Perioperative Considerations for Transplantation in Acute Liver Failure

  • C. P. SnowdenEmail author
  • D. M. Cressey
  • J. Prentis


In contrast to the intensive care management of the patient with acute liver failure (ALF), the perioperative anesthetic management of emergency liver transplantation for acute liver failure has received limited attention in the medical literature. Although many of the principles regarding recipient management can be transferred from the intensive care unit (ICU) setting into the intraoperative period, the liver transplantation procedure (including transfer to the operating room) creates specific concerns that require particular anesthetic attention.

Patient Population

The paucity of literature concerning the anesthetic management of ALF patients may in some part be explained by the fact that they comprise only 7% [1] to 10% [2] of all liver transplantation recipients. Paracetamol-induced liver injury remains the major etiological factor for ALF in adult patients in North America [3]. Similarly in the UK, paracetamol remains the predominant cause of ALF, but following the...


Fulminant hepatic failure Intracranial pressure Coagulopathy Fluid management Recovery Intracranial hypertension 


  1. 1.
    Hoofnagle JH, Carithers RL, Shapiro C, Ascher N. Fulminant hepatic failure: summary of a workshop. Hepatology. 1995;21:240–52.PubMedGoogle Scholar
  2. 2.
    Bernal W, Wendon J. Liver transplantation in adults with acute liver failure. J Hepatol. 2004;40(2):192–7.CrossRefPubMedGoogle Scholar
  3. 3.
    Stravitz RT. Critical management decisions in patients with acute liver failure. Chest. 2008;134(5):1092–102.CrossRefPubMedGoogle Scholar
  4. 4.
    Marudanayagam R, Shanmugam V, Gunson B, Mirza DF, Mayer D, Buckels J, et al. Aetiology and outcome of acute liver failure. HPB (Oxford). 2009;11(5):429–34.CrossRefGoogle Scholar
  5. 5.
    Bernal W, Wendon J. Acute liver failure. N Engl J Med. 2014;370(12):1170–1.CrossRefPubMedGoogle Scholar
  6. 6.
    Farmer DG, Anselmo DM, Ghobrial RM, Yersiz H, McDiarmid SV, Cao C, et al. Liver transplantation for fulminant hepatic failure: experience with more than 200 patients over a 17-year period. Ann Surg. 2003;237(5):666–75. discussion 675–6.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Germani G, Theocharidou E, Adam R, Karam V, Wendon J, O’Grady J, et al. Liver transplantation for acute liver failure in Europe: outcomes over 20 years from the ELTR database. J Hepatol. 2012;57(2):288–96.CrossRefPubMedGoogle Scholar
  8. 8.
    Bernal W, Lee WM, Wendon J, Larsen FS, Williams R. Acute liver failure: a curable disease by 2024? J Hepatol. 2015;62(1 Suppl):S112–20.CrossRefPubMedGoogle Scholar
  9. 9.
    O’Grady J. Timing and benefit of liver transplantation in acute liver failure. J Hepatol. 2014;60(3):663–70.CrossRefPubMedGoogle Scholar
  10. 10.
    Kjaergard LL, Liu J, Als-Nielsen B, Gluud C. Artificial and bioartificial support systems for acute and acute-on-chronic liver failure: a systematic review. JAMA. 2003;289(2):217–22.CrossRefPubMedGoogle Scholar
  11. 11.
    Husberg BS, Goldstein RM, Klintmalm GB, Gonwa T, Ramsay M, Cofer J, et al. A totally failing liver may be more harmful than no liver at all: three cases of total hepatic devascularization in preparation for emergency liver transplantation. Transplant Proc. 1991;23(1 Pt 2):1533–5.PubMedGoogle Scholar
  12. 12.
    Ringe B, Pichlmayr R. Total hepatectomy and liver transplantation: a life-saving procedure in patients with severe hepatic trauma. Br J Surg. 1995;82(6):837–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Ejlersen E, Larsen FS, Pott F, Gyrtrup HJ, Kirkegaard P, Secher NH. Hepatectomy corrects cerebral hyperperfusion in fulminant hepatic failure. Transplant Proc. 1994;26(3):1794–5.PubMedGoogle Scholar
