Liver 5 Flashcards
The anhepatic phase begins with
removal of the native liver
The anhepatic phase ends with
implantation of the donor liver
Surgical objectives of the anhepatic phase inlcude
removal of sick liver
implantation of donor liver
Neohepatic phase begins with
reperfusion of donor liver
The neohepatic phase ends with
biliary anastomosis (or transport to the ICU)
Surgical objectives of the neohepatic phase include
reperfusion of donor liver
anastomosis of hepatic artery
anastomosis of biliary structures
During the pre-anehpatic phase, patients are at risk of
gastric regurgitation and pulmonary aspiration d/t liver disease and ascites
The pre-anhepatic phase dictates a
rapid sequence induction
Items needed in the pre-anhepatic phase include
rapid infuser to administer warm fluids and replace blood products as needed b/c significant blood loss is a risk
Goals of the pre-anhepatic phase include
hgb >7 g/dL
platelets >40,000
fibrinogen >100 mg/dL
and MA (TEG) >45
With the pre-anhepatic phase, anticipate
CV instability (hypotension) as a result of drainage of ascites, compression of vascular structures, and ongoing blood loss
A lower CVP will reduce
blood loss during surgical dissection
Just before clamping the IVC, increase the CVP to
10 cmH2O
What are the approaches the surgeon can use for hepatic isolation?
bicaval clamp
piggyback technique
venovenous bypass
The bicaval clamp is when
clamps are applied to the IVC (above and below the liver) for full obstruction of IVC flow
Special considerations of the bicaval clamps include
significant preload reduction (hypotension, tachyardia)
aggressive fluid administration to combat hypotension can lead to volume overload when the clamps are released
The piggyback technique is when there is
side clamping of the IVC (partial obstruction to IVC flow)
Special considerations of the piggyback technique include
less preload reduction as compared to bicaval clamping
reduced operating and warm ischemic times
fewer blood products required
What is the venovenous bypass?
sites of cannulation include femoral vein & portal vein (outflow sites towards pump)
site of cannulation: axillary vein (return to body)
Special considerations of venovenous bypass include
piggyback technique has reduced the need for VVB
VVB is a reasonable choice if the patient does not tolerate piggyback
associated with less hemodynamic instability, less blood loss, and prevention of portal and splanchnic congestion but it has a higher complication rate
During the anhepatic phase, the patient will have no
liver function
Common problems during the anhepatic phase include
worsening coagulopathy, ongoing blood loss, lactic acidosis, and hypoglycemia
__________________ is used to combat acidosis during the anhepatic phase
Sodium bicarbonate (or another buffer)
How often should labs be monitored during the anhepatic phase?
q15-30
In preparation for reperfusion, pay close attention to
serum potassium as it will get higher when the donor liver is reperfused
Warm ischemic times begins when the donor liver is
removed from the ice and extends until the donor liver is reperfused
Warm ischemic time should not exceed
30-60 minutes
Key complications of the neohepatic phase include
hyperkalemia
hypocalcemia
cytokine release
lactic acidosis
embolic debris
hypovolemia
systemic hypotension
pulmonary hypertension
hypothermia
cardiac arrest
The risk of hyperkalemia is highest during
the neohepatic phase
First-line pharmacologic treatment for hyperkalemia includes
calcium chloride and sodium bicarbonate
Avoid _________ as this will cause congestion in the graft
increased CVP
Findings that suggest good graft function include
stabilization of serum glucose and acid-base status as well as prompt return to normothermia
Post-reperfusion syndrome is defined as
systemic hypotension more than 30% below baseline for at least 1 minute during the first 5 minutes of reperfusion of the donor liver
Signs of a poorly functioning graft include
continued hemodynamic instability and lack of bile output
Pain control for liver transplants typically includes _____ and not __________
opioids (often PCA) and not epidural analgesia b/c of coagulation status
Post-op considerations for liver transplant include
steroid-induced hyperglycemia
antirejection medications impact immune function
All of the following drugs improve biliary hypertension EXCEPT:
a. naloxone
b. nitroglycerine
c. glucagon
d. octreotide
d. octreotide
The most common gallbladder diseases are caused by
obstruction or inflammation
_____________increases the risk of PONB
glucagon
_________ can precipitate spasm of the sphincter of oddi
opioids- problem if it causes a false-positive during a cholangiogram
You can relax the sphincter of oddi with
glucagon, naloxone, or nitroglycerin
glycopyrrolate and atropine may help as well
___________ can cause an obstructive defect that impedes the flow of bile as well as pancreatic enzymes
Biliary stones
If bile and pancreatic enzymes can’t move into the small intestine, then they
back up into the liver and the pancreas
Obstruction of the cystic duct leads to
gallbladder distension
edema
risk of perforation
& jaundice
Obstruction of the common bile duct leads to
cholecystitis
jaundice
pancreatitis
peritonitis
The incidence of gallstones increases with
obesity, aging, rapid weight loss, pregnancy, and women>men
S/sx of biliary stones include
leukocytosis, fever, and RUQ pain
pain is worse with inspiration (Murphy’s sign)
Prolonged NPO status increases the
likelihood of gallstone formation
Biliary pathology includes
increased alkaline phosphatase, increased conjugated bilirubin, increased amylase, increased Y glutamyl transpeptidase, and increased 5’-nucleotidase
Treatment of cholecystitis and cholelithiasis is
cholecystectomy
treatment of choledocholithiasis is
ERCP
Choledocholithiasis is
stones in the common bile duct
___________ should be avoided due to bowel distension
Avoid N2O
If there is liver dysfunction, ____________ should be selected
a benzylisoquinolinium NMB (cisatracurium or atracurium)
Using naloxone in a surgical patient is
a poor choice
