UBP 5.7 (Long Form): Hepatic – Liver Transplant & Alcoholism

Question 1

Intra-operative Management:

What lines and monitors would you require for this case?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 1

My selection of lines and monitors would be made based on the potential for significant intra-operative blood loss and hemodynamic instability, combined with the potential complications associated with this patient’s end-stage liver disease, portopulmonary hypertension (PPH), and hepatorenal syndrome (HRS).

Therefore, in addition to the standard ASA monitors, I would place an arterial line for close hemodynamic monitoring and to facilitate frequent blood draws; a central venous line and pulmonary artery catheter to better monitor intra-operative pulmonary artery pressures, provide a route for central drug administration, and to facilitate both intra-operative and post-operative hemodynamic and fluid management (the PAC is especially useful in patients with HRS and/or PPH); and Foley catheter to closely monitor the urine output of this patient with HRS undergoing a case associated with large volume shifts and hemodynamic instability.

Given this patient’s history of bleeding esophageal varices, I would avoid the placement of a nasogastric tube and the use of TEE for this case, as the use of these devices could lead to significant bleeding that was difficult to manage.

Considering the potential for massive blood loss, I would require several large-bore intravenous catheters and high volume infusion equipment.

Finally, if veno-venous bypass were being utilized during the case, I would avoid the placement of any lines in the arm selected for this procedure.

Question 2

Intra-operative Management:

What is veno-venous bypass (VVBP)?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 2

Veno-venous bypass is a technique whereby the femoral (or distal inferior vena cava) and portal veins are cannulated to reroute blood flow from below the diaphragm to the suprahepatic vena cava (via the axillary, subclavian, or jugular vein) following the interruption of caval flow during the anhepatic phase.

The advantages of utilizing VVBP include:

• improved hemodynamic stability,
• better organ perfusion during the anhepatic phase,
• improved cardiac filling,
• decreased blood and fluid requirements,
• splanchnic decompression (promotes an earlier return of gut motility),
• preserved drainage of renal veins (potentially reducing renal impairment),
• limited metabolic impairment,
• improved cardiac filling,
• an improved surgical field (due to compression of portal pressures), and
• a reduced incidence of pulmonary edema.

Disadvantages include –

• an increased risk of air embolism, thromboembolism, arm lymphedema, hematoma, vascular injury, and nerve injury.

While VVBP is routinely used at some centers, others utilize this procedure for selected patients (i.e. cardiac disease, severe pulmonary hypertension, significant hemodynamic instability) or when clamping of the inferior vena cava results in significant hemodynamic instability.

Finally, some centers rarely utilize VVBP, believing that most patients are adequately managed using volume loading and vasopressors as required.

An alternative approach to the problem is to perform a piggyback technique, a surgical technique where the diseased liver is dissected away from the IVC, thus preserving the recipient IVC and avoiding the complete interruption of caval blood flow.

• This procedure, unfortunately, is technically more difficult and associated with increased surgical complications.

Question 3

Intra-operative Management:

Would you place an epidural for post-operative pain control?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 3

Given this patient’s thrombocytopenia (and possible thrombocytopathia); elevated PT, PTT, and INR; and the potential for a prolonged and significant perioperative coagulopathy, I would – avoid neuraxial analgesia for post-operative pain control.

My concern is the increased risk of epidural hematoma formation, particularly during placement and removal of the epidural catheter.

Therefore, I would consider other options for pain control, such as patient-controlled analgesia, opioid analgesics, and non-opioid analgesics.

Question 4

Intra-operative Management:

How would you induce this patient?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 4

Given the presence of ascites (although some of this fluid was removed with preoperative paracentesis, any remaining fluid may increase the risk of aspiration via increased intra-abdominal pressure), the emergent nature of liver transplantation (likely to have a full stomach), and the potential for gastroparesis (often associated with end-stage liver disease), I would prefer to perform a rapid sequence induction to reduce the risk of aspiration.

Therefore, assuming the patient’s airway exam was reassuring, he was hemodynamically stable, and that the appropriate monitors and intravenous access were in place, I would –

• administer metoclopramide, an H2-receptor antagonist, and sodium citrate;
• place the patient in the reverse trendelenburg position (to reduce the risk of passive regurgitation and facilitate intubation);
• pre-oxygenate with 100% oxygen for 5 minutes (a.k.a. denitrogenation);
• apply cricoid pressure;
• administer lidocaine, propofol, and succinylcholine (recognizing the potential for a prolonged effect due to reduced pseudocholinesterase); and
• rapidly secure the airway.

Question 5

Intra-operative Management:

Would you place an orogastric tube to reduce aspiration risk?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 5

While the pre-induction placement of an orogastric tube would be desirable to decompress the stomach, which serves to improve surgical exposure, and to reduce the gastric content volume of this patient at increased risk of aspiration,

I would AVOID placement in this case due to the risk of causing significant bleeding from his esophageal varices.