  14. 14.
    Rozga J, Podesta L, LePage E, Hoffman A, Morsiani E, Sher L, et al. Control of cerebral oedema by total hepatectomy and extracorporeal liver support in fulminant hepatic failure. Lancet. 1993;342(8876):898–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Bustamante M, Castroagudín JF, Gonzalez-Quintela A, Martinez J, Segade FR, Fernández A, et al. Intensive care during prolonged anhepatic state after total hepatectomy and porto-caval shunt (two-stage procedure) in surgical complications of liver transplantation. Hepatogastroenterology. 2000;47(35):1343–6.PubMedGoogle Scholar
  16. 16.
    Domínguez Fernández E, Lange K, Lange R, Eigler FW. Relevance of two-stage total hepatectomy and liver transplantation in acute liver failure and severe liver trauma. Transpl Int. 2001;14(3):184–90.CrossRefPubMedGoogle Scholar
  17. 17.
    Cheema SP, Hughes A, Webster NR, Bellamy MC. Cardiac function during orthotopic liver transplantation with venovenous bypass. Anaesthesia. 1995;50(9):776–8.CrossRefGoogle Scholar
  18. 18.
    Jalan R. Pathophysiological basis of therapy of raised intracranial pressure in acute liver failure. Neurochem Int. 2005;47(1–2):78–83.CrossRefPubMedGoogle Scholar
  19. 19.
    Ardizzone G, Arrigo A, Panaro F, Ornis S, Colombi R, Distefano S, et al. Cerebral hemodynamic and metabolic changes in patients with fulminant hepatic failure during liver transplantation. TPS. 2004;36(10):3060–4.Google Scholar
  20. 20.
    Lidofsky SD. Liver transplantation for fulminant hepatic failure. Gastroenterol Clin North Am. 1993;22(2):257–69.PubMedGoogle Scholar
  21. 21.
    Detry O, Arkadopoulos N, Ting P, Kahaku E, Margulies J, Arnaout W, et al. Intracranial pressure during liver transplantation for fulminant hepatic failure. Transplantation. 1999;67(5):767–70.CrossRefPubMedGoogle Scholar
  22. 22.
    Jalan R, Olde Damink SWM, Deutz NEP, Davies NA, Garden OJ, Madhavan KK, et al. Moderate hypothermia prevents cerebral hyperemia and increase in intracranial pressure in patients undergoing liver transplantation for acute liver failure. Transplantation. 2003;75(12):2034–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Jalan R, Pollok A, Shah SHA, Madhavan K, Simpson KJ. Liver derived pro-inflammatory cytokines may be important in producing intracranial hypertension in acute liver failure. J Hepatol. 2002;37(4):536–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Lidofsky SD, Bass NM, Prager MC, Washington DE, Read AE, Wright TL, et al. Intracranial pressure monitoring and liver transplantation for fulminant hepatic failure. Hepatology. 1992;16(1):1–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Dmello D, Cruz-Flores S, Matuschak GM. Moderate hypothermia with intracranial pressure monitoring as a therapeutic paradigm for the management of acute liver failure: a systematic review. Intensive Care Med. 2010;36(2):210–3.CrossRefPubMedGoogle Scholar
  26. 26.
    Detry O, De Roover A, Honore P, Meurisse M. Brain edema and intracranial hypertension in fulminant hepatic failure: pathophysiology and management. World J Gastroenterol. 2006;12(46):7405–12.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Blei AT. Monitoring cerebral blood flow: a useful clinical tool in acute liver failure? Liver Transpl. 2005;11(11):1320–2.CrossRefPubMedGoogle Scholar
  28. 28.
    Noun R, Zante E, Sauvanet A, Durand F, Bernuau J, Belghiti J. Liver devascularisation improves the hyperkinetic syndrome in patients with fulminant and subfulminant hepatic failure. Transplant Proc. 1995;27(1):1256–7.PubMedGoogle Scholar
  29. 29.
    Filho JAR, Machado MAC, Nani RS, Rocha JPS, Figueira ERR, Bacchella T, et al. Hypertonic saline solution increases cerebral perfusion pressure during clinical orthotopic liver transplantation for fulminant hepatic failure: preliminary results. Clinics (Sao Paulo). 2006;61(3):231–8.CrossRefGoogle Scholar
