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7835 Exam IV > Mod13: Liver Transplants > Flashcards

Mod13: Liver Transplants Flashcards

1
Q

Liver Transplants

Where are liver tpx performed?

A

in many centers across the country

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2
Q

Liver Transplants

Where is the healthy liver obtained?

A

​From deceased donor who has not suffered liver injury

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3
Q

Liver Transplants

How is the healthy liver transported?

A

in a cooled saline solution

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4
Q

Liver Transplants

How long could a healthy liver remain viable in the cooled saline solution prior to transplantation?

A

Up to 8 hours

This time permits analysis to determine blood and tissue donor-recipient matching

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5
Q

Liver Transplants

How long does a liver transplant operation last?

A

can take 12 hours to complete

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6
Q

Liver Transplants

Why do liver transplant operations require large volumes of blood transfusions?

A

Because the surgical procedure involves cutting and reconnecting multiple major blood vessels

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7
Q

Liver Transplants

For which conditions is liver tpx the definitive tx for?

A

Decompensated cirrhosis

Unresected or unresectable hepatic malignancy

Acute liver failure & other metabolic dz that irreversibly injure the liver

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8
Q

Liver Transplants

Why are post liver Tpx pts at high risk of developing atelectasis and small airway closure?

A

Large, transverse upper abdominal incision

Associate with high intensity pain

Incision is also close to diaphragm

Atelectasis and small airway closure due to not taking deep enough breaths because of pain

Pt should be coached to take deep breaths

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9
Q

Liver Transplants

Which vascular structures are affected during liver tpx?

A

Inferior vena cava

Hepatic veins

Hepatic areteries

Portal veins

Bile duct

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10
Q

Liver Transplants

Most pts requiring liver tpx are very sick. Which circumstance usually gets them to the top of the tpx list?

A

Being hospitalized, and requiring ICU care

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11
Q

Liver Transplants - Anesthesia Techniques

True or False: there is a specific anesthetic protocol for liver tpx

A

False

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12
Q

Liver Transplants - Anesthesia Techniques

True or False: it is recommended that each liver transplant facility comes up with a uniform approach to be used initially during transplantation.

A

True

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13
Q

Liver Transplants - Anesthesia Techniques

What’s an appropriate anesthetic technique for liver Tpx?

A

GETA with RSI

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14
Q

Liver Transplants - Anesthesia Techniques

Which drugs would you use for induction and intubation?

A

Fentanyl

Sodium pentothal/etomidate

Low dose non-depolarizing muscle relaxant (Cis), and

Succinylcholine

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15
Q

Liver Transplants - Anesthesia Techniques

Which drugs would you use for maintenance of anesthesia?

A

Fentanyl

Benzodiazepines

Non-depolarizing muscle relaxant (Cis)

Isoflurane in air/oxygen

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16
Q

Liver Transplants - Anesthesia Techniques

Which ventilatory strategy could you use to reduce the risk of air emboli and to prevent atelectasis during liver tpx?

A

Mechanical ventilation with 5 cmH2O of PEEP

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17
Q

Liver Transplants - Anesthesia Techniques

Why should Nitrous oxide be avoided in liver tpx?

A

Can lead to bowel distension

Issues with surgical exposure, since bowell and liver share the same area

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18
Q

Liver Transplants - Preparation

What are considered standard monitors during liver tpx?

A

Central line for fluid replacement

(insert before or after induction - <u>add two large bore IVs 16g</u>)

CVP for monitoring fluid status

A-line for beat-to-beat monitoring of heart rate/pressure and multiple blood draws

Foley catheter for urine output

TEE for CO and wall motion monitoring

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19
Q

Liver Transplants - Preparation

Why should you have a rapid transfuser available

A

In case you must administer large amounts of volume/blood in a very short period of time

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20
Q

Liver Transplants - Preparation

Why should you have Fluid and body warmers available

A

The prevent hypothermia

21
Q

Liver Transplants - Preparation

What should you do in anticipation of LARGE blood loss?

A

Contact Blood Bank

Have large amounts of blood readied

22
Q

Liver Transplants - Intraoperatively

A liver transplant last 12 hours on average, with a range of 4 to 18 hours and is divided into three phases. What are those phases?

A

Preanhepatic (Dissection)

Anhepatic (No liver connected)

Neohepatic (Revascularization

23
Q

Liver Transplants - Intraoperatively - Preanhepatic

When does the Preanhepatic phase starts? when does it end?

A

Sarts at incision

Ends when all the vessels are clamped off (Vascular exclusion),

and the native and non functioning liver is taken out (hepatectomy)

24
Q

Liver Transplants - Intraoperatively - Preanhepatic

When the liver is dissected in the Preanhepatic phase, which vessels does it remain attached to only?

A

Inferior vena cava

Portal vein

Hepatic artery and

Common bile duct

All except hepatic veins

25
Q

Liver Transplants - Intraoperatively - Preanhepatic

Which factors in the pt’s history could prolong the dissection part of the Preanhepatic phase

A

Adhesions from previous abdominal surgery

26
Q

Liver Transplants - Intraoperatively - Preanhepatic

In the Preanhepatic phase, when would you anticipate large amount of blood loss?

A

When they start to clamp the different areas and actually cut the vessels

Be ready to transfuse

27
Q

Liver Transplants - Intraoperatively - Preanhepatic

Which two electrolyte disturbances are commonly associated with liver tpx?

A

Hyponatremia

Hyperkalemia

28
Q

Liver Transplants - Intraoperatively - Preanhepatic

Why should you not treat hyponatremia a/w liver tpx too quickly?

