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liver transplant Flashcards

0
Q

Organ Transplant Objectives

  1. Identify the unique anesthetic implications of organ transplant surgery.
  2. State the comorbidities associated seen in renal and liver transplant patients. Discuss the alterations in metabolism, hemodynamics, neurologic changes, pulmonary, etc.
  3. Describe the blood, blood component, and fluid requirements for each type of transplant recipient case (heart, liver, renal), renal donor case, and prior heart transpant patient presenting for surgery.
  4. Identify the characteristics of a denervated heart and the anesthetic implications.
  5. State the medications that must be available during a renal transplant case.
  6. Describe the hemodynamic changes that can occur during a renal transplant case, why they occur, and the appropriate intervention.
  7. Recognize safe and unsafe mediations for a prior renal transplant patient.
  8. State the correct albumin replacement dosage during a liver transplant case.
A

-Organ Transplant Objectives

  1. Identify the unique anesthetic implications of organ transplant surgery.
  2. State the comorbidities associated seen in renal and liver transplant patients. Discuss the alterations in metabolism, hemodynamics, neurologic changes, pulmonary, etc.
  3. Describe the blood, blood component, and fluid requirements for each type of transplant recipient case (heart, liver, renal), renal donor case, and prior heart transpant patient presenting for surgery.
  4. Identify the characteristics of a denervated heart and the anesthetic implications.
  5. State the medications that must be available during a renal transplant case.
  6. Describe the hemodynamic changes that can occur during a renal transplant case, why they occur, and the appropriate intervention.
  7. Recognize safe and unsafe mediations for a prior renal transplant patient.
  8. State the correct albumin replacement dosage during a liver transplant case.
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1
Q

HEPATIC TRANSPLANT

  • discuss cantidates for othotopic liver transplant
  • discuss preoperative assessment for liver failure
  • discuss alteration in pharmacokinetics/dynamics
  • discuss preoperative preparation
  • discuss induction and maintenance of anesthesia
  • discuss anesthetic considerations during first 3 phases of liver transplant surgery
A

HEPATIC TRANSPLANT

  • discuss cantidates for othotopic liver transplant
  • discuss preoperative assessment for liver failure
  • discuss alteration in pharmacokinetics/dynamics
  • discuss preoperative preparation
  • discuss induction and maintenance of anesthesia
  • discuss anesthetic considerations during first 3 phases of liver transplant surgery
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3
Q

(1)

what type of patients NEED an othotopic liver transplant?

A

(1)
what type of patients get othotopic liver transplant?
1. end stage chronic liver disease (cholecystatic, hepatpocellular, vascular disease)
2. fulmonate liver failure (viral hepatitis, toxins, wilson’s disease)
3. inherited metabolic abnormalities (primary hyperoxaluria, famial cholesterolemia)
4. hepatic malignancies

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4
Q

(2)

what are current CONTRAINDICATIONS to liver transplant:

A

(2)
what are current contraindications to liver transplant:
-widespread malignancy
-uncontrolled infection outside of the hepatobilliary tree
-severe cardiac disease (HUGE VOLUME SHIFTS)
-major neurologic pathology
-intractable drug or alcoholism (have to be clean for x months to be considered)
-acuired immunodefeciency syndrome (aids or other)
-inability to maintain imunosuppressive medication post op (mental illness, mental retardation etc.)

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5
Q

(3)

what are conditions which may COMPLICATE liver transplant:

A

(3)
what are conditions which may complicate liver transplant:
-advanced age
-hepatic encephalopathy
-chronic renal failure
-severe hypoxemia
-protal vein thrombosis
-prior portosystemic shunt (if you have had prior shunting, it may be too late)
-massive ascites
-associated malignancies (cholangiocarcinoma)- (once you have cancer, it is too late)

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6
Q

(4)
liver transplant cantidates
liver transplant should be performed BEFORE progressive clinical deterioration:
AEB:

