Liver Transplant

Question 1

What are some contraindications to liver transplant?

Answer 1

Significant CAD
Mod-severe pul HTN >50
Advanced malignant or metastatic disease
Uncontrolled infection or sepsis

Question 2

Pathophys of ESLD?

Answer 2

portal HTN due to increased hepatic resistance to flow

Systemic vasodilation and volume expansion

Question 3

Hyponatremia-what does it need to be before liver transplant? What else needs to be corrected prior to a liver transplant?

Answer 3

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

Question 4

What is hepatopulmonary syndrome?

Answer 4

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

Question 5

What is hepatorenal syndrome?

Answer 5

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

Question 6

Liver is site of synthesis of coag stuff except for what?

Answer 6

Factor 8 and VWF

Question 7

Should curative transplant be postponed due to need to correct coagulation issues:

Answer 7

NO

Question 8

Liver failure and opioids?

Answer 8

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

Question 9

T/F- ALL liver transplant cases are considered an emergency with the exception of living donors

Answer 9

TRUE

Question 10

Diagnosed pul HTN should be treated before transplantation right? What can you do to make sure?

Answer 10

Yes-place PAC-that will allow you to be able to guide therapy and cancel case if Pul artery pressure is too high

Question 11

All liver transplant patients are ____ _____

Answer 11

Full stomach!

Question 12

Would you do epidural catheter in ESLD patient?

Answer 12

Nope!

Question 13

Anesthesia in ESLD pts with transplant:

What are you NOT going to use?

Answer 13

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

Question 14

Send a base set of labs after what? ESLD/Liver transplant

Answer 14

Send a base set of labs after intubation in ESLD/Liver transplant

Question 15

Dissection phase of OLT: What happens? What can you expect?

Answer 15

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.

Question 16

Anhepatic phase of OLT: What’s happening? What can you expect?

What can you do if surgeon uses traditional technique?

Answer 16

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.

Question 17

VVBP adverse outcomes:

Answer 17

arm lymphedema, air embolism, and vascular injury

VVBP has limited benefits when the bypass time is short

Question 18

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?

Answer 18

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

Question 19

What is post-reperfusion syndrome?

Answer 19

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

Question 20

What is an early indication of graft function:

Answer 20

Lack of calcium requirement even when FFP is being infused

Within first hour, cardiac output decreases and SVR increases

Question 21

HOw much blood needs to be ready?

Answer 21

MTP 
RBC 10-20 units 
FFP 5-10 units 
Single donor platelets (4-10 units) 
Cryo: 10 units

Question 22

Post op-where do pts need to go, what can you anticipate monitoring and giving?

Answer 22

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

Question 23

How can you topicalize an airway?

Answer 23

nebulized lidocaine 2-4% for 10 minutes or have pt gargle wiht 5 mL of 2% viscous lidocaine

Question 24

T/F: Neck circumference alone is an independent predictor of difficult airwaY

Answer 24

TRUE