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Anesthesiology pp 697-705 | Cite as

Anesthesia for Liver Transplantation

  • Philip L. Kalarickal
  • Daniel J. Viox
Chapter

Abstract

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

Reasoning/management

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

Position

Supine

Access

≥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

GETA

 IV induction

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

 RSI

Increased risk for regurgitation and aspiration

 Maintenance

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

Procedural adverse events

 Aspiration

RSI as above

 Coagulopathy

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

 Hemorrhage

Transfuse pRBCs to goal of hematocrit > 25

Rapid infuser should be available

 Hypotension

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

 Extubation

May consider if hemodynamically stable and no significant transfusion requirements

Keywords

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

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Emory University School of MedicineAtlantaUSA

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