1. Liver Transplantation & its Anaesthetic
Management
Dr. Swadheen kumar Rout
2nd year P.G
Dept. of Anaesthesiology
M.K.C.G College & hospital

2. Introduction:-
 Liver transplantation is the only life saving procedure in pts. with end –
stage
liver disease & some cases of acute liver
failure.
Orthotopic Heterotopic
 First orthotopic liver transplant was performed by Dr Thomas Starzl in
1963.
 Patient was a 3 year old child with biliary atresia, who died in the
operating room from massive haemorrhage caused by venous
collaterals & uncontrollable coagulopathy.
 However with continued improvements in Organ preservation
technique,
Surgical technique,
Immunosuppressive agents,
Management of
 Has become highly successful in prolonging survival & improving
coagulopathy,in affected patients.
quality of life
Treatment of

3.  Data from the United Network for Organ Sharing (UNOS) on 24,900 ad
patients undergoing liver transplantation in a 10 year study showed tha
yr,
4-yr, and 10-yr patient survival rates were 85%, 76%, and 61%,
respectively,
 Survival (%) after adult liver transplantation by
thus confirming that liver transplantation results in prolongation of life.
diagnosis*
Diagnosis
1-yr
4-yr
10-yr
Primary sclerosing cholangitis
91
84
78
Primary biliary cirrhosis
89
84
79
Autoimmune hepatitis
86
81
78
Chronic hepatitis C
86
75
67
Alcoholic liver disease
85
76
63
Cryptogenic cirrhosis
84
76
67
Chronic hepatitis B
83
71
63
Malignancy
72
43
34
 Liver transplantation can be performed in patients of all ages.
Paediatric liver transplantation has a better survival rate (10-yr = 80–

4. Indications for liver transplantation: Acute liver failure
Acute hepatitis A,B,C infection
Drug/toxin hepato-toxicity
 Cirrhosis from chronic liver diseases
Chronic hepatitis B virus and chronic hepatitis C virus infection
Alcoholic liver disease
Autoimmune hepatitis
Cryptogenic liver disease
Primary biliary cirrhosis and primary sclerosing cholangitis
 Metabolic Disorders
Alpha-1 antitrypsin deficiency
Hereditary haemochromatosis
Wilson‟s disease
Glycogen-storage disorders
Type 1 hyperoxaluria
Familial homozygous hypercholesterolemia
 Malignancy
Primary hepatic cancer: hepatocellular carcinoma and cholangiocarcinoma
Metastatic: carcinoid tumors and islet cell tumours
 Miscellaneous
Polycystic liver disease
Budd-Chiari syndrome

5.  The decision to list a patient for transplantation is based more on
the severity of hepatic dysfunction than the underlying aetiology.
 Determining the need for liver transplantation must take into account
the natural history of the patient‟s disease and carefully compare it to
the anticipated survival after liver transplantation.
 Priority is based on specific prognostic criteria using a number of
scoring systems devised by United Network for Organ Sharing
(UNOS) for optimal use of the limited number of available organs.
 In the past Childs-Turcotte-Pugh (CTP) score plus the amount
of time on the waiting list.
 For listing purposes, a patient
must have at least 7 points (i.e,
be at least a Child‟s class B),

6.  However this did not always ensure that organs were allocated to
the sickest patients with the greatest risk of mortality.
 In 2002, model for end-stage liver disease (MELD) , based on
the patient‟s risk of dying while awaiting transplantation.
 The MELD risk score is a mathematical formula based on
the following factors:
1) Creatinine
2) Bilirubin (mg/dL)
3) International normalized ratio
 Most patients on the liver transplant waiting list have a MELD score between
11 & 20.