  30. 30.
    Kang YG, Martin DJ, Marquez J, Lewis JH, Bontempo FA, Shaw BW, et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg. 1985;64(9):888–96.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Massicotte L, Lenis S, Thibeault L, Sassine M-P, Seal RF, Roy A. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl. 2005;12(1):117–23.CrossRefGoogle Scholar
  32. 32.
    Bolliger D, Szlam F, Molinaro RJ, Rahe-Meyer N, Levy JH, Tanaka KA. Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. Br J Anaesth. 2009;102(6):793–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Wikkelsø A, Lunde J, Johansen M, Stensballe J, Wetterslev J, Møller AM, et al. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev. 2013;8:CD008864.Google Scholar
  34. 34.
    Sabate A, Gutierrez R, Beltran J, Mellado P, Blasi A, Acosta F, et al. Impact of pre-emptive fibrinogen concentrate on transfusion requirements in liver transplantation: a multicenter, randomized, double-blind, placebo-controlled trial. Am J Transplant. 2016;16:2421–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Clevenger B, Mallett SV. Transfusion and coagulation management in liver transplantation. World J Gastroenterol. 2014;20(20):6146–58.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Franchini M, Lippi G. Prothrombin complex concentrates: an update. Blood Transfus. 2010;8(3):149–54.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Arshad F, Ickx B, van Beem RT, Polak W, Grüne F, Nevens F, et al. Prothrombin complex concentrate in the reduction of blood loss during orthotopic liver transplantation: PROTON-trial. BMC Surg. 2013;13:22.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Shami VM, Caldwell SH, Hespenheide EE, Arseneau KO, Bickston SJ, Macik BG. Recombinant activated factor VII for coagulopathy in fulminant hepatic failure compared with conventional therapy. Liver Transpl. 2003;9(2):138–43.CrossRefGoogle Scholar
  39. 39.
    Lodge JPA, Jonas S, Jones RM, Olausson M, Mir-Pallardo J, Soefelt S, et al. Efficacy and safety of repeated perioperative doses of recombinant factor VIIa in liver transplantation. Liver Transpl. 2005;11(8):973–9.CrossRefGoogle Scholar
  40. 40.
    Surudo T, Wojcicki M, Milkiewicz P, Czuprynska M, Lubikowski J, Jarosz K, et al. Rapid correction of prothrombin time after low-dose recombinant factor VIIA in patients undergoing orthotopic liver transplantation. Transplant Proc. 2003;35(6):2323–5.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Hendriks HG, Meijer K, de Wolf JT, Klompmaker IJ, Porte RJ, de Kam PJ, et al. Reduced transfusion requirements by recombinant factor VIIa in orthotopic liver transplantation: a pilot study. Transplantation. 2001;71(3):402–5.CrossRefGoogle Scholar
  42. 42.
    Pavese P, Bonadona A, Beaubien J, Labrecque P, Pernod G, Letoublon C, et al. FVIIa corrects the coagulopathy of fulminant hepatic failure but may be associated with thrombosis: a report of four cases. Can J Anaesth. 2005;52(1):26–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Chavez-Tapia NC, Alfaro-Lara R, Tellez-Avila F, Barrientos-Gutiérrez T, González-Chon O, Mendez-Sanchez N, et al. Prophylactic activated recombinant factor VII in liver resection and liver transplantation: systematic review and meta-analysis. PLoS One. 2011;6(7):e22581.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, et al. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med. 2011;154(8):529–40.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med. 2010;363(19):1791–800.CrossRefPubMedGoogle Scholar
  46. 46.
    Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CAA, De Robertis E, Filipescu DC, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013;30(6):270–382.CrossRefPubMedGoogle Scholar