A

(4)
liver transplant cantidates
liver transplant should be performed before progressive clinical deterioration: AEB:
-preterminal varicial bleeding
-irreversible hepatorenal or hepatopulmonary syndrome
-

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7
Q

(5)
cantidates for liver transplantation: should be performed BEFORE____
1-7

A

(5)
cantidates for liver transplantation: should be performed before [progressive clinical deterioration]
1. preterminal variceal bleeding
2. irreversible hepatorenal or hepatopulmonary syndrome
3. progressive catabolic state
4. hemodynamic instability
5. uncorrectable coagulopathy
6. hemodynamic instability
7. subacute bacterial peritonitis or sepsis
E

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8
Q

(6)

in other words, your patient is too late to have a transplant if:

A

(6)

  1. bleeding from varices (pre terminal)
  2. has renal failure or respiratory failure d/t liver
  3. is wasting away
  4. has brain damage
  5. has coagulopathy but has not had vitamin k or cryo
  6. blood pressure /HR are (too low/ too high) unstable
  7. infection to peritoneum or sepsis
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9
Q

(7)
assessment of potential liver transplant patient:
1. is hepatic failure pattern predictable?
2. what issues are superimposed on top of the failing liver?

A

(7)
assessment of potential liver transplant patient:
1. is hepatic failure pattern predictable?
–yes, it has a predictabe pattern of clinical manifestations either directly related to the failing liver or its affect on oher organ systems.
2. what issues are superimposed on top of the failing liver?
–the effects of hepatotoxins (alcohol) or infectious organisms (viral hepatitis) on organ systems other than the liver

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10
Q

(8)

what 3 clinical pulmonary dysfunction issues will a patient with hepatic failure have?

A

(8)
what 3 clinical pulmonary dysfunction issues will a patient with hepatic failure have?
1. intrapulmonary shunting: caused by intrapulmonary vascular dilation
2. VQ mismatch: caused by pleural effusions, ascites, diaphragm dysfunction and increased closing capacities
3. diffusion abnormalities: caused by interstitial pneumonitis and/or pulmonary HTN; also by impaired hypoxic pulmonary vasoconstriction

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11
Q

(9)
pre op assessment of patient with acute or chronic liver disease:
PULMONARY:
1. what happens to lungs (1-3)?
2. how should you treat #3?
3. what should you do with a liver patient with copd to alleviate pulmonary symptoms?

A

(9)
pre op assessment of patient with acute or chronic liver disease:
PULMONARY:
1. what happens to lungs?
–a restrictive lung defect can occur from
—-depleted skeletal muscle mass,
—-osteoporosis
—-the presence of pleural effusions/ascites
2. how should you treat these?
–drainage of pleural effusions
3. what should you do with a liver patient with copd to alleviate pulmonary symptoms?
–bronchodilator therapy if obstructive lung disease (copd)

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12
Q

(10)
pre op assessment of patient with acute or chronic liver disease:
CARDIAC: (part 1)
1. What happens to hemodynamic numbers?
1b. In what percent of pre-transplant patients?
2. what is this phenomenon not to be confused with?
3. why does this occur (3 theories)?
4. what is the formula for SVR?

A 
(10)
pre op assessment of patient with acute or chronic liver disease:
CARDIAC: (part 1)
1. What happens to hemodynamic numbers?
--increased C.I.
--decreased SVR
1b. In what percent of pre-transplant patients?
--69%
2. what is this phenomenon not to be confused with?
--hyperdynamic circulation with sepsis
3. why does this occur (3 theories)?
--SNS overactivity
--inadequate clearence of vasoactive substances
--presence of AV shunts
--relative hypoxia in peripheral tissues
4. what is the formula for SVR?
--[(MAP-CVP)/CO] * 80
(map-cvp/c.output *jerry rice)
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13
Q

(11)
pre op assessment of patient with acute or chronic liver disease:
CARDIAC (PART 2):
1. What issues will be seen LESS in patients with cirrhosis?
1b. why?
2. what cardiac disease should be considered?
2b. especially in what age patient?
3. what should the volume status be for a patient awaiting transplant?
3b. why?
3c. what happens if you dont keep this volume status?

