Hepatic Resection or Transplant Flashcards
What are considerations for hepatic resection/transplant?
- Acute or chronic hepatic failure (Hep B or C, or ETOH cirrhosis)
- Hepatic mets, cholestatic diseases, or donation for hepatic transplantation
Liver failure is a multi-system disease. Explain how it affects CV.
CV: hyperdynamic circulation, increased CI, LVH, PHTN
How does liver disease affect the resp?
Resp: restrictive defect (ascites), pleural effusion, shunting (hepatopulmonary syndrome)
How does liver disease affect Renal?
Renal: hepatorenal syndrome, ATN
How does liver disease affect metabolic?
Metabolic: hyponatremia, hypomagnesemia, hyperkalemia, metabolic acidosis, hypoglycemia
How does liver disease affect heme?
Heme: reduced synthesis of vitamin K dependent factors, DIC, anemia, thrombocytopenia
How does liver disease affect CNS?
CNS: encephalopathy, cerebral edema
What is a major risk of hepatic resection/transplant? what maneuvers can be done to reduce hepatic inflow and reduce bleeding? What does this maneuver do to CO and afterload?
What’s another surgical move that can be done?
Risk of massive bleeding and hemorrhage
Pringle maneuver-clamp portal vein and hepatic artery. This decreases CO, and increases afterload
Total hepatic vascular occlusion can also be done-that is clamping the supra and infra hepatic IVC, portal vein and hepatic artery-this causes hypotension and decreases CO up to 60%.
Postoperative liver failure-what would you see and when?
Jaundice, encephalopathy, coagulopathy-72 hrs post surgery.
What hx would you want to gain from patient prior to going back with hepatic resection/liver transplant?
I would want to assess the presenting conditon-hepatitis B or C, ETOH cirrhosis, tylenol overdose, hepatic tumor or a cholestatic disease (Primary biliary cirrhosis) -autoimmune disease of the liver. It results from a slow, progressive destruction of the small bile ducts of the liver, causing bile and other toxins to build up in the liver, a condition called cholestasis.
what symptoms would you see in a patient requiring hep res/liver transplant? What co-morbid diseases can you expect?
nausea, fatigue, diarrhea, bleeding, pruritus.
Can expect cardiac, respiratory, and renal issues
what things can make this dissection more difficult?
scarring/adhesions can make dissection difficult and increase blood loss
What would you be looking for/see on Physical exam of this patient? What would you be assessing
encephalopathy, ascites, jaundice, scleral icterus, spider angioma, palmar etythema, gynecomastia, and asterixis
I would assess a cardiopulmonary exam and would be looking at sites for IV access, and central access
What lab tests/Imaging would you want to order for this hep resection/liver transplant?
Any consults?
CBC, electrolytes, albumin, bilirubin, PT/INR, ECG, CXR, echocardiogram, cardiac stress as required
Cardiology, intensive care, or neurosurgery as required.
What are conflicts you can have with these patients?
Secure airway quickly and safely (RSI) but also avoid induction hypotension (significant ascites)
How can you optimize these patients from a CV standpoint? When would you avoid this hep resec/liver transplant?
CV: maintain low CVP (goal <5 mmHg)
support MAP with pressors, consider piggyback technique (avoids total vascular occlusion-allows spontaneous return through the IVC) or venovenobypass-especially if patient has cardiac disease (i’m guessing lower preload, hypotension not handled well). Would avoid it if MPAP >35.
what is veno veno bypass?
diverting blood from the inferior vena cava (IVC) and the portal circulation back to the right heart.
How can you optimize these pts from RESP standpoint?
drain large pleural effusions, administer PEEP
How can you optimize these pts from a Renal standpoint?
consider CVVHD for hyperkalemia, renal failure
how can you optimize these pts from a Metabolic standpoint?
aggressively treat hyperkalemia, monitor and treat hypo/hyperglycemia and hyponatremia
How can you optimize these pts from a Heme standpoint?
treat coagulopathy, maintain normothermia, consider TXA or aminocaproic acid or Factor VIIIa as required
How can you optimize pts from CNS standpoint? How can you reduce iscemia/reperfusion injury?
conside ICP monitoring; maintain CPP >60 with norepi, mannitol, hypertonic saline; reduce ischemia-reperfusion injury-consider N acetylcysteine
what are options for anesthesia in this liver resection/hepatic transplant?
GA with ETT-often RSI
Regional anesthesia with combined GA (single shot spinal opioids or continuous epidural-depends on clinical scenario and if there are contraindications.
Preoperatively-what are you thinking as far as Premed/blood, ICU/stepdown?
Premed-gastric PPX and midaz? (card said no?)
Blood: cross match for PRBC, FFP, platelets as requested
ICU bed-definitely
Room setup and special drugs/monitors
Large bore IVs
arterial line
+/- central line, PAC, TEE as required
Foley catheter
Vasopressors, inotropes, insulin, blood products, abx, immunosuppresants and CVVHD as required
Rapid transfusion device and cell salvage as indicated
How would you induce these pts?
GA/ETT with RSI. Avoid induction hypotension
Maintenance of these pts? If the pt experiences reperfusion hypotension-what is your DDx? How would you treat?
Balanced technique-avolid N20 due to chance for gas embolus
reperfusion hypotension: DDX-acidosis, hyperkalemia, hypocalcemia, and hypovolemia
I would treat with hyperventilation, sodium bicarbonate, insulin, CACL2, blood products and epinephrine.
Emergence of these patients:
Assess airway-keep intubated if required
Disposition/pain for these patients:
What should you avoid?
ICU as required, monitor for bleeding, liver, renal, or metabolic dysfuction. AVOID TYLENOL and paracetamol