7.  Pediatric End-Stage Liver Disease (PELD) scoring system
incorporates the
following criteria(<12 yr)
1) Albumin:
2) Total bilirubin
(Growth failure is calculated based on
3) INR
age
4) Growth failure and gender using the current
WHO growth chart)
PELD score = 0.436 (age) – 0.687 x Log e (albumin g/dL) + 0.480 x
Log e (total bilirubin mg/dL) + 1.857 x Log e (INR) + 0.667 (growth failure)

8. Contraindications to Liver Transplantation: Absolute contraindications
Brain death
Extrahepatic malignancy
Active uncontrolled infection
Active alcoholism and substance abuse
AIDS
Severe cardiopulmonary disease
Uncontrolled sepsis
Anatomic abnormalities precluding liver transplantation
Compensated cirrhosis without complications
 Relative contraindications
Cholangiocarcinoma
Portal vein thrombosis
Psychologic instability

9. Anaesthetic importance: According to (UNOS) most deaths occurred within the first week
following OLTX, and the most common causes of death during that
interval were cardiovascular disease (28.2%), operative mortality
(14.6%), primary graft failure (13.5%), and haemorrhage (13.0%).
 The disease process causes major patho-physiological changes in
all other organ systems,hence requiring a thorough examination of the
recipient and a carefully scheduled anaesthesia to reduce morbidity &
mortality during & after the procedure.
Anaesthetic management
Living donors
Recipients

10. Anesthetic management of the living donors:Careful selection of donors (physically
& psychologicaly stable)
Organ Matching (ABO compatible)
 For successful transplantation of the liver, it is necessary to provide excellent
conditions for the donor especially during harvesting (i.e removal) while
preserving optimal hemodynamic parameters.
 By maintaining sufficient organ perfusion, adequate cardiac output,
avoiding excessive bleeding, keeping hematocrit at about 30% and
preventing coagulopathies.
 Invasive monitoring is obligatory to ensure sufficient organ perfusion. Many
protocols suggest a central venous pressure (CVP) below 5 cm H20 reduce
blood loss & graft oedema.
 Harvesting is only half the job done & anaesthesiologist plays a vital role both
in successful recovery of the living donor and the donor liver.

11. Anaesthetic management of the recipients:
Preoperative evaluation:-selection of appropriate and perfectly
The
prepared recipient is the gold standard for the
success of liver
Multi-disciplinary approach transplantation.
Tests to Exclude Contraindications:
Prior assessment Infectious disorders : HIV, syphilis, EBV,
& tests
cytomegalovirus, toxoplasmosis
Malignancy : Colonoscopy, ERCP
Anaesthesist role
(cholangiocarcinoma)
In HCC: bone scan, lung CT (metastatic
work-up)
Screening (colon, breast,cervical, prostate
cancer)
Complexity of the operationDisturbed patho-physiology of all
major organ systems
Decides recipient fit
Requires medical manageme
Proper planning
Successful transplantation

12. Patho-physiological changes & its
evaluation: Most of the recipients have End stage liver disease,
Secondary dysfunction of virtually
all other organ system(CNS,CVS)
Metabolic derangement
Anaesthetic Complications
 One must have sound knowledge of these changes which dictate
planning of anaesthetic management during the entire peri-operative
period

13. Respiratory system:- Pulmonary complications
associated with liver disease
include:
results
a) Restrictive Lung Disease: from ascites or pleural effusion
and
management involves removal of this
fluid.
Triad of
b) Hepatopulmonary syndrome (HPS): liver disease, hypoxaemia, (Pao2
<70 mm Hg) and right to left shunt due to
Intrapulmonary Vasodilation.
Patients are more prone to hypoxia ,ventilation-perfusion mismatch,
diffusion derfects however liver transplantation is not contraindicated.
c) Portopulmonary hypertension(POPH):
 Best defined as pulmonary artery hypertension (PAH) associated with
portal hypertension whether or not that portal hypertension is secondary to
underlying liver disease. The diagnosis of POPH is defined as a mean
pulmonary artery pressure >25 mm Hg in the presence of a normal
pulmonary capillary wedge pressure. progress rapidly and carries high
 Portopulmonary hypertension may
perioperative morbidity and mortality when significant. Pulmonary
hypertension responding to

