Anesthesiology pp 697-705 | Cite as

Anesthesia for Liver Transplantation

  • Philip L. KalarickalEmail author
  • Daniel J. Viox


Liver transplantation is amongst the most challenging surgeries for the anesthesiologist to manage. Due to advances in medical, surgical and perioperative management, 1-year survival following transplant is greater than 90%. At 5 years, more than 75% of liver transplant recipients survive, making it one of the most successful organ transplant procedures. The majority of the body’s organ systems are affected by end-stage liver disease (ESLD), mandating an in-depth knowledge of cerebral, cardiac, pulmonary and renal physiology when caring for these patients. Additionally, transplant surgery is associated with significant coagulopathy and blood loss that requires familiarity with blood product resuscitation. This chapter describes the surgical approach to liver transplant and examines the effects of ESLD by organ system. Extensive considerations are reviewed in this chapter including preoperative evaluation, intraoperative management, and the author’s preferred technique to provide a stepwise approach for liver transplantation. Table 72.1 provides a summary of anesthesia considerations in patients undergoing Liver Transplantation.
Table 72.1

Summary of anesthesia considerations in patients undergoing liver transplantation

Plan/preparation/adverse events


Preoperative evaluation (see Table 72.2)

Room-air ABG, contrast-enhanced TTE, CXR, PFTs, CT chest

ECG, TTE, ± noninvasive stress testing

CBC, PT, PTT, INR, fibrinogen, d-dimer

Serum BUN, serum Cr, BMP




≥1 14- or 16-gauge IV—Rapid fluid and blood product administration

Arterial line—Anticipation of hemodynamic instability, frequent blood sampling, vasoactive drug administration

Central venous catheter—CVP and PAP transduction, rapid fluid and blood product administration, vasoactive drug administration


 IV induction

Even if metabolism and/or excretion are hepatic, duration of action determined by redistribution


Increased risk for regurgitation and aspiration


Isoflurane or sevoflurane preferred given no significant decrease in hepatic blood flow or O2 delivery

Procedural adverse events


RSI as above


Transfuse blood products to approximate goals of INR < 3.5, platelets > 20, and fibrinogen > 100 and clinical coagulation status


Transfuse pRBCs to goal of hematocrit > 25

Rapid infuser should be available


Relative hypovolemia during dissection phase, euvolemia after; titrate vasopressors to effect

 Hyperkalemic cardiac arrest

Apply defibrillation pads before induction; send ABGs q20–30 min during anhepatic phase; administer Ca2+, dextrose, and insulin as indicated

 Postreperfusion syndrome

Titrate inotropes and vasopressors to effect

Postoperative and post-discharge considerations


May consider if hemodynamically stable and no significant transfusion requirements


Anesthesia Cirrhosis End-stage liver disease Cirrhotic cardiomyopathy Hepatopulmonary syndrome Liver disease Liver failure Liver transplant OLT Portopulmonary hypertension 