Esophageal varices develop when increasing portal pressures ( > 12 mmHg) result in dilation of the superficial veins in the esophageal mucosa.

These distended vessels are usually thin-walled and poorly supported by surrounding tissue, making them highly susceptible to significant bleeding with minimal trauma (i.e. gastric tube and TEE probe).

Question 6

Intra-operative Management:

Would you use succinylcholine for RSI?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 6

Given this patient’s increased risk of aspiration, I would use succinylcholine to facilitate securing the airway as rapidly as possible, recognizing that there may be a prolonged effect due to the reduced production of pseudocholinesterase often associated with end-stage liver disease.

While there are other options for rapid muscle relaxation, such as high dose rocuronium, none of these options provide optimal intubation conditions as rapidly and reliably as succinylcholine.

Therefore, I would administer succinylcholine, keeping in mind that the length of the case will allow a significant period of time for metabolism and the transfusion of fresh frozen plasma will provide additional pseudocholinesterase.

Question 7

Intra-operative Management:

The surgeon is planning infracaval interposition of the new liver.

Briefly describe the three stages of liver transplantation?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 7

The three stages of liver transplantation include:

1. the dissection (pre-anhepatic) phase, in which the liver is dissected and mobilized until it is only attached by the inferior vena cava, portal vein, hepatic artery, and common bile duct;
2. the anhepatic phase, which begins with clamping of the hepatic artery, and proceeds through removal of the native liver and implantation of the donor liver; and
3. the reperfusion (neohepatic or post-anhepatic) phase, which involves completion of anastomosis (i.e. venous, hepatic artery, common bile duct), ensuring adequate hemostasis, and completion of the surgery.

Question 8

Intra-operative Management:

At the start of the anhepatic phase, the surgeon clamps the inferior vena cava.

The patient’s blood pressure drops to 78/44 mmHg.

What will you do?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 8

I would first ask the surgeon to release the clamp, since the timing of his hypotension suggests the most likely cause is the reduced cardiac preload associated with clamping of the inferior vena cava.

Recognizing that there could be other causes of his hypotension, I would then – switch the patient to 100% oxygen, confirm the accuracy of the measurement, verify proper endotracheal tube placement, auscultate the lungs, administer fluids and vasopressors as indicated, and initiate a discussion with the surgeon about using VVBP.

If VVBP were not desirable for some reason, I would volume load the patient to a target CVP of 10-20 mmHg and ensure the presence of the appropriate vasopressors prior to replacing the clamp on the inferior vena cava.

Question 9

Intra-operative Management:

During the anhepatic phase the patient’s ECG begins to exhibit peaked T-waves and a widening QRS.

What do you think is going on?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 9

Peaked T-waves and a widening QRS on EKG are consistent with significant hyperkalemia.

This patient is at increased risk of becoming hyperkalemic during the anhepatic phase due to the acidemia that often develops during this phase (interrupted liver metabolism), the reduced urine output associated with HRS, reduced hepatic uptake of K+ ions, the high potassium levels often present in stored blood, and the washout of potassium-containing preservative solution into the systemic circulation following reperfusion.

Therefore, I would order a plasma potassium level, notify the surgeon, and initiate treatment.

In treating the patient, I would:

1. administer calcium chloride or calcium gluconate to depress cardiac membrane excitability (immediate effect);
2. ensure immediate access to a cardiac defibrillator and prepare to treat cardiovascular dysrhythmias and instability as necessary;
3. attempt to correct any factors that may exacerbate hyperkalemic cardiotoxicity, such as acidosis, hyponatremia, and hypocalcemia;
4. administer insulin and glucose (effective in 10-20 minutes), B2-adrenergic drugs (albuterol, salbutamol), and sodium bicarbonate (or THAM) to facilitate intracellular movement of potassium;
5. hyperventilate the patient to promote alkalosis and subsequent intracellular movement of potassium; and
6. give consideration to hemodialysis if temporizing measures are insufficient.

Question 10

Intra-operative Management:

Could these EKG findings represent citrate toxicity?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 10

While widened QRS complexes may be associated with citrate toxicity, the presence of peaked T-waves is more consistent with hyperkalemia.

However, patients undergoing liver transplant are at increased risk of developing citrate toxicity due to the rapid administration of blood products (which contain citrate) combined with decreased or interrupted perfusion of the liver (citrate is metabolized in the liver).

Therefore, I would look for additional signs consistent with a hypocalcemic patient under general anesthesia, such as – hypotension, narrow pulse pressure, prolonged QT interval, elevated intraventricular end-diastolic pressure, elevated central venous pressure, and flattened T-waves.

If at any point citrate toxicity did develop, I would administer calcium chloride (3-5 mL of a 10% solution) or calcium gluconate (10-20 mL of a 10% solution), correct any hypothermia (slows metabolism of citrate), optimize perfusion of the liver, monitor serium calcium levels, repeat calcium administration as necessary, and be prepared to treat significant hypotension or cardiac arrhythmias.