A

(11)
pre op assessment of patient with acute or chronic liver disease:
CARDIAC (PART 2):
1. What issues will be seen LESS in patients with cirrhosis?
–less atherosclorosis than healthy patients
1b. why?
–d/t alcohol related effect on serum lipids and enhanced fibrinolytic activity
2. what cardiac disease should still be considered?
–CAD
2b.especially in what age patient?
–patients older than 60
3. what should the volume status be for a patient awaiting transplant?
–normovolemic
3b. why?
–maintain RBC flow, GFR, abd delay hepato-renal syndrome
3c. what happens if you dont keep this volume status?
-hypovolemia is associated with ascites and the formation of interstitial edema

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14
Q

(12)
pre op assessment of patient with acute or chronic liver disease:
CARDIAC (part 3):
1. how is a hyperdynamic state used as a compensatory mechanism?
2. what should be done if a hyperdynamic state exists as a compensatory mechanism?
3. what should be administered to maintain oncotic pressures?

A

(12)
pre op assessment of patient with acute or chronic liver disease:
CARDIAC (part 3):
1. how is a hyperdynamic state used as a compensatory mechanism?
–hypertension is used to maintain oxygen delivery to peripheral tissues
2. what should be done if a hyperdynamic state exists as a compensatory mechanism?
–do not attempt to correct this state (and achieve normal values)
3. what should be administered to maintain oncotic pressures?
–salt poor albumin (25 grams) for every liter of ascites removed.

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15
Q

Rule to anesthesia for transplant patients:

A

KEEP IN MIND WHAT IS ALTERED OR MISSING: check for it and plan your anesthetic around it

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16
Q

(13)

what is Orthotopic:

A

(13)
what is Orthotopic:
–to take the old one out and put a new one in

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17
Q

(14)
conditions which indicate liver transplant
Major indications for othotopic liver transplantation (OLT) in adults are: (4 things)

A

(14)
conditions which indicate liver transplant
Major indications for othotopic liver transplantation (OLT) in adults are;
• end-stage chronic liver disease (cholestatic, hepatocellular, vascular disease)
• fulminate hepatic failure (viral hepatitis, toxins, Wilson’s disease)
• inherited metabolic abnormalities (primary hyperoxaluria, familial cholesterolemia
• hepatic malignancies (hepatocellular or polycystic)- functional portion of liver is replaced with cystic tissue which pushes on other functional portions. there is loss of function and hypertrophy

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18
Q

(15)

Conditions currently thought to CONTRAINDICATE liver transplant: (7)

A

(15)
Conditions currently thought to CONTRAINDICATE liver transplant:
1. Widespread Malignancy
2. Uncontrolled infection outside of the hepatobiliary
tree
3. Severe cardiac disease
4. Major neurologic pathology
5. Intractable drug or alcoholism (have to be clean for >6 months)
6. Acquired immunodeficiency syndrome (HIV or others)
7. Inability to maintain appropriate
immunosuppression and medical follow up (is poorly controlled s

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19
Q

(16)
neurological alterations in patients with acute and chronic liver disease:
1. what is hepatic encephalopathy?
2. what are s/s of hepatic encephalopathy?
3. what is the treatment?
4. what should be avoided pre-op?

A

(16)
neurological alterations in patients with acute and chronic liver disease
-hepatic
1. what is hepatic encephalopathy?
-encephalopathy is caused by accumulation of toxins (ammonia etc.)
2. what is the range of s/s of hepatic encephalopathy?
-slightly altered mental status to coma
3. what is the treatment?
-control protein intake, destroy GI bacteria, lactulose, treat GI bleed
4. what should be avoided pre-op?
-sedatives if primarily metabolized by the liver.

