Difference between revisions of "Liver transplant"
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}}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, 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 | #*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 | #*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. -->=== | ||
Line 161: | Line 167: | ||
*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 -->=== |
Latest revision as of 07:24, 12 November 2024
Anesthesia type |
General |
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Airway |
ETT |
Lines and access |
Large bore IVs Arterial line Central line Introducer / PAC |
Monitors |
Standard 5-lead ECG Temperature Urine output ABP CVP PAP EEG TEE |
Primary anesthetic considerations | |
Preoperative |
Encepholapthy Multi-organ system derangements |
Intraoperative |
Decreased anesthetic requirement Systemic vasodilation Decreased hepatic metabolism Hemorrhage Thrombocytopenia Coagulopathy Renal insufficiency Hypo/hyperglycemia |
Postoperative |
Hemorrhage |
Article quality | |
Editor rating | |
User likes | 3 |
A liver transplant is performed in adult or pediatric patients with end-stage liver disease (ESLD).
For living donor hepatic resection, see 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
Indications
Liver transplant is indicated in patients with end-stage liver failure. Reasons for liver failure are many and include acute fulminant hepatitis, inborn errors of metabolism, primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis, chronic hepatitis B or C, alpha-1 antitrypsin disease, Wilson's disease, and hepatocellular carcinoma.
Surgical procedure
Liver transplantation is a complex surgical procedure that can be separated into three distinct phases [1][2]:
- Dissection (hepatectomy, pre-anhepatic) phase
- 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.
- 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
- Anhepatic phase
- 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.
- 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.
- 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.
- Veno-veno bypass.
- Post-revascularization (neo-hepatic) phase
- 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.
- Massive air embolism is also a major immediate concern during reperfusion.
- 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.
- 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.
- After initial stabilization, this phase involves hepatic artery and bile duct reconstruction.
- Following hepatic artery reconstruction, MAP should be maintained above 65 mm Hg to prevent hepatic artery thrombosis.
- A feeding G-tube may be placed at the end of the case. An OG or NG tube is typically placed and confirmed prior the end of this phase.
Preoperative management
Patient evaluation
Patient with advanced and decompensated liver disease suffer secondary injury and varying degrees of dysfunction in the majority of vital organs and organ processes. It is essential to thoroughly review laboratory, imaging, additional diagnostics, history, and recent medical course, to best anticipate this dysfunction and optimally manage your patient in the operating theatre. Our preoperative checklist provides a step-wise and systemic approach to preoperative evaluation of these patients.
System | Considerations |
---|---|
Neurologic |
|
Cardiovascular |
|
Pulmonary |
|
Gastrointestinal |
|
Hematologic |
|
Renal |
|
Endocrine |
|
ID |
|
Labs and studies
- Full workup prior to transplant.
- CBC
- CMP
- Coagulation panel
- CXR
- EKG
- Cardiac evaluation possibly including stress test or TTE
- Thromboelastogram/viscoelastogram (TEG, ROTEM, Hemosonics Quantra)
Operating room setup
- 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
- RBC salvage machine, Cellsaver
Patient preparation and premedication
- Generally sedative premedication is avoided due to patient susceptibility to exacerbation of underlying hepatic encephalopathy.
Regional and neuraxial techniques
- Avoided due to coagulopathy.
Intraoperative management[4]
Monitoring and access
- Large bore PIVs
- arterial line (at some institutions it is common to place two arterial lines)
- Central access (often large-bore volume line and an infusion line).
- Common practice can include introducer catheter for volume and a triple lumen catheter for infusions.
- CVP monitoring.
- Intraoperative TEE and/or pulmonary artery catheter are routine in many centers
Induction and airway management
- Increased intra-abdominal pressure and high probability of gastroparesis necessitate rapid sequence induction.
- Induction dose of propofol should be reduced in patients with severe liver disease due to altered pharmacodynamics (low albumin level), and increased sensitivity.
- Non depolarizing neuromuscular blocking agents should be chosen with patients organ function in mind. Often Cis-atricurium is chosen due to its predictable metabolism.
Positioning
- Supine
Maintenance and surgical considerations
- Anesthetic requirements for patients with end-stage liver disease will often be reduced, due to underlying cerebral disturbances.
- 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.
- 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
Postoperative management
Disposition
- ICU
- Generally patients require additional fluid resuscitation and/or blood products.
- Frequent monitoring of hemoglobin, fibrinogen, glucose, and phosphate is required.
- Renal duplex ultrasound is also needed.
Pain management
- PCA, typically fentanyl or hydromorphone
- Consider acetaminophen after communication with transplant team
Potential complications
- These patients are at risk for further clinical deterioration post-operatively, as graft function improves and SVR normalizes, resulting in increased afterload to a susceptible myocardium. Careful extended monitoring should be considered.
Procedure variants
Variant 1 | Variant 2 | |
---|---|---|
Unique considerations | ||
Position | ||
Surgical time | ||
EBL | ||
Postoperative disposition | ||
Pain management | ||
Potential complications |
References
- ↑ "Anesthesiologist's Manual of Surgical Procedures". www.wolterskluwer.com. Retrieved 2021-11-22.
- ↑ Brezeanu, Lavinia Nicoleta; Brezeanu, Radu Constantin; Diculescu, Mircea; Droc, Gabriela (2020-05-06). "Anaesthesia for Liver Transplantation: An Update". The Journal of Critical Care Medicine. 6 (2): 91–100. doi:10.2478/jccm-2020-0011. ISSN 2393-1809. PMC 7216023. PMID 32426515.
- ↑ Møller, Søren; Bendtsen, Flemming (2018-04). "The pathophysiology of arterial vasodilatation and hyperdynamic circulation in cirrhosis". Liver International. 38 (4): 570–580. doi:10.1111/liv.13589. Check date values in:
|date=
(help) - ↑ Adelmann, Dieter; Kronish, Kate; Ramsay, Michael A. (2017-09). "Anesthesia for Liver Transplantation". Anesthesiology Clinics. 35 (3): 491–508. doi:10.1016/j.anclin.2017.04.006. Check date values in:
|date=
(help)