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Anaesthesia for Liver transplantation
The document provides a comprehensive overview of liver transplantation, detailing its history, indications, complications, and management strategies. It discusses various physiological and pathological considerations, including preoperative, intraoperative, and postoperative phases for both recipients and living donors. Specific attention is given to complications such as cirrhotic cardiomyopathy, hepatic encephalopathy, and various forms of hypertension related to portal hypertension, along with their diagnostic criteria and treatment options.
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Anaesthesia for Liver transplantation
- 1. Liver Transplantation Speaker: DrS. N Bhagirath Moderated by Dr Jayanth
- 2. History • First humanliver transplantation – 1963 • Attempted by Thomas Starzl • First recipient was a three year old – unsuccessful • First Successful transplant was in 1967
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- 5. Pathophysiology Chronic Parenchymal Inflammation& Necrosis Fibrosis Disruption of hepatic architecture Increased resistance to blood flow Portal HTN Formation of vascular shunts between portal & systemic shunts 10 – 12 mm of Hg of pressure gradient between portal & hepatic veins Complications Ascites, Esophageal Varices, Encephalopathy, Hepatorenal Syndrome
- 6. Complications - Cardiovascular PortalHTN Vasodilators • Natriuretic Peptides • VIP • Endotoxin • Glucagon • Nitric Oxide Circulating volume sequestered into splanchnic circulation • Low SVR/ Low Arterial Blood Pressure • Hyperdynamic Circulation – High CO • Blunted response to Sympathetic stimulation Cirrhotic Cardiomyopathy
- 7. Complications - Cardiovascular CirrhoticCardiomyopathy • Systolic dysfunction – inability to increase CO • Diastolic dysfunction – Vulnerability to Heart failure • Resistance to β-adrenergic stimulation • Electro physiologic abnormalities • Autonomic dysfunction Chronotropic/ Hemodynamic incompetence Prolonged QTc interval • Increased risk of CAD
- 8. Complications - Pulmonary TwoEntities Hepatopulmonary Syndrome Porto-Pulmonary Syndrome • Fluid retention • Pleural Effusion • Decreased lung capacity sec to large volume ascites • α – 1 Antitrypsin deficiency Broad Etiology
- 9. Complications – Pulmonary– Hepatopulmonary Syndrome Diagnostic Criteria • Portal HTN • PaO2 < 80 mm of Hg on room air or Alveolar – Arterial O2 gradient > 15 mm of Hg • Evidence of Intrapulmonary Vascular Dilatation (IPVD) More about IPVD • Normally, Micro bubbles/ Albumin injected into venous circulation get trapped in pulm. capillary bed • But with IPVD, these are no longer trapped • They re-appear in left atrium (2D Echo) • Suggestive of increase in pulm. capillary diameter from between 8 – 15 μm to 50 – 500 μm • This compromises O2 diffusion causing hypoxia
- 10. Complications – Pulmonary– Porto-pulmonary Syndrome Definition • Pulm. HTN in presence of Portal HTN Diagnostic Criteria • Clinical evidence of Portal HTN • Mean Pulm. artery pressure of 25 mm of Hg. at rest or 30 mm of Hg. during exercise • Mean Pulm. artery occlusion pressure < 15 mm of Hg • PVR > 240 Dyn Sq. Cm2 or 3 Wood units. Implication • Poor prognosis for liver transplantation (without treatment) • Post – treatment P.A. pressure < 35 mm of Hg. & PVR < 400 Dyn Sq. Cm2 Favourable candidates for Liver transplantation
