Liver Transplant Flashcards
What are some contraindications to liver transplant?
Significant CAD
Mod-severe pul HTN >50
Advanced malignant or metastatic disease
Uncontrolled infection or sepsis
Pathophys of ESLD?
portal HTN due to increased hepatic resistance to flow
Systemic vasodilation and volume expansion
Hyponatremia-what does it need to be before liver transplant? What else needs to be corrected prior to a liver transplant?
Liver transplant should be postponed for Na less than 120 due to risk of central pontine myelinosis
Hyperkalemia needs to be corrected prior to a liver transplant
What is hepatopulmonary syndrome?
Triad of liver disease, arterial hypoxemia (PaO2 <70), and intrapulmonary vascular dilatations
Patients may have changes in Ox saturation with change from supine to standing
What is hepatorenal syndrome?
Liver failure that results in renal failure. Type 1-rapid with high morbidity
Type 2: follows a less acute course and is mainly seen in patients that are resistant to diuretic therapy
Liver is site of synthesis of coag stuff except for what?
Factor 8 and VWF
Should curative transplant be postponed due to need to correct coagulation issues:
NO
Liver failure and opioids?
They bind to albumin and therefore a low albumin level can lead to an increase in the free fraction of the drug and theoretically exaggerated clinical effect
T/F- ALL liver transplant cases are considered an emergency with the exception of living donors
TRUE
Diagnosed pul HTN should be treated before transplantation right? What can you do to make sure?
Yes-place PAC-that will allow you to be able to guide therapy and cancel case if Pul artery pressure is too high
All liver transplant patients are ____ _____
Full stomach!
Would you do epidural catheter in ESLD patient?
Nope!
Anesthesia in ESLD pts with transplant:
What are you NOT going to use?
Balanced technique using volatile anesthetic, muscle relaxants, and opioids
Not going to use Nitrous-should be avoided due to the risk of bowel distention and IV air embolism
Send a base set of labs after what? ESLD/Liver transplant
Send a base set of labs after intubation in ESLD/Liver transplant
Dissection phase of OLT: What happens? What can you expect?
They are mobilizing the structures around the liver and isolating common bile duct. This can impede venous return and result in hypotension. Also, acute decompression of ascites can result in hypotension
Blood loss may be very high, adequate fluid replacement is important.
Anhepatic phase of OLT: What’s happening? What can you expect?
What can you do if surgeon uses traditional technique?
Begins with the excision of native liver and control of bleeding by clamping the liver off from circulation.
You can expect:
Profound acidosis
Hypocalcemia (liver normally metabolizes citrate)
Hyperkalemia (give b agonists, insulin plus glucose, alkaliization)
Hyper or hypoglycemia (liver is major regulator of glucose)
If surgeon uses traditional technique and clamps off everything your venous return will be affected. you could use VVBP if not, volume load with target CVP of 10-20 before clamps are placed.
VVBP adverse outcomes:
arm lymphedema, air embolism, and vascular injury
VVBP has limited benefits when the bypass time is short
Reperfusion phase: What happens? What can you expect, what should be done prior to clamp removal? What should be available? what can you consider giving?
Vascular clamps are removed, associated with significant hemodynamic instability and cardiac arrest
Prior to clamp removal, pt should be on 100% O2, have adequate CVP, and have crit in the mid 30s
ALL emergency drugs need to be available
consider g iving 50 mEq of HcO3-, 500 mg IV infusion of CaCl to counteract the effects of elevated potassium on the heart
Glucose
What is post-reperfusion syndrome?
Hemodynamic instability of unknown cause that is associated with high potassium concentrations in the preservative soln and decreased SVR-hypotension bradycardia, elevted pulmonary artery pressures
What is an early indication of graft function:
Lack of calcium requirement even when FFP is being infused
Within first hour, cardiac output decreases and SVR increases
HOw much blood needs to be ready?
MTP RBC 10-20 units FFP 5-10 units Single donor platelets (4-10 units) Cryo: 10 units
Post op-where do pts need to go, what can you anticipate monitoring and giving?
Pts need to go to ICU whether intubated or not.
Recovery requires frequent evaluations of cardiac and pulmonary fxn, electrolytes, renal and liver fxn and coagulation
How can you topicalize an airway?
nebulized lidocaine 2-4% for 10 minutes or have pt gargle wiht 5 mL of 2% viscous lidocaine
T/F: Neck circumference alone is an independent predictor of difficult airwaY
TRUE
