Liver Transplant Anaesthesia- perioperative care
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An overview of the processes and things we do as anaesthesiologists while giving perioperative care for liver transplant recipients. Key areas include preoperative assessment, focusing on different organ systems, intraoperative management with an emphasis on reperfusion , pros and cons of pre-emptive versus responsive pressors. A quick recap of the postoperative areas of interest and ways to monitor effectively.
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- 1. Liver transplant anesthesia –an overview Karthik Ponnappan T MD DM EDAIC
- 2. Anaesthesia for Liver Transplant Postoperative Critical Care Surgical Preoperative Assessment Optimization Intraoperative Monitoring Concerns
- 4. Neurologic Cerebral edema -ALF patient with fulminant hepatic failure, the basal cisterns are absent, and there is loss of sulci and loss of differentiation between gray matter and white matter due to diffuse brain swelling
- 5. Cardiac AASLD recommend noninvasive cardiac testing (either exercise stress testing or pharmacologic stress testing) for all adults being evaluated for liver transplantation Evaluation for liver transplantation in adults: 2013 practice guideline by AASLD and the American Society of Transplantation. Hepatology 2014; 59:1144.
- 6. Cardiac Cirrhotic Cardiomyopathy • impaired contractile responsiveness to stress and/or diastolic dysfunction • QT prolongation, electro- mechanical dyssynchrony, and chronotropic incompetence • Dilated LA , N/dilated LV
- 8. Respiratory Restrictive Lung – Ascites Hepatic hydrothorax( 5-10%) • Pleural effusion (usually >500 mL) in a patient with cirrhosis after R/O cardiac, pulmonary, or pleural disease. Clinical Liver Disease, Volume: 4, Issue: 2, Pages: 35-37, 25 August 2014
- 9. Respiratory Hepatopulmonary syndrome Rodríguez-Roisin R, et al . N Engl J Med 2008;358:2378- 2387
- 10. Respiratory Hepatopulmonary syndrome Hepatology, Volume: 41, Issue: 5, Pages: 1122-1129, First published: 19 April 2005
- 11. Respiratory Hepatopulmonary syndrome • Panel A: apical four-chamber view before injection of agitated saline (contrast); • Panel B: apical four-chamber view after contrast injection showing opacification of the RA and RV. • Panel C: apical four-chamber view showing microbubbles within the LA and LV 5 heart beats after its appearance in the right heart European Journal of Echocardiography, Volume 8, Issue 5, October 2007
- 12. Renal Hepatorenal Syndrome F, Leung W, Al Beshir M, Marquez M, Renner EL. Outcomes of patients with cirrhosis and hepatorenal syndrome type 1 treated with liver transplantation. Liver Transplantation. 2015 Mar;21(3):300-7.
- 14. Renal Hepatorenal Syndrome Saxena V, Lai JC. Kidney Failure and Liver Allocation: Current Practices and Potential Improvements. Adv Chronic Kidney Dis 2015; 22: 391-398
- 15. Monitoring
- 18. Monitoring
- 19. Monitoring • Incision clamping of the hepatic vessels Rapid ascites removal Hemodynamics Coagulopathy - TEG Electrolytes
- 21. Monitoring • removal of the native liver re- anastomosis of the transplanted liver graft • prior to vascular unclamping and reperfusion Hypotension • Avoid fluids • Vasoactive agents Acidosis • Bicabonate infusion • Hyperventilation for brief period Hyperkalemia Hypocalcemia • Insulin/Glucose, Bicarb • CRRT Coagulopathy worsens • Avoid transfusions unless needed
- 22. Monitoring • Desaturated/acidotic blood • Il-6 and TNF alpha, potassium, protons, and intrahepatic cold fluids/components • Rapidly enter circulation Portal vein unclamping • 30% decrease in mean arterial blood pressure for more than 1 minute during the first 5 minutes after reperfusion • Risk of right heart failure Post Reperfusion syndrome • Manage hyperkalemia, hypocalcemia • Defib pads connected, ready to go Arrhythmias
- 23. Preventive Reactive Predictive Phenylephrine 100 mcg bolus Adrenaline 10 mcg bolus Bicabonate bolus Lidocaine Fluid resuscitation Reperfusion Models
- 24. Monitoring Graft function a rise in body temperature due to increased metabolism hyperglycaemia from enhanced gluconeogenesis, bile production, normalization of coagulopathy, lactate clearance Vasculature Ultrasound/Doppler patent hepatic and portal vasculatures Check before weaning