Scribd
Upload
19 views21 pages

Anesthesia For Hepatectomy and Liver Transplantation

Uploaded by

sajid aalam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
19 views21 pages

Anesthesia For Hepatectomy and Liver Transplantation

Uploaded by

sajid aalam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 21

Anesthesia for Hepatectomy

and Liver Transplantation


- DR NIROJ KARKI
Outline

 Introduction
 Liver Transplant
 Preoperative Considerations
 Intraoperative Management
 Postoperative Management
 Living Donor Transplantation
Introduction

 Hepatic surgeries, including resections and transplants, pose


unique challenges due to significant blood loss and
complications associated with liver disease.
 Anesthetic management requires careful monitoring and
balancing intravascular volume for hepatic perfusion while
minimizing bleeding.
 Goal-directed fluid therapy is recommended, and
antifibrinolytics may reduce blood loss. Postoperative
complications include hepatic dysfunction, sepsis, and pain
hindering mobilization.
 Mechanical ventilation may be necessary postoperatively.
Liver Transplant

 Opening a liver transplantation program necessitates


appointing a qualified liver anesthesia director, typically an
anesthesiologist with specialized experience.
 A dedicated team of anesthesiologists should be assembled,
well-versed in the indications, contraindications, and
perioperative implications of associated comorbidities such as
coronary artery disease, cirrhotic cardiomyopathy, and others.
 Studies show that this comprehensive approach leads to
improved outcomes, including reduced blood transfusions,
decreased need for postoperative mechanical ventilation, and
shorter intensive care unit stays.
Contraindications
Preoperative Considerations

 The Model for End-stage Liver Disease (MELD) score is used by the United
Network for Organ Sharing (UNOS) to prioritize patients on the liver
transplantation waiting list.
 The score is based on the patient’s serum bilirubin, serum creatinine, and INR
and is a predictor of survival time if the patient does not receive a liver
transplant.
 A score of 20 predicts a 20% risk of mortality at 3 months, whereas a score of
40 predicts a 71% risk of mortality at 3 months
• Multiply the resulting value by 10, and round to the nearest whole
number. The minimum for all values is 1.0; the maximum value for
creatinine is 4.0.

• Most liver transplant candidates have high MELD scores and


present with jaundice, kidney failure, and coagulopathy.
• Patients undergoing liver transplantation may present with jaundice, kidney failure,
coagulopathy, emaciation, massive ascites, and comorbidities such as encephalopathy,
hepatopulmonary syndrome (HPS), cirrhotic cardiomyopathy, and portopulmonary
hypertension (POPH).

• They often exhibit increased cardiac index and reduced systemic vascular resistance.

• Anticipating significant blood loss, large-bore intravenous catheters should be placed,


and a rapid infusion pump made available.

• Intraarterial pressure monitoring is routine, and transesophageal echocardiography (TEE)


is widely used.
• Pulmonary artery catheterization is replaced by central venous catheterization
and TEE in many centers, except for concerns regarding POPH or cirrhotic
cardiomyopathy.

• The immediate availability of intraoperative continuous venovenous


hemodialysis (CVVHD) is beneficial for volume and electrolyte management
in patients with compromised kidney function.

• CVVHD allows for close management of electrolyte abnormalities by


adjusting the dialysate solution.
Intraoperative Management
• Hepatic disease leads to endothelial dysfunction, which affects all organs.

• The heart may develop cirrhotic cardiomyopathy, while the brain may experience
encephalopathy and eventual cerebral edema.

• Hepatorenal syndrome and eventual acute tubular necrosis may affect the
kidneys.

• The lungs may suffer from hepatopulmonary syndrome (HPS) or portopulmonary


hypertension.

• As a result, each organ must be meticulously managed during both the operative
procedure and postoperative period.
• In patients with cerebral edema, maintaining cerebral perfusion
pressure (CPP) is paramount, with some centers monitoring
intracranial pressure.
• Additional protective measures include:
• Elevating the head by 20°.
• Inducing mild hypothermia.
• Maintaining mild hypocarbia.
• Providing vasopressor support to sustain mean arterial pressure.

• To ensure accurate determination of CPP when the head is


elevated, the arterial pressure transducer should be zeroed at the
level of the external auditory meatus.
• Coagulopathy during liver surgery is managed using point-of-care viscoelastic
coagulation assays (TEG, ROTEM, or Sonoclot) or conventional coagulation
tests.

• Transfusions aim to maintain a hemoglobin level greater than 7 g/dL due to


potential significant blood loss.