  1. 1.
    Starzl TE, Marchioro TL, Vonkaulla KN, Hermann G, Brittain RS, Waddell WR. Homotransplantation of the liver in humans. Surg Gynecol Obstet. 1963;117:659–76.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Starzl TE, Groth CG, Brettschneider L, Penn I, Fulginiti VA, Moon JB, Blanchard H, Martin AJ Jr, Porter KA. Orthotopic homotransplantation of the human liver. Ann Surg. 1968;168(3):392–415.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Starzl TE, Brettschneider L, Penn I, Bell P, Groth CG, Blanchard H, Kashiwagi N, Putnam CW. Orthotopic liver transplantation in man. Transplant Proc. 1969;1(1):216–22.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Based on OPTN data as of March 23, 2017.
  5. 5.
    Malik SM, Ahmad J. Preoperative risk assessment for patients with liver disease. Med Clin North Am. 2009 Jul;93(4):917–29.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Martin P, DiMartini A, Feng S, Brown R Jr, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59(3):1144–65.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Changes to OPTN bylaws and policies from actions at the OPTN/UNOS Executive Committee meetings July 2015–November 2015. Accessed 9 May 2017.
  8. 8.
    Kim WR, Biggins SW, Kremers WK, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med. 2008;359(10):1018–26.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D’Amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–70.CrossRefPubMedGoogle Scholar
  10. 10.
    Gleisner AL, Muñoz A, Brandao A, et al. Survival benefit of liver transplantation and the effect of underlying liver disease. Surgery. 2010;147:392–404.CrossRefPubMedGoogle Scholar
  11. 11.
    Schaubel DE, Guidinger MK, Biggins SW, et al. Survival benefit-based deceased-donor liver allocation. Am J Transplant. 2009;9:970–81.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Merion RM, Schaubel DE, Dykstra DM, et al. The survival benefit of liver transplantation. Am J Transplant. 2005;5:307–13.CrossRefPubMedGoogle Scholar
  13. 13.
    Lladó L, Figueras J. Techniques of orthotopic liver transplantation. HPB. 2004;6(2):69–75.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Gallo AE, Melcher ML, Desai DM, Esquivel CO, Angelotti T, Lemmens HJM. Chapter 7.12. Liver/kidney/pancreas transplantation. In: Jaffe RA, Schmiesing CA, Golianu B, editors. Anesthesiologist’s manual of surgical procedures. 5th ed. Philadelphia: Wolters Kluwer Health; 2014.Google Scholar
  15. 15.
    Siniscalchi A, et al. Post reperfusion syndrome during liver transplantation: from pathophysiology to therapy and preventive strategies. World J. Gastroenterol.. 2016;22(4):1551–69.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Muilenburg DJ, Singh A, Torzilli G, Khatri VP. Surgery in the patient with liver disease. Anesthesiol Clin. 2009;27(4):721–37.CrossRefPubMedGoogle Scholar
  17. 17.
    Karvellas CJ, Fix OK, Battenhouse H, Durkalski V, Sanders C, Lee WM, et al. Outcomes and complications of intracranial pressure monitoring in acute liver failure: a retrospective cohort study. Crit Care Med. 2014;42(5):11571157s.CrossRefGoogle Scholar
  18. 18.
    Carey WD, Dumot JA, Pimentel RR, et al. The prevalence of coronary artery disease in liver transplant candidates over age 50. Transplantation. 1995;59:859–64.CrossRefPubMedGoogle Scholar
  19. 19.
    Tiukinhoy-Laing SD, Rossi JS, Bayram M, et al. Cardiac hemodynamic and coronary angiographic characteristics of patients being evaluated for liver transplantation. Am J Cardiol. 2006;98:178–81.CrossRefPubMedGoogle Scholar
  20. 20.
    Steadman RH, Wray CL. Cardiovascular assessment of the liver transplant candidate. Int Anesthesiol Clin. 2017;55:42–66.CrossRefPubMedGoogle Scholar
  21. 21.
    Findlay JY. Patient selection and preoperative evaluation for transplant surgery. Anesthesiol Clin. 2013;31(4):689–704.CrossRefPubMedGoogle Scholar
  22. 22.
    Hannaman MJ, Hevesi ZG. Anesthesia care for liver transplantation. Transplant Rev. 2011;25(1):36–43.CrossRefGoogle Scholar
  23. 23.
    DuBrock HM, Channick RN, Krowka MJ. What’s new in the treatment of portopulmonary hypertension? Expert Rev Gastroenterol Hepatol. 2015;9(7):983–92.CrossRefPubMedGoogle Scholar
  24. 24.
    Krowka MJ, Plevak DJ, Findlay JY, Rosen CB, Wiesner RH, Krom RAF. Pulmonary hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation. Liver Transpl. 2000;6:443–50.CrossRefPubMedGoogle Scholar
  25. 25.
    DeMartino ES, Cartin-Ceba R, Findlay JY, Heimbach JK, Krowka MJ. Frequency and outcomes of patients with increased mean pulmonary artery pressure at the time of liver transplantation. Transplantation. 2017;101(1):101–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Emory University School of MedicineAtlantaUSA

Personalised recommendations