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20
Q

(17)
neurological changes with hepatic failure:
1. what grade of encephalopathy has adverse cerebral effects?
1b. what are the effects?
2. what is the treatment?
3. what else can be done (during induction)?

A

(17)
neurological changes with hepatic failure:
1. what grade of encephalopathy has adverse cerebral effects?
–Grade IV
1b. what are the effects?
–cytotoxic or vasogenic cerebral edema (causes increased ICP)
2. what is the treatment?
–treatment of ICP with osmotic or loop diuretics and barbiturates
3. what else can be done (during induction)?
–elevating the HOB 10-15 degrees during intubation or using reverse trendelenberg during induction

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21
Q

(18)
renal assessment of hepatic patients:
1. what renal issues may a potential OLT patient have?
2. what are the characteristics of this condition?
3. what vasoactive substances may cause deterioration of renal function
4. how quick is the deterioration of persons with this syndrome?
4b. what is the recovery prognosis post OLT?

A

(18)
renal assessment of hepatic patients:
1. what renal issues may a potential OLT patient have?
–varying degrees of heapatorenal syndrome
2. what are the characteristics of this condition?
–reduction in renal blood flow
–reduction in glumerular filtration rate
–reduction in urine output and dilutional hyponatremia in absence of histological abnormalities
3. what vasoactive substances may cause deterioration of renal function
–renin
–angiotensin
–catecholamines
–renal prostaglandins
–ADH
–endotoxins and nitric acid
4. how quick is the deterioration of persons with this syndrome?
–rapid hepatic deterioration possibly ending in death
4b. what is the recovery prognosis post OLT?
–if OLT is timely, renal function may return to normal in some cases

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22
Q

what is the sole definitive treatment for end stage liver disease

A

transplantation

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23
Q

where does liver transplantation rank in transplantation surgery?

A

2nd most common transplant surgery

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24
Q

what is the leading indication for transplantation in the US?

A

hepatitis c (21%)

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25
Q
  1. what should anesthetic management considerations for end stage liver patients iclude?
  2. why?
A
  1. anesthetic management should include protection of other organs damaged by liver failure.
  2. because ESLD patients have secondary dysfunction of virtually all other organ systems.
26
Q

what is a HUGE complication with end stage liver disease?

A

cerebral edema with increased ICP

27
Q
  1. what is the best test for cardiovascular assessment in end stage liver patients?
  2. why?
A
  1. dobutamine stress test
  2. because it assesses myocardial oxygen supply, valve function, and presence of intrapulmonary shunting and or pulmonary HTN
28
Q 
what is the most important factor in success of organ transplantation:
is it:
a) blood (ABO) type
b) cost  
c)immunosuppression?
A

c) immunosuppression

29
Q
  1. if a hepatic failure patient comes to the ER with hypotension, pallor and tachycardia, what could be the problem?
  2. what should you do?
A
  1. esophageal varices

2. low pressure, high volume blakemore (have it ready), octreotide

30
Q

how does ascites develop?

A

there is a loss of intravascular proteins d/t liver inability to synthesize new protein and liver catabolizes proteins in body (including muscle wall of vessels) for fuel

  • porus vessels leak proteins into extravascular fluid causing osmotic pooling of fluid from intravascular spaces
  • patient is malnourished and intravasularly depleted with edema
  • endotoxins from GI tract also enter vascular system causing vasodilation (hypotension)
31
Q

what is a major side effect of ascites?

A

pleural effusions and restrictive lung defects (pushes up on diaphragm causing loss of FRC)

32
Q

peritoneal tap (pericentesis) has a high risk of 2 things?

A
  1. infection

2. loss of protein

33
Q
  1. What is the important fact to remember with SVR?

2. what is the formula?

A
  1. MAP and CVP are inversely proportional to C.O. (if SVR goes down, C.O. goes up)
  2. SVR=[(map-cvp)/c.o.]*80
  3. these patients are vasodilated and intravascular depleted so they will have low SVR and high C.O. (10-15 mmHg)
34
Q

how is the heart in a hepatic failure?

