|Lines and access||
Large bore IVs Arterial line Central line Introducer / PAC
Standard 5-lead ECG Temperature Urine output ABP CVP PAP EEG TEE
|Primary anesthetic considerations|
Encepholapthy Multi-organ system derangements
Decreased anesthetic requirement Systemic vasodilation Decreased hepatic metabolism Hemorrhage Thrombocytopenia Coagulopathy Renal insufficiency Hypo/hyperglycemia
A liver transplant is performed in patients with end-stage liver disease.
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.
- Disection (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 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 venovenous bypass.
- 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
- 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 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.
- 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.
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.
Labs and studies
- Full workup prior to transplant.
- Coagulation panel
- Cardiac evaluation possibly including stress test or TTE
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
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.
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.
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.
- 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.
- PCA, typically fentanyl or hydromorphone
- Consider acetaminophen after communication with transplant team
- 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.
|Variant 1||Variant 2|
- "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:
- 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: