Keywords

Drugs

Table 40.1 Common medications organized by action to have prepared when performing a liver transplant
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Extra Equipment (*institutional variation, often run by perfusionist) (Table 40.1)

  1. 1.

    Belmont Machine

  2. 2.

    Arterial Blood Gas analyzer/iSTAT

Blood Products

  1. 1.

    Designated fridge in the OR for blood (Tables 40.3 and 40.4)

  2. 2.

    Verify with OR RN that hospital blood bank has been notified of liver transplant.

  3. 3.

    Double check that PRBCs, FFP, and platelets (10 + 10 + 2) will be in the room by the time dissection begins.

  4. 4.

    Order cryoprecipitate if needed (not automatically part of the massive transfusion protocol).

Monitors and Lines

  1. 1.

    Routine ASA monitors

  2. 2.

    Radial arterial line ± awake, depends on underlying cardiac and pulmonary function

    1. (a)

      Example: severe aortic stenosis, severe pulmonary hypertension

  3. 3.

    Femoral arterial line

  4. 4.

    Right Internal Jugular Vein (IJ) (RIJ) large bore central line, ± left Internal Jugular Vein (IJ) (LIJ) large bore central line

    1. (a)

      Option 1: Double stick: 2 × Cordises in R IJ

    2. (b)

      Option 2: 1 R IJ Cordis +1 L J Cordis

    3. (c)

      Option 3: 14/16 G PIV + R IJ Cordis

    4. (d)

      1 central line is for Belmont machine

  5. 5.

    ± Swan Ganz catheter

    1. (a)

      Risks of PA catheter: atrial or ventricular arrhythmias, clot formation, traumatic placement

    2. (b)

      Benefits of catheter: assess hemodynamic changes, volume status, acute RV failure, pulmonary hypertension, prolonged ICU course

  6. 6.

    ± TEE probe

    1. (a)

      Caution with esophageal varices. May place TEE probe and not manipulate, leave in mid-esophageal 4 chamber view.

    2. (b)

      At least have available in room in case of emergency.

  7. 7.

    Airway

    1. (a)

      Largest size possible in case of fiberoptic bronchoscopy, pulmonary edema, suctioning

Preoperative Evaluation

  1. 1.

    Rapid sequence induction

    1. (a)

      All full-stomachs

    2. (b)

      Ascites

    3. (c)

      NPO status: called in from home, not planned

  2. 2.

    Hemodynamic state

    1. (a)

      Volume-depleted? Hemorrhaging?

  3. 3.

    Any contraindications to liver transplant?

    1. (a)

      Unstable arrhythmias

    2. (b)

      Severe pulmonary hypertension

  4. 4.

    Airway exam

    1. (a)

      Direct laryngoscopy ok?

    2. (b)

      Difficult intubation anticipated? – awake FOB

  5. 5.

    Cardiac function

    1. (a)

      Affects type of induction: any variation of etomidate, propofol with narcotic, benzodiazepines

  6. 6.

    Esophageal varices

    1. (a)

      Risk of TEE probe causing trauma, bleeding

  7. 7.

    Neurologic: mentation, hepatic encephalopathy

    1. (a)

      Hyperalgesia

  8. 8.

    Hematologic: coagulopathic? Prothrombotic? Thrombocytopenic?

Manifestations of Liver Disease and Their Anesthetic Implications

Adelmann et al. [1] (Table 40.2)

  1. 1.

    Neurological

    1. (a)

      Hepatic encephalopathy, coma, altered mental status, seizures, asterixis

    2. (b)

      In fulminant liver failure --> cerebral edema --> increased intracranial pressure --> herniation, intracerebral hemorrhage

    3. (c)

      Most liver failure patients will die of ICH

  2. 2.

    Cardiovascular

    1. (a)

      Hyperdynamic heart, high ejection fraction, low systemic vascular resistance, and high cardiac output.

    2. (b)

      If the liver disease is due to Wilson’s disease which causes a cardiomyopathy, a low ejection fraction can be done.

  3. 3.

    Pulmonary

    1. (a)

      Restrictive lung physiology, decreased functional residual capacity due to ascites

    2. (b)

      Pulmonary edema, pleural effusions R > L

  4. 4.

    Gastrointestinal

    1. (a)

      Ascites, esophageal varices, peptic ulcer disease

    2. (b)

      High aspiration risk because ascites, so do rapid sequence induction

    3. (c)

      Massive splanchnic vasodilation

  5. 5.

    Renal

    1. (a)

      Massive splanchnic vasodilation --> low renal perfusion pressure --> renal vascular urge tries to vasoconstrict by activating the renin-angiotensin-aldosterone system --> salt and water retention

    2. (b)

      Diagnosis of exclusion

    3. (c)

      Kidneys sense they are underperfused

  6. 6.

    Hematologic

    1. (a)

      Hypercoagulable and hypocoagulable

    2. (b)

      Even with an elevated INR, a patient’s TEG can show hypercoagulability

    3. (c)

      Just because a patient has a high INR doesn’t mean they have a propensity to bleed, because the INR tests for specific factors only

    4. (d)

      Liver makes factors 2, 7, 9, and 10, and proteins C and S, but proteins C and S have shorter half-lives

  7. 7.

    Endocrine

    1. (a)

      Impaired glucose homeostasis, decreased gluconeogenesis --> hypoglycemia

  8. 8.

    Infectious Disease

    1. (a)

      Prone to infection, bacterial translocation across gut wall

    2. (b)

      Everyone always thinks of spontaneous bacterial peritonitis, but the most common infection is actually pneumonia

  9. 9.

    Metabolic

    1. (a)

      Electrolyte imbalances, malnourished, chronically hyponatremic (water > sodium), hypokalemia, hypomagnesemia

    2. (b)

      High volume of distribution – theoretically need higher dosage of induction drugs, but impaired hepatic metabolism of drug, so lasts longer, don’t need higher doses in real life

  10. 10.

    Hepatorenal (see above)

  11. 11.

    Hepatopulmonary

    1. (a)

      Increased shunting from arterial to venous (right to left) within the intrapulmonary vasculature --> hypoxia

    2. (b)

      Do better when lie down because less shunting

    3. (c)

      Basically the liver makes and clears VEGF (vascular endothelial growth factor), and in liver failure, VEGF makes it to the pulmonary circulation and creates AVMs

  12. 12.

    Portopulmonary

    1. (a)

      Pulmonary hypertension due to portal hypertension (portal to systemic circulation)

    2. (b)

      Toxic mediators are not cleared by the failing liver --> systemic circulation --> severe pulmonary artery hypertension

Phases of Liver Transplant

Table 40.2 Description of key events that occur during the pre-anhepatic, anhepatic, and reperfusion stages of a liver transplant
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Guidelines for Acute Massive Blood Loss (Table 40.3)

Table 40.3 Management of massive blood loss
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Table 40.4 Options for blood transfusion
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Contents of Blood Products

Blood products are separated into specific components which should be transfused according to the patient’s coagulopathy status (Fig. 40.1 and Table 40.4)

  • Cryo = factor VIII, factor XIII, vWF, fibrinogen

  • 1 unit of FFP = 2 × fibrinogen and 2 × factor VIII in 1 unit of Cryoprecipitate

  • 1 pack Cryo = 5 units Cryo

  • Typical ratios of transfusion: 2–3: 2–3: 1 of PRBC: FFP: Plt

Non-blood Products

  • Recombinant factors

    • VIII, IX, VIIa, etc.

    • K-Centra = PCC = Prothrombin Complex Concentrate = II, VII, IX, X, Protein C + S

  • Antifibrinolytics

    • TXA = tranexaminic acid

    • Amicar = aminocaproic acid

  • Protamine

Fig. 40.1
figure 1

Diagram outlining how whole blood is separated into individual components for blood transfusion

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