A

…

29
Q

Liver Transplants - Intraoperatively - Preanhepatic

Hyperkalemia a/w liver tpx must be treated promptly, but which precautions must be taken?

A

Remember the steps

How do we treat the symptoms

How do we treat the disturbance

How bad is the hyperkalemia

How agressive do we need to be in treating it?

30
Q

Liver Transplants - Intraoperatively - Anhepatic

When does the Anhepatic phase starts? When does it end?

A

Starts at the occlusion of vascular inflow to liver being taken out

Ends at Graft reperfusion

31
Q

Liver Transplants - Intraoperatively - Anhepatic

When is the inferior vena cava clamped above and below the liver? Which other major vessels are clamped at the same time?

A

Once the dissection is completed and the liver is freed

Hepatic artery and portal vein will be clamped at the same time

32
Q

Liver Transplants - Intraoperatively - Anhepatic

Once the liver is freed, the inferior vena cava is clamped above and below the liver as well as the hepatic artery and portal vein. What happens next?

A

The liver is then completely excised and

Veno-venous bypass may be employed at this time

Donor liver is then anastomosed to recipient patient

33
Q

Liver Transplants - Intraoperatively - Anhepatic

What’s the effect of clamping large vessels (inferior vena cava and portal vein) during the Anhepatic phase of liver tpx on CO and BP

A

Marked decreases in CO and

Hypotension can be encountered

Occurs when inferior vena cava and portal vein are clamped

34
Q

Liver Transplants - Intraoperatively - Anhepatic

Which vascular strategy is employed for patients at increased risk during the vena cava clamping?

A

Veno-venous bypass

35
Q

Liver Transplants - Intraoperatively - Venovenous Bypass

How does the veno-venous bypass redirects blow flow during liver tpx?

A

Diverts IVC and portal venous flow to the superior vena cava via the axillary vein

36
Q

Liver Transplants - Intraoperatively - Venovenous Bypass

What are the benefits of Venovenous Bypass?

A

Can help minimize:

Severe hypotension

Intestinal ischemia

Build up of acid metabolites and

Postoperative renal dysfunction

37
Q

Liver Transplants - Intraoperatively - Venovenous Bypass

What risks are a/w Venovenous Bypass?

A

VAE

Thromboembolism

Inadvertent Decannulation

38
Q

Liver Transplants - Intraoperatively - Neohepatic

When does the Neohepatic phase starts? When does it end?

A

Starts with the completion of venous anastomosis

Ends with when circulation to the new liver is completed and blood is allowed to enter the new liver

39
Q

Liver Transplants - Intraoperatively - Neohepatic

When is circulation to the new liver allowed?

A

Following completion of venous anastomosis

The venous clamps are removed and circulation to the new liver is allowed

40
Q

Liver Transplants - Intraoperatively - Neohepatic

Following completion of venous anastomosis the venous clamps are removed and the circulation to the new liver is completed. Reperfusion syndrome may occur. What are possible causes of Reperfusion syndrome?

A

Cold, acidotic, hyperkalemic solution floading the system

Could happen quickly and as soon as blood flow is resumed

41
Q

Liver Transplants - Intraoperatively - Neohepatic

What potential risks are a/w reperfusion syndrome?

A

Emboli - Arrhythmia - Cardiac arrest

Hypotension

42
Q

Liver Transplants - Intraoperatively - Neohepatic

Which drugs could be used to prophylactically treat risks a/w reperfusion syndrome?

A

CaCl or Bicarb

Eliminates huge shift when reperfusion occurs

43
Q

Liver Transplants - Intraoperatively - Neohepatic

Following completion of venous anastomosis the venous clamps are removed and the circulation to the new liver is completed. Ischemia/reperfusion injury is possible. What could be reponsible this?

A

Endothelial dysfunction and non functioning graft

Happens overtime

Could manifest beyond the Neohepatic phase

44
Q

Liver Transplants - Intraoperatively - Neohepatic

Following completion of venous anastomosis the venous clamps are removed and the circulation to the new liver is completed. What’s the last structure to be connected?

A

Common bile duct of the donor is connected to the recipient

45
Q

Liver Transplants - Intraoperatively - Management of liver reperfusion

When it does occur, how is reperfusion syndrome managed?

A

Take steps to bring potassium to appropriate level (< 4.0)

(Go back and review how to treat Hyperkalemia and associated symptoms)

Replace calcium to ensure normal (> 5.0)

Correct lactic acidosis (pH normal)

Appropriate volume infusion to maintain euvolemia

Hemoglobin appropriate (9 – 10 for most patients)

Epinephrine 10 mcg/cc attached to iv ready for administration (bolus)

Epinephrine 20 mcg/cc on baxter pump ready for infusion

Communication with surgeon – OK for reperfusion

46
Q

Liver Transplants - Intraoperatively - Management of liver reperfusion

In the management of reperfusion syndrome, what should be your target potassium level?

A

< 4.0

47
Q

Liver Transplants - Intraoperatively - Management of liver reperfusion

In the management of reperfusion syndrome, what should be your target calcium level?

A

> 5.0

48
Q

Liver Transplants - Intraoperatively - Management of liver reperfusion

In the management of reperfusion syndrome, what should be your target Hemoglobin level?

A

9 – 10 for most patients

49
Q

Liver Transplants - Intraoperatively - Management of liver reperfusion

In liver tpx case, when should you start preparing for reperfusion and potential reperfusion syndrome?

A

During the initial phases of the case

7835 Exam IV (21 decks)

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