Liver Transplant Flashcards
What is hepatopulmonary syndrome?
Hepatopulmonary syndrome is severe hypoxemia due to liver
disease. The defining characteristics are the presence of portal
hypertension, an increased alveolar-arterial oxygen gradient,
and intrapulmonary vasodilation. Patients may exhibit clubbing
of the fingers, spider angiomata, arterial hypoxemia, and
dyspnea that worsens when the patient moves from a
recumbent to an upright position.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1054.
A patient with aortic stenosis, a patient with renal
failure and a patient with a mean PA pressure of 52
mmHg all present for liver transplant surgery. Which
patient cannot proceed with the surgery?
Renal failure is a common diagnosis in patients presenting for
liver transplantation. Aortic stenosis has an associated
increase in risk, but can often be treated preoperatively with
valvuloplasty prior to surgery and then aortic valve replacement
may be undertaken after the transplant. Patients with
portopulmonary hypertension have an extremely high
perioperative mortality rate with liver transplant surgery. A
mean PA pressure greater than 50 mmHg is considered an
absolute contraindication to liver transplant.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1469-1470.
Why is rapid-sequence induction indicated in all
patients presenting for liver transplant surgery?
End stage liver disease is associated with gastroparesis as well
as increased intra-abdominal pressure due to ascites that
places the patient at risk for aspiration of gastric contents.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1470.
A patient with hepatorenal syndrome is undergoing a
liver transplant. Is dopamine a useful adjunct for the
preservation of renal function in this patient?
No, dopamine does not improve renal function in patients
undergoing liver transplant. Norepinephrine and the alpha1-
agonist, midodrine have both been shown to improve renal
function during liver transplant, however.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1471.
A patient with hepatorenal syndrome and severe
ascites is about to undergo a large-volume (> 5 L)
paracentesis. What can be done to prevent the
renal decompensation as a result of the removal of
such a large volume of abdominal fluid?
Albumin 6-8 grams per liter of ascites removed should be
administered to help prevent renal decompensation.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1471.
What is the difference between type I and type II
hepatorenal syndrome?
Hepatorenal syndrome is renal dysfunction associated with
hepatic disease. Type I is acute renal decompensation, exhibits
a creatinine > 2.5 mg/dL and is often fatal. Type II hepatorenal
syndrome is chronic, exhibits a creatinine > 1.5 mg/dL, and a
glomerular filtration rate
What coagulation parameters are monitored and
how are they maintained in patients undergoing liver
transplant surgery?
Fresh frozen plasma is administered to maintain an INR 150 mg/dL.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1471.
What medications would you be prepared to
administration prior to the reperfusion of a newly
transplanted liver?
When the liver is about to be reperfused, you should anticipate
the administration of bicarbonate and calcium chloride to
counteract the effects of potassium on the heart.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1472.
In what phase of a liver transplant would you expect
to see the most hemodynamic instability?
The greatest hemodynamic changes are typically seen during
the neohepatic period when the transplanted liver is
reperfused. Reperfusion of the vena cava is usually well
tolerated, but reperfusion of the portal vein is associated with a
drop in the systemic vascular resistance that is even greater
than that seen with vena cava cross-clamp. Severe
bradycardia may also be seen, although it is becoming less
common due to changes in the preservative solutions used.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1472
What hemodynamic change would you expect to see
when the anhepatic phase of a liver transplant is
initiated?
Hypotension usually ensues as the vena cava is cross-clamped
due to a 50-60% reduction in venous return.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1471.
What vessels are clamped during the anhepatic
phase of a liver transplant?
Typically, the vena cava is clamped above and below the liver
and the portal vein and hepatic artery are clamped below the
liver.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1471.
What are the three phases of liver transplant
surgery?
The dissection phase, in which the incision and access to the
liver is obtained, the anhepatic phase, in which the liver is
isolated from the circulation, and the neohepatic period in which
the new liver is reperfused.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1471-1472.
Within the first hour of the neohepatic period, the
patient exhibits a decrease in cardiac output and an
increase in systemic vascular resistance. What does
this change indicate?
A decrease in cardiac output and an increase in the SVR
indicates that the graft is functioning correctly and the new liver
is beginning to metabolize the vasoactive substances that
produce the characteristic low SVR and high cardiac output in
patients with end stage liver disease. Other signs that the graft
is functioning correctly include: calcium is no longer needed
even when large volumes of FFP are infused as the new liver is
able to metabolize the citrate preservative and the base deficit
normalizes.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1472.