Question 11

Intra-operative Management:

You begin treatment of the hyperkalemia and proceed through the anhepatic phase without further difficulty. However, at the beginning of the reperfusion phase the patient’s blood pressure drops from 112/78 mmHg to 64/37 mmHg.

What do you think is going on?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 11

The occurrence of hypotension at the beginning of the reperfusion phase, is often due to the removal of the vascular clamps (especially the portal vein), with subsequent development of post-perfusion syndrome, a condition associated with systemic hypotension, bradycardia, cardiac arrhythmias, and elevated pulmonary artery pressures.

However, other considerations would include –

• hemorrhage (i.e. bleeding esophageal varices, surgical bleeding, and severe coagulopathy),
• tension pneumothorax (i.e. central line placement, smoker),
• congestive heart failure (i.e. HPS, complicated fluid management), and
• hyperkalemia (patient was already hyperkalemic prior to reperfusion of the graft which may have added an additional potassium load).

Question 12

Intra-operative Management:

What causes reperfusion syndrome?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 12

While the precise etiology of reperfusion syndrome is unknown, several proposed mechanisms include:

1. an excessive potassium load with flushing of the graft perfusate into the systemic circulation;
2. the release of vasoactive substances and acid metabolites from the lower extremity or graft;
3. the deleterious effects of cold blood from the graft on the heart; and
4. the release of cytokines.

Factors that may exacerbate this condition include – metabolic acidosis, pre-existing hypovolemia, hypothermia, hypocalcemia, and hyperkalemia.

Measures that can be taken to reduce the incidence of this syndrome include –

• careful flushing of the graft just prior to reperfusion;
• the administration of calcium (500 mg of CaCl₂) with the initiation of perfusion, to counter the effects of potassium on the heart; and
• the administration of inotropes or vasoconstrictors to correct any preexisting hypotension.

Question 13

Post-operative Management:

Would you extubate this patient immediately following the case?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 13

While many post-liver transplant patients are extubated in the operating room, I would prefer to delay extubation of this patient with preoperative ascites, PPH, HRS, and hepatic encephalopathy.

Given his significant pathology, I would transport him to the ICU and delay extubation until all extubation criteria had been met and a more thorough evaluation of his condition could be performed.

Question 14

Post-operative Management:

What potential post-operative complications should be anticipated following liver transplantation?

• (A 54-year-old, 5’10”, 62 kg gentleman is scheduled for orthotopic liver transplantation.*
• HPI: The patient has alcoholic cirrhosis with portal hypertension, jaundice, ascites, and esophageal varices that are currently not bleeding. He abused alcohol for 22 years, quit drinking alcohol 3 years ago, and has recently developed mild encephalopathy for which he is receiving lactulose and neomycin.*
• PMH: His past medical history is significant for smoking two packs of cigarettes per day for over 30 years and mild COPD.*
• Meds: lactulose, neomycin, and vitamin K*
• PE: Vital signs: BP = 104/68, P = 97, R = 26, T = 36.5ºC*
• Airway: Mallampati score of II*
• Pulmonary: diminished breath sounds in the lung bases*
• Abdomen: hepatomegaly, splenomegaly, caput medusa*
• Extremities: edematous lower extremities, palmar erythema*
• General: The patient appears jaundiced. He is responsive and cooperative, but seems somewhat confused.*
• Lab: H/H = 10.2/24; K+ = 3.1; Na+ = 132; Albumin = 2.9; INR = 1.4; Platelets = 76; ABG: pH = 7.36, PaCO2 = 32; PaO2 = 78; Bun/Cr = 38/1.8; PT/PTT = 16/30*
• CXR: SIgnificant atelectasis*
• DSE: estimated pulmonary artery pressure of 46 mmHg; otherwise negative*
• ECG: Normal)*

Answer 14

Potential post-operative complications that I would be anticipating in this patient would include:

1. bleeding esophageal varices,
2. vascular anastomotic leakage or failure,
3. coagulopathy (i.e. DIC, hyperfibrinolysis, residual heparin, dilutional coagulopathy, uremia, and inadequate clotting factor synthesis due to poor graft function),
4. renal dysfunction (i.e. HRS, drug toxicity, pre-renal azotemia, and ATN),
5. congestive heart failure (PPH, fluid overload),
6. TRALI (massive blood transfusion),
7. pulmonary edema (congestive heart failure, fluid overload, TRALI),
8. biliary complications (i.e. bile leaks),
9. hepatic or portal vessel thrombosis,
10. encephalopathy,
11. peripheral nerve injury (increased risk due to length of case),
12. diaphragmatic or phrenic nerve injury,
13. systemic infection,
14. acute graft failure or rejection, and
15. metabolic abnormalities (especially metabolic alkalosis and hypokalemia)