14. Assessment of the patient`s pulmonary
system:1) Chest radiography
2) Lung function tests
3) Arterialial blood gas analysis(ABG)
4) Occasionally MAA( microaggregated albumin) scan - quantify
intrapumonary shunting

15. Cardiovascular system: Patients with end-stage liver disease develop a hyperdynamic
circulation
characterized by increased cardiac output and arteriolar vasodilatation,
systemic vascular resistance(SVR) is low.
 This condition has been attributed to sympathetic nervous system
overactivity,
inadequate clearance of vasoactive substances (bypassing the liver
due to ventricular dysfunction may occur secondary to
 Right
decreased hepatic function).
portopulmonary hypertension(POPH).
 Another important consideration in adults undergoing transplant is the
preoperative evaluation for ischaemic heart disease .
 Cirrhotic cardiomyopathy characterized by abnormal or blunted
cardiovascular response to stress, is present in as many as 50% of
the patients undergoing liver transplant.

16. Assessment of the patient`s cardiovascular
system:Routinely,
1) Electrocardiogram (ECG ) &
2) Echocardiography (ECHO)
useful in identifying ventricular dysfunction,
valvular pathology, pulmonary
Hypertension
Special tests
like
3) Pharmacologic stress tests:
dobutamine stress echocardiography
(DSE) / myocardial perfusion scan.
4) Coronary angiography:
Test myocardial function
(Ischaemic heart disease)

17. Renal System: Renal function is an important predictor of survival with chronic liver
failure and liver transplantation.
 Diagnosing HRS requires the absence of
primary renal disease, proteinuria,
↑ levels of endogenous vasodilators
nephrotoxins, hypovolemia, or hemodynamic
causes of renal
peripheral vasodilatation + hypoperfusion.
low blood pressure
 A urinary sodium level <10 mEq/L or a
hyperdynamic
fractional excretion of sodium <1% ,with a
circulation
ctivation of the sympathetic creatinine level of more than 1.5 mg/dL & a
nervous system & RAAS
urine volume of less than 500 mL/day is
Routinely
Vasoconstriction
required for diagnosis. ,BUN &
Serum urea, creatinine
End stage liver disease
Renal hypo-perfusion
electrolytes
Hepatorenal syndrome(HRS)

18. Central nervous system: Any organic disease, that contributes to the changes in cerebral
functions is a contraindication for liver transplantation.
 Hepatic Encephalopathy -hepatic clearance failure leads to
accumulation of toxins such as ammonia, GABA & other neuroactive
substances. exclude a pre-existing organic disease mimicing hepatic
 In order to
encephalopathy, EEG, stimulated potential tests & CT Scan are
recommended.
Grade 0
Normal
Grade 1
Altered spatial orientation, sleep patterns and affect
Grade 2
Drowsy but arousable, slurred speech, confusion,
asterixis
Grade 3
Stuporous, responsive only to painful stimuli
Grade 4
Unresponsive, with decorticate or decerebrate
posturing

19.  Patients with grade IV encephalopathy may develop cytotoxic and
vasogenic cerebral oedema with associated increase in intracranial
pressure (ICP).
 In such patients, intracranial pressure monitoring and first line
therapy with mannitol should be instated when ICP is greater than 25
mm refractory to mannitol, the following may be considered in the
 If Hg.
following
order based upon ease and safety of administration, and efficacy based
upon the available literature.
1) hypertonic saline,
2) induced moderate hypothermia
3) barbiturate coma
4) indomethacin
 A cerebral perfusion pressure >60 mmHg must be maintained.
Intractable ICP is a contraindication for surgery.
 In pre-encephalopathic patients benzodiazepines can precipitate
encephalopathy & should be avoided.