- 11. Complications – Renal– Hepatorenal Syndrome Definition • Pre-renal abnormality due to circulatory derangements Etiology • NO & other vasodilators which divert circulation thus compromising renal perfusion. Type I HRS Type II HRS • Rapidly progressive Renal Failure • Doubling of Creatinine over 2 weeks • Precipitating causes: Sepsis, Peritonitis, Surgical Stress • Median survival – 2 – 4 weeks. • Median survival – 6 months Treatment 1. Arginine – Vasopressin 2. Nor-Epinephrine, Somatostatin 3. Midodrine 4. Volume expansion 5. TIPS 6. Definitive treatment – Liver Transplantation. Focus not on renal vasodilation but on splanchnic vasoconstriction
- 12. Complications – HepaticEncephalopathy Definition • Serious, reversible neuro-psychiatric complication Etiology • Hyperammonemia • Gut – derived neurotoxins • γ – Amino butyric Acid • Oxidative stress, Inflammatory mediators • Hyponatremia • Abnormal Serotonin/ Histamine Neurotransmitters Treatment 1. Non-absorbable Disaccharide - Lactulose 2. Non-absorbable Antibiotics – Neomycin, Metronidazole, Rifaximin. 3. Floral washout reduces production of Ammonia. Etiology • Uremia – Sepsis • Glucose & Electrolyte abnormalities • Endocrinopathies • Infections • Vascular lesions
- 13. Complications – Ascites Etiology• Cirrhosis • Malignancy • Cardiac Failure • Renal disease • Pancreatitis • Tuberculosis Eventuality May progress to Spontaneous Bacterial Peritonitis Management • Serial Paracentesis • Liver Transplantation • TIPS placement • Peritoneovenous shunt • Never rapidly correct Hyponatremia–Central Pontine Myelinosis
- 14. Complications – Varices Definition• Dilatation of Porto – Systemic shunts sec to Portal HTN Diagnosis • Wedge Hepatic Venous Pressure (WHVP) > 10 – 12 mm of Hg. • Gold standard – Esophago-gastro duodenoscopy Acute Variceal Bleeding 1. Intravascular volume resuscitation 2. Correction of severe coagulopathy 3. Pharmacologic manipulation of portal pressure (eg. Vasopressin & Somatostatin) 4. Endoscopic variceal ligation 5. Elective Intubation 6. Balloon Tamponade Treatment • Non selective β - Blockers (β1 reduces Cardiac Output & β2 causes Splanchnic Vasoconstriction) • Endoscopic Ligation • TIPS Buy time until Liver Transplantation.!
- 15. Complications - Hemostasis •Imbalance between Pro and Anticoagulant factors • Thrombocytopenia (Splenic sequestration) • Altered Fibrinolysis (TEG) • DIC
- 16. Why are allthese important..? Liver Transplant Recipient AUTONOMIC DYSFUNTION HEPATORENAL SYNDROME HEPATIC ENCEPHALOPATHY ASCITES VARICES ACUTE VARICEAL BLEEDING COGULATION ABNORMALITIES PRE-EXISTENT CO-MORBIDITY HEPATOPULMONARY SYNDROME PORTOPULMONARY HYPERTENSION BUNTED RESPONSE TO SYMPATHETIC STIMULATION CIRRHOTIC CARDIOMYOPATHY For Pre-operative preparation Alert the Blood Bank Neurologist consultation Nephrologist consultationCardiologist consultation, Inotropic Support, etc. Pulmonologist consultation Oral immunosuppresants / bowel decontamination antibiotics
- 17. Preoperative considerations 1. CompleteBlood Work Up • Hb, Platelets, WBCs, INR, Coagulation profile with Fibrinogen and PTT, ABG • Electrolytes – Na+, K+, Cl-, Mg2+ Ca2+, Phosphate 2. Liver Function Tests • Albumin (drug binding and oncotic pressure) 3. Renal Function Tests • Urea and Creatinine 5. Baseline Cytomegalovirus and Epstein Barr Virus status. 6. Blood cultures 7. Chest X Ray • Fluid overload, Infection 5. 2D Echo (Pulm. HTN/ Hepatopulmonary Syndrome) 6. Complexity of previous surgery (e.g.: Kasai’s Procedures)
- 18. Preoperative considerations 1. SpecificMedication • Immunosuppressants: Tacrolimus 0.2 mg/kg, Cyclosporine 5 mg/kg • Mycostatin: 2 – 5 ml • Depending on Coagulation status: transfuse 1 FFP. 2. Premedication • Anxiolysis (especially in children): 0.25 – 0.5 mg/kg • Supplemental O2 (in presence of HPS) 3. Counseling • Psychological counseling to dispel fears and answer any lingering doubts.