A

usually normal (as opposed to renal patients)

35
Q

what type of lines will the hepatic transplant patient have (and where will they be)?

A
  1. cordis on the left with swan ganz
  2. cordis on right
  3. arterial line
36
Q
  1. what will the hemodynamics be in a hepatic transplant patient?
  2. how does this differ from renal transplant patients?
A
  1. what will the hemodynamics be in a hepatic transplant patient?
    a. low SVR
    b. low CVP (0-2 mmHg)
    c. high C.O. (10-15 mmHg
  2. how does this differ from renal transplant patients?
    it is the opposite of renal patients
37
Q

what cardiac condition do (especially alcoholic) hepatic patients usually NOT have issues with?

A

ususlly do not have atherosclerosis

38
Q

what is hepatorenal syndrome?

A

(liver failure causes renal failure)
–HEPATORENAL SYNDROME. This syndrome is characterized by a reduction of renal blood flow, glomerular filtration rate, urine output and dilutional hyponatremia in the absence of renal histologic abnormalities d/t decreased hepatic function.

39
Q

what volume status is desired prior to transplantation of organs?

A

normovolemia

40
Q
  1. hepatic patients are prone to bleeding d/t changes in what mechanisms?
  2. how does that differ from renal patients?
A
  1. hepatic patients are prone to bleeding d/t changes in clotting factors (loss of factors)
  2. renal patients have bleeding d/t platelet issues
41
Q
  1. what neuropsychotic issues accompany hepatic failure?
  2. how can these situations be treated?
  3. what medications should be avoided or used sparingly in hepatic encephalopatic patients?
A
  1. toxins and ammonia cause confusion,seizure, coma
  2. control protein intake, decrease ammonia, control GI bacteria, control GI bleeding
  3. avoid benzos and sedatives in lethargic hepatic patients (plus primarily metabolized by the liver)
42
Q
  1. grade IV encephalopathy may be complicated by the deveolpment of what?
  2. how is this treated?
  3. what else can help to reduce this during intubattion?
A

Neuropsychiatric

  1. Grade IV encephalopathy may be complicated by development of cytotoxic or vasogenic cerebral edema.
  2. Treatment of increased ICP includes osmotic or loop diuretics and, barbiturates.
  3. Elevating the HOB 10-15 degrees during intubation or using reverse Trendellenberg position is appropriate on induction.
43
Q

what might a hepatic patient with hepatorenal syndrome need prior to liver transplant?

A

dialysis

44
Q

what is portal hypertension?

A

PORTAL HYPERTENSION:
inability of blood to flow thru liver causes a back up into the esophagus, abdomen and lower GI tract. this can cause tortuous varices in these areas along with ascites.

45
Q

what factors are affected by hepatic failure and how?

A

Chronic liver failure is associated with:

a) malabsorption of Vitamin K decreasing availability of two fibrinolytic proteins (plaminogen & α2- antiplasmin)
b) decreased production of coagulation factors III, VII, IX, & X.

46
Q

what are changes in metabolic state d/t hepatic failure?

A

Metabolic State
• Severe loss of muscle and fat stores
• Resting energy expenditure is not increased however protein catabolism occurs and leaves the patient in a negative nitrogen balance.
• Protein intake is limited to renal and hepatic tolerance
- hypoalbumenia affects protein bound drugs (by affecting distribution of the drug Vd)
• Increased susceptibility to bacteria infections.