20. Gastrointestinal System:Portal hypertension
Upper GI Endoscopy
Oesophageal Varices.
Blood in stomach
Ascites
Delayed
gastric emptying
Patient considered full stomach
Aspiration prophylaxis
pre-medication

21. Haematological system: Anaemia is common secondary to blood loss, haemolysis from
hypersplenism, anaemia of chronic illness or nutritional deficiency
 Thrombocytopenia due to portal hypertension-induced splenic
sequestration and alcohol or sepsis induced bone marrow suppression
isIn ESLD balance between prohaemostatic & antihaemostatic
 common.
mechanisms is impaired.
 Levels of procoagulant factors (II, V, VII, IX, X) and anticoagulant
factors (protein C and S, antithrombin III) are frequently decreased.
 There is a correlation between the severity of preoperative
coagulopathy and
Intra-operative requirement for blood and blood products; as the
severity increases, requirements are increased.

22. Tests for haemostatic status:1) Bleeding time (BT)
2) Prothrombin time (PT)
3) Activated partial thromboplastin time
(APTT)
4) Platelets count
5) Thmromboelastogram (TEG)
 Administration of fresh frozen plasma (FFP), vitamin K, platelets
and other blood products before the surgery should be considered.
However no special
preoperative coagulation management is necessary in the absence
of bleeding.
 Optimisation of electrolytes, intravascular volume status,
coagulation, nutritional and infection status of recipient preoperatively is essential to decrease the risk of peri-operative
complications or death.

23. Preoperative Preparation: Blood bank services should have sufficient packed cells/whole
blood/platelets/cryoprecipitate and FFP`s in stock. Some centres
recommend up to 24 units of each be available per transplant case
with a minimum of 2-10 units immediately available in theatre.
 Lab services should be immediately available for blood sampling of
ABG`s and coagulation studies including platelet count, PT, APTT,
TEG ,etc.
 Preparation of the operating theatre includes the following
1) Warm room to 21-26 °C
2) Fluid warming devices
3) Forced air warming device
4) Rapid fluid infusion systems
5) Blood salvaging devices (eg cell saver)
6) Antibiotics prepared: Tazocin 4gm +
Flagyl 500mg
7) Syringe pumps
8) Emergency Drugs: norepinephrine ,
epinephrine, atropine, calcium, dextrose,
insulin, lignocaine

24. Premedication: One large bore peripheral venous access secured for
premedications & induction
 Aspiration prophylaxis – H2 receptor blocker
Prokinetic agent
Particulate free
ANTACIDS
 Intramuscular injections should be avoided in patients with
coagulopathy.
 Sedative premedication can be given as long as pt. does not have
encephalopathy.

25. Intra-operative Management:Haemodynamic monitoring is essential for successful
Monitoring:
liver transplantation
 Routine monitoring should be established pre-induction.
•
•
•
•
•
ECG
Pulse Oximetry
Capnography
Temperature
Urine output
 Invasive monitoring can be established post-induction.
• Arterial Catheter
• Central Venous Catheter
• Pulmonary Artery Catheter
• Transesophageal
Echocardiography

26.  Invasive arterial catheter is essential to provide continuous monitoring
of intra-arterial BP to see frequent hemodynamic changes usually
secondary to surgical manipulations such as caval clamping, blood loss,
hepatic reperfusion.Provides access for blood sampling for ABG &
coagulation tests.
 Central Venous Catheter(CVC) / Pulmonary Artery Catheter(PAC)
provide
information to aid the maintenance of intravascular volume and the need
for vasopressors to maintain adequate perfusion pressures. PAC is
considered gold-standard but has its own limitations. (invasive &
induced ventricular arrythmia)
 Transoesophageal echocardiography (TEE) is non invasive , hence
preferred nowadays. It provides real time monitoring of ventricular filling
and contractile function. This information may guide the administration
of i.v. fluids as well as inotropic drugs. In addition, intracardiac
microthrombi/air emboli may be observed during dissection or hepatic
reperfusion.
Contraindication - varices.

