglycemia
	\| considerations_postoperative = Hemorrhage		\| considerations_postoperative = Hemorrhage
	}}A '''liver transplant''' is performed in patients with end-stage liver disease.		}}A '''liver transplant''' is performed in adult or pediatric patients with end-stage liver disease.

	For living donor hepatic resection, see [https://wikianesthesia.org/wiki/Hepatic_resection#Hepatectomy_for_living_donor_liver_transplant Hepatectomy for living donor liver transplant]		For living donor hepatic resection, see [https://wikianesthesia.org/wiki/Hepatic_resection#Hepatectomy_for_living_donor_liver_transplant Hepatectomy for living donor liver transplant]

Tony.Wang at 14:52, 24 May 2023

2023-05-24T14:52:47Z

← Older revision		Revision as of 07:52, 24 May 2023
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	* Mental status may be further depressed by coexisting metabolic derangements, including hyponatremia and hypoglycemia.		* Mental status may be further depressed by coexisting metabolic derangements, including hyponatremia and hypoglycemia.
	* Limited hepatic clearance of various toxins, such as ammonia, can lead to alterations in endogenous neurotransmitters and neuro-signaling pathways, largely involving y-aminobutyric acid (GABA), glutamate and nitric oxide.		* Limited hepatic clearance of various toxins, such as ammonia, can lead to alterations in endogenous neurotransmitters and neuro-signaling pathways, largely involving y-aminobutyric acid (GABA), glutamate and nitric oxide.
			*Reperfusion is typically most complicated step, as old ischemic liver blood rushes into the new patient's bloodstream, causing hypotension, bradycardia, RV stunning. Treating with baby epinephrine pushes is common (10 mcg/mL syringe, several cc's at a time).

	===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===		===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===

Tony.Wang at 15:38, 26 January 2023

2023-01-26T15:38:59Z

← Older revision		Revision as of 08:38, 26 January 2023
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	\| considerations_postoperative = Hemorrhage		\| considerations_postoperative = Hemorrhage
	}}A '''liver transplant''' is performed in patients with end-stage liver disease.		}}A '''liver transplant''' is performed in patients with end-stage liver disease.

			For living donor hepatic resection, see [https://wikianesthesia.org/wiki/Hepatic_resection#Hepatectomy_for_living_donor_liver_transplant Hepatectomy for living donor liver transplant]

	==Overview==		==Overview==

SLindberg: multiple minor edits, and a couple of sections

2022-08-07T21:56:19Z

multiple minor edits, and a couple of sections

Show changes

Eeshwar.Chandrasekar at 02:40, 18 July 2022

2022-07-18T02:40:37Z

← Older revision		Revision as of 19:40, 17 July 2022
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	CVP		CVP
	EEG		EEG
			TEE
	\| considerations_preoperative = Encepholapthy		\| considerations_preoperative = Encepholapthy
	Multi-organ system derangements		Multi-organ system derangements
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	===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===		===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===

			*Alaris brain with multiple channels -- Possible infusions include: Epinephrine, Norepinephrine, Insulin, Carrier fluid, Antibiotics, Calcium Chloride
			*Belmont or Level 1 Rapid Infuser for aggressive resuscitation

	===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===		===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===

Chris.Rishel: Text replacement - "Art line" to "Arterial line"

2022-04-05T19:40:17Z

Text replacement - "Art line" to "Arterial line"

← Older revision		Revision as of 12:40, 5 April 2022
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	\| airway = ETT		\| airway = ETT
	\| lines_access = Large bore IVs		\| lines_access = Large bore IVs
	~~Art~~ line		Arterial line
	Central line		Central line
	Introducer		Introducer

Chris.Rishel at 07:03, 5 April 2022

2022-04-05T07:03:39Z

← Older revision		Revision as of 00:03, 5 April 2022
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	<references />		<references />
			[[Category:General surgery]]
			[[Category:Hepatic surgery]]
			[[Category:Transplant surgery]]