47
Q
  1. what hepatic alterations occur in regards to pharmacokinetics? (how much reserve do these patients have is a clue)
  2. in terms of drugs, is there a difference between tissue distribution of a drug and volume of distribution (Vd) of a drug?
  3. how does the Vd of a hepatic patient change?
  4. what happens to plasma albumin levels?
    4b. what type drugs do plasma albumin bind to?
  5. what blood protein binds to basic drugs?
    5b. what happens to these levels?
A

Pharmokinetic Changes
1• With extensive hepatic reserves, presenting patients hepatic function ranges from being almost normal to severely impaired
2• Although related, there is an important distinction between tissue distribution of a drug and its Vd
3• Vd varies widely in patients depending on alterations in plasma and tissue protein binding
4• Plasma concentrations of albumin levels are low.
4b. serum albumin binds primarily to acidic drugs
5• α1-acid glycoprotein binds to basic drugs
5b. levels of A1-acid glycoprotein may be elevated

48
Q

Pharmokinetic Changes
1• Hepatic extraction is dependent on what three independent factors?
2. if a drug has a higher metabolizing enzyme activity what will its protein binding extraction be (higher or lower)?
3. Persons with cirrhosis will have (increased or decreased) effective hepatic flow?

A

Pharmokinetic Changes
1• Hepatic extraction is dependent on three independent factors

  • -1) liver blood flow
  • -2) drug protein binding
  • -3) the maximal intrinsic capacity of metabolizing enzymes
    2• The higher a drug’s metabolizing enzyme activity, the less sensitive its extraction will be to protein binding
    3• The development of cirrhosis is associated with reduced effective hepatic flow
49
Q

what medications have a flow limited clearence?

A
  • morphine
  • lidocaine
  • propanolol
  • labetolol
  • nitroglycerine
  • versed
50
Q

What medications that are flow and enzyme limited:

A
  • demorol
  • metoprolol
  • alfentanil
51
Q

what medications are enzyme limited and binding sensitive

A
  • valium (diazepam)
  • coumadin (warfarin)
  • dilantin (phenytoin)
  • ativan (lorazepam)
52
Q

what medications are enzyme insensitive and binding limited?

A
  • thiopental

- theophylline

53
Q

anesthesia setup for hepatic transplant:

  1. what type of monitoring?
  2. how many blood warmers?
  3. what is the IV fluid of choice?
  4. what is the name of the warmer if high volume bleeding is expected?
  5. Bair hugger…?
  6. what should be set up for blood pressure etc?
    6b. set up how?
  7. what drip should be set up and at what rate?
  8. what type of canula setup should you have?
  9. what size if greater than 150 lbs; what size if less than 150 lbs?
A
  1. Anesthesia machine setup with ASA standard monitors
  2. 2 blood warmer setup,
  3. use plasmalyte for all IV fluid except other specific indications.
  4. Set up a Belmont warmer if heavy bleeding is anticipated
  5. Upper and lower forced air warming device.
  6. Pressure transducers for A-line and pulmonary artery catheter and cardiac output module, zeroed at the patient’s mid axillary line
  7. Infusion pump with dopamine infusion 2.0 ug/kg./min.
  8. Veno-Veno bypass cannula setup.
  9. Use 18F. if patient’s weight greater than150 lbs,16 F for less than 150 lbs.
54
Q
  1. Table Top: besides normal induction drugs, what syringes should you have and at what doses?
  2. what catheters should be on the table?
  3. what blood products should be available? (who is responsible for ordering these blood products)
A
  1. Table Top drugs plus…
    -(2)-10 ml syringe, filled with epinephrine sol. 32 mcg/ml
    -(2)-10 ml syringe, filled with neosynephrine sol. 80 mcg/ml
    -(2)-1.0 gm CaCl2
    -(4)-Amps sodium bicarbonate
    -(2) vials of Amicar
  2. what catheters should be on the table?
    -One peripheral IV line
    -Radial artery cannulation
  3. Blood products:
    – 6u PRBC
    – 6 u FFP
    – 6 u platelets.
    Staff anesthesiologist is responsible for ordering blood products to be brought to the OR.
55
Q
  1. what medications are the best for induction of a hepatic patient?
  2. which one should be avoided or used in a smaller dose with hepatic patients (especially with ascites)
  3. what MR should be used?
A
  1. Several intravenous drugs are suitable for induction:
    - -Etomidate is best because it is hydrolyzed in the liver but despite decreased clearance duration is increased because of increased Vd.
  2. propofol. Recovery time after Propofol is longer with moderate to severe cirrhosis. Metabolites of propofol were found in urine during anhepatic phase suggesting alternate organs of metabolism.
  3. Succinlycholine. The presence of high intaperitoneal pressure associated with ascites and the emergent scheduling of surgery mandates the use of rapid sequence technique with succinylcholine.
56
Q
  1. what pre-op antibiotic is best for hepatic transplant?
  2. what if patient has a PCN allergy?
  3. how much decadron is given?
A
  1. Zosyn 4.5 gm pre-op and q. 8 hrs.
  2. If patient is allergic to PCN, give Vancomycin 1.0 gm & Ciprofloxacin (Cipro) 500 mg IV).
  3. Dexamethasone 160 mg.
57
Q
  1. how often should labs be drawn during liver transplant?
  2. what labs should be drawn?
  3. after how many amps of bicarb should you be checking serum osmo?
A
  1. Labs: at least one set of labs in each stage of liver TX or after one estimated blood volume exchange.
  2. May repeat labs following correction of abnormal data:
    - H&H
    - ABG with lactate (lactic acid)
    - Na
    - Cl
    - K
    - Ca ++
    - RBS
    - Coagulation profiles (PT, aPPT, platelet, fibrinogen, pfa)
  3. Serum osmolarity is required if more than (5) NaHCO3
58
Q