- 19. Intraoperative considerations -Preliminaries 1. Rapid Sequence Induction 2. Arterial Blood Pressure monitoring 3. CVP 4. PA Cath (?) 5. TEE 6. Rapid Infusion Systems 7. Volatile Anaesthetic – 0.5 to 1.0 MAC (preferably Isoflurane as it preserves Splanchnic Circulation) 8. Opioid (Fentanyl) 9. Muscle Relaxant (Cis-atracurium)
- 20. Intraoperative considerations –Stages of surgery 1. Preanhepatic stage Surgical Incision Vascular exclusion of native liver 2. Anhepatic stage Vascular occlusion Graft Reperfusion (inflow to liver obstructed) 3. Neohepatic stage Post reperfusion via portal vein
- 21. Preanhepatic stage (Dissection) SubcostalIncision dissection of liver retaining the vascularity.
- 22. 1. Trial clampingof infrahepatic IVC for 30 – 60 seconds 2. Anesthesiologist should judge CVS effects, adequacy of blood replacement and patients ability to withstand drop in preload. 3. If SBP falls by 70% of pre-existent values, then bypass support may be needed. Trial Clamping Preanhepatic stage (Dissection Phase) Considerations 1. Blood loss, Manipulation of liver hilum and direct compression of IVC. 2. Adequate volume resuscitation (blood & colloid) is required. 3. Calcium chloride is preferred over Calcium Gluconate.
- 23. Anhepatic stage Clamping of •Suprahepatic IVC • Infrahepatic IVC • Portal Vein • Hepatic Artery Diversion of portal flow via Venovenous bypass to axillary v. Clamping of vessels before hepatectomy.
- 24. Anhepatic stage Order ofanastomosis • IVC Clamp – Suprahepatic, then Infrahepatic IVC • Portal Vein • Hepatic Artery Order of clamping 1. Suprahepatic IVC 2. Infrahepatic IVC 3. Portal Vein 4. Infrahepatic IVC Removal of Vascular clamps • Portal Vein • Suprahepatic IVC • Infrahepatic IVC
- 25. Anhepatic stage DisadvantagesAdvantages Venovenous bypass 1.Prevention of precipitous reduction in preload 2. Improves Renal Perfusion Pressure 3. Lessens Splanchnic Congestion 4. Delays development of Metabolic Acidosis 1. Air Embolism 2. Thromboembolism 3. Inadvertent decannulation 4. Delays development of Metabolic Acidosis Fibrinolysis during anhepatic stage is a risk due to unopposed action of tissue plasminogen activator.
- 26. Neohepatic stage 1. Whenwas it harvested i.e. Graft Ischemia time.? 2. Is the Graft compatible.? 3. Is the donor an adult or child.? (dictates requirement of size down surgery on the side and consequent blood loss) 4. Has the new liver been washed to minimize reperfusion effects.? (washed with Stabilized Human Serum, Ringers Lactate or Albumin) 5. If the Liver was cut down, how was the free edge sealed (This has an impact on blood loss following revascularisation) What do we need to know about the new liver..?
- 27. Neohepatic stage Reperfusion ofgraft through portal vein Consequences of Reperfusion 1. Hyperkalemia • ECG changes • Calcium Chloride/ Sodium Bicarbonate – treatment • Albuterol & Insulin • Intraoperative Dialysis 2. Hydrogen ion concentration increases 3. Increase in preload 4. Decrease in SVR, decrease in B.P. Post – Reperfusion Syndrome Azathioprine, Medrol 10 mg/kg Antibiotics
- 28. Neohepatic stage Systemic Hypotension+ Pulmonary HTN (5 mins) 1. Probable Causes • Hyperkalemia • Acidosis • Hypothermia • Air/ Thrombotic emboli • Vasoactive substances • First venous reperfusion, then arterial anastomosis and biliary reconstruction comes later. Post – Reperfusion Syndrome 1. Risk factors for PRS • Elevated Preanhepatic K+ levels • Use of “donated after cardiac death” liver • Suboptimal grafts i.e. > 50 yrs. of age h/o Cardiac arrest Hypotension Need for high dose inotropes > 5 days of ICU stay Elevated Liver fat content • Graft Cold Ischemia time > 6 hours
