Liver transplant

Liver transplant

Anesthesia type
Airway
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Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Surgical Description

Liver transplantation is a complex surgical procedure that can be separated into three distinct phases :

1. Pre-anhepatic (hepatectomy) 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 pulmonary hypertension (pHTN), coagulopathy, or previous abdominal operations. Mobilization of the liver during dissection may partially or completely occlude the IVC causing a drop in blood pressure
2. Anhepatic phase - This encompasses the time from clamping of hepatic venous inflow until the graft is completely reperfused. During this stage of the operation, the donor liver is implanted into the recipient. Because the IVC is clamped during this phase of the operation, blood return to the heart is severely limited. Hemodynamically unstable patients may benefit from venous bypass. Venous bypass during this phase involves placement of cannulas in the femoral and portal veins that empty into the axillary or jugular vein, which maintains venous return.
3. 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 preservative solution. 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. Reperfusion also frequently results in systemic hypotension likely from kinins, and cytokines from the liver allograft. Immediately prior to this phase, 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.

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.

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
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Procedure variants

	Variant 1	Variant 2
Unique considerations
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EBL
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