veno-veno bypass:

  1. at what stage of hepatic bypass is it used?
  2. what is the desired maximum blood flow through the veno-veno bypass system? How is this achieved?
A
  1. A venous bypass system was thought to be desirable during the anhepatic phase to improve hemodynamic stability and reduce bleeding from the engorged portal system.
  2. Pump rotation is increased until maximal blood flow is achieved 800-1000 ml/min
59
Q

Controversy related to veno-veno bypass use include:
1. why do we not know that veno-veno bypass is beneficial?

  1. what are the reported benefits (regarding blood transfusion amounts)
  2. what test is used to predict hemodynamic stability during anhepatic phase?
  3. caval occlusion without veno-veno bypass may cause…?
  4. what are the complications of veno-veno bypass?
A

1• There are no randomized clinical trials to evaluate potential benefits
2• Use during the anhepatic phase reduces the transfusion requirements. Transfusion requirements are reportedly decreased (33 +/- 25 vs. 19 +/- 8)
3• A vascular occlusion test is sometimes used as a predictor of hemodymanic stability during the anhepatic phase
4• Caval occlusion without veno-veno bypass is associated with decreased renal perfusion
5• Complications include: hypothermia, air embolism, thromboembolism, and trauma to brachial plexus

60
Q
  1. how is anesthesia maintained with hepatic transplant patinets?
  2. what must be considered when formulating an anesthesia plan?
  3. what inhaled agent gives the best hepatic results?
    3b. how?
A
  1. Anesthesia is maintained with a combination of intravenous narcotics, muscle relaxants and inhaled agent.
  2. The effects of anesthetics on hepatic blood flow must be considered when formulating a plan to maintain organ oxygen supply.
  3. isoflurane is beter than other inhaled agents.
    3b. Hepatic arterial autoregulation and oxygen delivery may be maintained with iso.
61
Q
  1. what is the best anesthetic supplement during OLT?

2. when is the use of these drugs most important and why?

A
  1. Intravenous benzodiazepines are often used to supplment the anesthetic during OLT.
  2. The amnestic properties of benzos may be particularly useful if inhaled anesthetic is reduced below amnestic levels at times of hemodynamic instability.
62
Q
  1. liver presentation is achieved via what fluid?

2. what does it contain?

A
  1. belzer solution
  2. it contains:
    a) lactobionate, raffinose, (to suppress hypothermia induced cell swelling)
    b) K-phos, adenosine, mag sulfate, gluthione, allopurinolnas, insulin, penicilin, decadron and hydroxymethyl starch

2. adv principles 3 exam 2 (4 decks)

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