- 29. Steps & Implications Hypovolemia Colloid Infusion Bleeding/Coagulopathy 1. FFP after Incision 2. Prothrombin Complex Concentrates (PCCs) 3. Recombinant activated factor VII 4. Parameters to assess • TEG • PT • Fibrinogen • Platelet Count Risk of TRALI, Circ. Overload Thrombo-embolic complications I. Abdominal Incision & Drainage of Ascites II. Hyponatremia Central Pontine Myelinosis
- 30. Steps & Implications Hyperkalemia III.Blood Transfusions - Citrate Intoxication VII. Other precautions Hypocalcaemia, Hypomagnesaemia IV. Reperfusion 1. Hourly blood gases 2. Electrolytes, Glucose, Ionised Ca2+ and Hb levels 3. Maintain Urine Output V. Hyperglycaemia Wound site infection Diuretics, Insulin + Glucose or last resort Dialysis VI. Massive Infusions Hypothermia Heated Venovenous bypass
- 31. 1. Preanhepatic stage 2.Anhepatic stage 3. Neohepatic stage Bleeding Cardiovascular Compromise Hypoglycemia Hypoglycaemia Hypocalcemia Severe Hypotension Bradycardia Arrhythmia Dyselectrolytemia
- 32. Signs of successfulgraft function 1. Decreased Ca2+ requirements. 2. Improvements in acidosis. 3. Increased Urine Output. 4. Rise in core temperature. 5. Bile Output. Antifibrinolytics Graft Endothelial cell Tissue Plasminogen activator releases Severe Fibrinolysis Treatment with Antifibrinolytics & cryoprecipitates.
- 33. Post Operative Care BroadBased goals 1. Hemodynamic Stability 2. Metabolic Homeostasis 3. Analgesia • Opioids • Patient Controlled infusion • Epidural analgesia is contraindicated (Coagulopathy) 4. Monitoring Graft Function • Transaminase levels • PT • Bilirubin levels • Bile • Urine Output • Acid Base Status
- 34. Post Operative Care BroadBased goals 5. Watch out for • Bleeding • Bile leaks • Vascular thrombosis • Primary Non-function • Hyperglycemia (steroid usage) 6. Bear in mind • Derangement of Transaminase levels (first 2 -3 days) is common. Persistence beyond this period should raise suspicion of Hepatic Artery Thrombosis. • No clear guidelines for early extubation.
- 35. Organ Matching andallocation Primary Criteria 1. ABO Blood type 2. Graft Size • ABO incompatible is for emergent situations. • Disease severity decides que priority • Disease severity was earlier assessed by Child – Turcott – Pugh Score 1 2 3 Encephalopathy None 1-2 3-4 Ascites Absent Slight Moderate Prothrombin time <4 4-6 >6 Albumin >3.5 2.8 – 3.5 <2.8 Bilirubin <2 2-3 >3
- 36. Organ Matching andallocation • Presently Disease severity is assessed by MELD score 1. Serum Bilirubin 2. Creatinine level 3. INR • MELD score fails to recognise HCC patients early on so they are given priority. • MELD score between 12 – 14 benefit most from Liver Transplantation.
- 37. Living Liver Donor 1.First introduced in 1988 2. Full regeneration in 2 – 3 weeks 3. For pediatric recipients – left lobe is preferred 4. For adult recipients – right lobe is preferred Anaesthetic Management 1. G.A.+ IPPV + Muscle relaxant 2. Adequate Venous Access 3. Arterial line 4. Nasogastric Tube
- 38. Living Liver Donor 1.During mobilization of liver watch for hypotension and bradycardia 2. To minimize blood loss • Maintain low CVP (<5 cms H2O) (decreases Graft Edema) • However, newer surgical techniques no longer require low CVP. Anaesthetic Management Blood Saving Strategies 1. Cell salvage technique 2. Preop donation of 1 – 2 units of autologous blood. 3. Intraoperative isovolemic hemodilution with retrieval of 1 – 2 units of blood.
- 39. Living Liver Donor 1.Living donors can be extubated 2. Discontinuation of Mechanical ventilation reduces intrathoracic pressure which reduces congestion. 3. Maintain optimal perfusion of liver by • Adequate CO • Avoidance of Hypovolemia • Anemia • Hypothermia induced coagulopathy 4. Post op analgesia • Epidural Placement is advised (risk of hematoma due to coagulopathy have to be weighed) 5. Statistical • R Hepatectomy has higher complication than L Hepatectomy.
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