Liver Transplant Flashcards
What are the complications in the pre-anhepatic stages?
Obvious and insidious blood loss from adhesions and dissection
Potential compression of native vessels
Worsening of pre-existing coagulopathy
What is contained in the University of Wisconsin solution?
Potassium (120 mmol/l)
Lactobionate and raffinose (to prevent cell swelling)
Hydroxylethyl starch (to increase oncotic pressure)
Allopurinol
Glutathione
Adenosine
Dextrose
What does the MELD score look at?
Creatinine
Bilirubin
INR
Albumin
How does the simple venous cross clamping technique work?
The liver is removed with retro hepatic IVC after cross clamping the supra hepatic and infra hepatic IVC, hepatic artery and portal vein
Re-anastomosis the supra and infra IVC then flush the liver with 1LR thru a cannula in the portal vein
Then reperfuse
How does veno-venous bypass work?
A cannula is out in the femoral vein and iliac vein or axillary vein for bypass.
Bypass –> hepatectomy –> reperfusion –> decannulate
What is the piggyback technique?
- Diseased liver is removed WITHOUT the retro hepatic IVC (so venous return is preserved)
- Anastomosis done with left and middle hepatic v. To supra hepatic IVC or graft for hepatic drainage
What are the issues in the anhepatic stage?
Decrease in venous return due to cross clamping
Progressive coagulopathy
Progressive metabolic acidosis
Hypocalcemia
What are the goals in the first stage of OLT?
Keep euvolemic (keeping up with blood loss) Correct coagulopathy Octreotide for splanchnic vasoconstriction to control bleeding
What are the goals of the anhepatic stage?
Maintain hemodynamic stability Correct coagulopathy Give solumedrol Turn off octreotide Tank up for reperfusion Treat hyperkalemia with goals if K of 4 Treat glucose Treat hypocalcemia Treat metabolic acidosis
What happens in reperfusion?
Hypothermia Cytokine load Hyperkalemia Emboli --> pulmonary HTN, increased ICP, hypotension, arrhythmias, worsened coagulopathy
Why is the heart hyper dynamic in ESLD?
Because there are lots of vasodilators (NO made from gut flora) that cause a decrease in SVR, so you increase CO to maintain your MAP
What are your sources of preload loss in the first stage?
Ascites, surgical bleeding, vascular compression
What are the issues with MTP?
Hypothermia
Hypocalcemia
Hypomagnesemia
Hyperkalemia
What are the hemodynamic changes due to in the anhepatic phase?
Decreased preload from cross clamping of the IVC and portal vein
What happens in the anhepatic stage?
Ischemia
Blood sequestering in kidneys, GI and pelvic organs leads to renal venous congestion with associate acidosis, intestinal swelling, hematuria
What is the transient hypovolemia and hypotension after unclamping of the infra hepatic IVC and portal vein due to?
Acute sequestration of the blood in the engrafted liver
What does unclamping of the supra hepatic IVC result in?
Increased preload from mobilization of blood from lower extremities and splanchnic circulation
What is postreperfusion syndrome
A decrease in MAP greater than 30% of baseline for 1 minute in the first 5 minutes of reperfusion
What are the associated hemodynamic changes with postreperfusion syndrome?
Bradycardia High CVP High PCWP Low SVR (from vasodilators released from the allograft and congested viscera) Arrhythmias Myocardial depression RV strain (from acute increase in preload) Hypothermia Embolism Hyperkalemia Acidosis
What is the MOA of octreotide?
Increases splanchnic tone and SVR by affecting VIP
What happens to minute ventilation in OLT.
Decreases to match reduced oxygen consumption
Increased during neohepatic stage due to increased oxygen consumption and high ETCO2
Why is there an increase in tPA level in neohepatic stage?
Because the new live has not begun clearing tPA yet and plasminogen activator inhibitor is overwhelmed
How long does it take from fibrinolysis to resolve?
2 hours after reperfusion
What is EACA.
An anti-fibrinolytic used for severe fibrinolysis to minimize the loss of factors I, V, VIII.