  47. 47.
    Blasi A, Hessheimer AJ, Beltrán J, Pereira A, Fernández J, Balust J, et al. Liver transplant from unexpected donation after circulatory determination of death donors: a challenge in perioperative management. Am J Transplant. 2016;16(6):1901–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Dzik WH, Arkin CF, Jenkins RL, Stump DC. Fibrinolysis during liver transplantation in humans: role of tissue-type plasminogen activator. Blood. 1988;71(4):1090–5.PubMedGoogle Scholar
  49. 49.
    Porte RJ, Bontempo FA, Knot EA, Lewis JH, Kang YG, Starzl TE. Tissue-type-plasminogen-activator-associated fibrinolysis in orthotopic liver transplantation. TPS. 1989;21(3):3542.Google Scholar
  50. 50.
    Porte RJ, Knot EA, Bontempo FA. Hemostasis in liver transplantation. Gastroenterology. 1989;97(2):488–501.CrossRefPubMedGoogle Scholar
  51. 51.
    Lisman T, Leebeek FWG, Meijer K, Van Der Meer J, Nieuwenhuis HK, De Groot PG. Recombinant factor VIIa improves clot formation but not fibrolytic potential in patients with cirrhosis and during liver transplantation. Hepatology. 2002;35(3):616–21.CrossRefGoogle Scholar
  52. 52.
    Fergusson DA, Hébert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358(22):2319–31.CrossRefGoogle Scholar
  53. 53.
    Porte RJ, Molenaar IQ, Begliomini B, Groenland TH, Januszkiewicz A, Lindgren L, et al. Aprotinin and transfusion requirements in orthotopic liver transplantation: a multicentre randomised double-blind study. EMSALT Study Group. The Lancet. 2000;355(9212):1303–9.CrossRefGoogle Scholar
  54. 54.
    LaMattina JC, Kelly PJ, Hanish SI, Ottmann SE, Powell JM, Hutson WR, et al. Intraoperative continuous veno-venous hemofiltration facilitates surgery in liver transplant patients with acute renal failure. Transplant Proc. 2015;47(6):1901–4.CrossRefPubMedGoogle Scholar
  55. 55.
    Douthitt L, Bezinover D, Uemura T, Kadry Z, Shah RA, Ghahramani N, et al. Perioperative use of continuous renal replacement therapy for orthotopic liver transplantation. Transplant Proc. 2012;44(5):1314–7.CrossRefPubMedGoogle Scholar
  56. 56.
    Sedra AH, Strum E. The role of intraoperative hemodialysis in liver transplant patients. Curr Opin Organ Transplant. 2011;16(3):323–5.CrossRefPubMedGoogle Scholar
  57. 57.
    Tobias MD, Jobes CS, Aukburg SJ. Hemofiltration in parallel to the venovenous bypass circuit for oliguric hypervolemia during liver transplantation. Anesthesiology. 1999;90(3):909–11.CrossRefPubMedGoogle Scholar
  58. 58.
    Blackwell MM, Chavin KD, Sistino JJ. Perioperative perfusion strategies for optimal fluid management in liver transplant recipients with renal insufficiency. Perfusion. 2003;18(1):55–60.CrossRefPubMedGoogle Scholar
  59. 59.
    Davenport A. Continuous renal replacement therapies in patients with liver disease. Semin Dial. 2009;22(2):169–72.CrossRefPubMedGoogle Scholar
  60. 60.
    Srinivas Reddy M, Wilson C, Torpey N, Manas DM. ABO incompatible liver transplantation: a case of immediate need. Transpl Int. 2007;20(10):904–5.CrossRefPubMedGoogle Scholar
  61. 61.
    Kluger MD, Guarrera JV, Olsen SK, Brown RS, Emond JC, Cherqui D. Safety of blood group A2-to-O liver transplantation: an analysis of the United Network of Organ Sharing database. Transplantation. 2012;94(5):526–31.CrossRefPubMedGoogle Scholar
  62. 62.
    Shen T, Lin B-Y, Jia J-J, Wang Z-Y, Wang L, Ling Q, et al. A modified protocol with rituximab and intravenous immunoglobulin in emergent ABO-incompatible liver transplantation for acute liver failure. Hepatobiliary Pancreat Dis Int. 2014;13(4):395–401.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Perioperative Medicine and Critical CareFreeman HospitalNewcastle Upon TyneUK

Personalised recommendations