• Transfusions during liver surgery are limited to maintain low central venous
pressure (CVP) and prevent liver congestion and dysfunction.

• Coagulopathies often resolve with a healthy new liver, but factors promoting
bleeding should be corrected.

• Intraoperative platelet and fresh frozen plasma transfusions should be carefully


administered.
• The preanhepatic phase focuses on managing hemodynamic changes due to blood loss and
compression of major vessels during surgical dissection.

• Entry into large varices can lead to significant blood loss, requiring careful monitoring and
intervention.

• Hyponatremia management should avoid rapid correction to prevent osmotic demyelination


syndrome.

• Hyperkalemia may necessitate aggressive treatment such as diuresis, transfusion of washed


packed red blood cells, or continuous venovenous hemodialysis (CVVHD).

• Citrate toxicity, leading to hypocalcemia, can occur with blood transfusion, necessitating
close monitoring and administration of calcium salts.

• Maintaining a low central venous pressure (CVP) is beneficial for minimizing blood loss
while ensuring adequate systemic arterial pressure.
• The anhepatic phase initiates with vascular occlusion of the
liver's inflow and concludes with reperfusion.

• Some centers employ venovenous bypass to prevent visceral


organ congestion, improve venous return, and potentially
safeguard kidney function.

• In cases with few varices, such as hepatocellular cancer patients,


total or partial occlusion of the vena cava may lead to a
significant low-flow state due to reduced venous return to the
heart.
• Many transplant centers administer 3000 units of intravenous heparin three
minutes before applying the cava clamp to prevent clotting during the "low-
flow state".

• In the neohepatic phase, reperfusion of the graft via the portal vein may trigger
two pathophysiological events.

• The first is reperfusion syndrome, characterized by hypotension, right heart


dysfunction, arrhythmias, and even cardiac arrest, preempted to some extent
by prophylactic calcium chloride and sodium bicarbonate administration.

• The second event is hepatic ischemia/reperfusion injury, stemming from


impaired reperfusion due to severe endothelial dysfunction, occasionally
leading to primary graft nonfunction.
Postoperative Management

• Malnourished patients with multiorgan dysfunction require


meticulous support and continuous monitoring until they recover.
• Early extubation is suitable for patients who are comfortable,
cooperative, and not experiencing bleeding.
• Immunosuppression must be carefully regulated to reduce the
risk of sepsis.
• Close monitoring of graft function is essential, with a low
threshold for assessing hepatic artery patency and flow.
• Postoperative complications such as bleeding, biliary leaks, and
vascular thromboses may necessitate surgical reexploration.
• Patients with elevated intracranial pressure (ICP) or at risk of its development
should ideally have ICP monitoring to facilitate the management of cerebral
perfusion pressure (CPP).
• Management strategies for patients with elevated ICP or at risk include:
• ICP maintained below 20 mm Hg
• CPP maintained above 50 mm Hg
• Mean arterial pressure (MAP) maintained above 60 mm Hg
• Proper bed positioning with the head elevated by 20-25°
• Controlled airway and ventilation
• Controlled sedation, such as with propofol
• Vasopressor support like vasopressin or norepinephrine as needed
• Controlled hypothermia within the range of 32-33°C
• Glycemic control
• Aggressive treatment of metabolic acidosis and coagulopathy
• Continuous venovenous hemodialysis (CVVHD) if indicated
Living Donor Transplantation
• The utilization of living donors has expanded the pool of available organs for
transplantation, yet it exposes healthy individuals to risks of morbidity and
mortality.

• Obtaining informed consent from donors is imperative, ensuring they


understand the associated risks and that consent is freely given without
coercion, especially considering potential emotional pressures on family
members.

• In donor anesthesia protocols, maintaining a central venous pressure (CVP)


below 5 cm H2O is often employed to minimize intraoperative blood loss.
• Adequate postoperative analgesia is crucial for comfortable
extubation of donor patients, often achieved through
techniques like transversus abdominus plane (TAP) block with
rectus sheath block.

• Complications for donor patients may include transient hepatic


dysfunction, wound infection, postoperative bleeding, portal
vein thrombosis, biliary leaks, and rarely, death.

• An increased incidence of perioperative brachial plexus injury


has been reported, possibly due to rib cage retraction during
the procedure.

• Postoperative monitoring of hepatic artery flow in the recipient


is commonly performed overnight using an implantable
Doppler probe in many centers.

You might also like