27. Induction of Anaesthesia:
 A routine rapid sequence induction with cricoid pressure should be
performed because of the risk of aspiration.
 All ETT should be placed orally. Nasotracheal intubation is
contraindicated as it may cause bleeding, especially in the presence of
coagulopathy and thrombocytopenia.
Choice of anaesthetic agents:

28. Drug metabolism:
 Drug elimination half-life is a function of clearance and volume of
distribution.
 Decrease in albumin levels results in intra and extravascular volume
changes, leading to an increase in distribution volume of drugs (e.g.
neuromuscular blocking agents(highly ionised)-duration of action
prolonged).
 There may be a prolonged duration of action for succinylcholine as a
result of reduced levels of pseudocholinesterase, but it is rarely of
clinical consequence.
 End stage liver disease results in diminished hepatic drug
clearance due to reduced hepatic blood flow and hepatic extraction
ratio.
 Clearance of drugs with a high hepatic extraction ratio (morphine,
pethidine ) is diminished when hepatic blood flow is compromised.
Hence these drugs should have a dosage decreased but not a
decrease in frequency of dosing.
 One must have sound knowledge of drugs pharmacokinetics &
pharmacodynamics with respect to liver disease.

29. Induction of Anaesthesia:
 A routine rapid sequence induction with cricoid pressure should
be performed because of the risk of aspiration.
 All ETT should be placed orally. Nasotracheal intubation is
contraindicated as it may cause bleeding, especially in the presence of
coagulopathy and thrombocytopenia.
Choice of anaesthetic agents:
 Propofol - An excellent choice
- short half-life even in patients with decompensated cirrhosi
(considerable extra-hepatic metabolism).
- It should be remembered that sensitivity to the sedative & cardio
respiratory effects of propofol are increased in liver failure & so the dose
should be reduced.

30.  Thiopentone - A reduced dose is again needed, as reduction in
plasma proteins causes an increased unbound fraction of the drug.
The distribution half life and duration of action are also prolonged.
 Ketamine - is highly extracted by the liver and not significantly bound
to albumin leading to a variable clearance depending on the degree of
synthetic liver function.
 Etomidate can also be used.
Muscle
relaxants:
 All non-depolarizing agents have been used successfully in liver
transplantation as long as appropriate neuromuscular monitoring is
performed.
 Atracurium and cisatracurium are metabolized independent of the
liver and are therefore preferred in patients with liver disease.
 Vecuronium and rocuronium also provide optimal conditions, (increase
requirement of first dose of nondepolarizing muscle relaxants & prolong
duration of their action).

31. Maintenance of anaesthesia: A balanced anaesthetic is used which consists of a volatile agent in
low to moderate concentrations (0.5–1 MAC) in an air-oxygen mixture
to ensure unconsciousness, while an opioid, is chosen to blunt the
sympathetic response to stimulation.
 Nitrous oxide should be avoided, in order to minimize gaseous
distension of the bowel & to avoid its effect on expansion of venous
air emboli which may occur during the procedure
Maintenance of blood flow to the liver is crucial once
Volatile agentthe new allograft has been transplanted.
 Nearly all volatile anaesthetic agents reduce cardiac output and MAP,
hence reduce hepatic blood flow.
 Isoflurane has been the volatile agent to be preferred because of its
vasodilation effect on hepatic circulation, preserving splanchnic
blood flow better than the others;(advantageous for the reperfused
graft)
 Different studies give conflicting reports on desflurane & sevoflurane
effect on hepatic blood flow.

32. Opioids:-
 Elimination of morphine is delayed in cirrhotic patients due to reduced
hepatic blood flow and extraction ratio.(accumulation of the active
metabolite morphine-6-glucuronide occurs).Morphine may therefore
precipitate encephalopathy and possibly best avoided in severe liver
dysfunction.
 Fentanyl, Sufentanil & Remifentanil are commonly used as their
clearance is unaffected.

Following induction - Invasive monitoring
 Positioning & Padding.
 Orogastric tube insertion.
 Multiple venous access.
 Antibiotic adminstration.

33. Haemodynamic management: Complexity of surgery cause rapid fluid shift, blood loss.
Haemodynamic stability is essential intra-op to maintain perfusion to
vital organs & successful transplantation.
 The transplant operation can be conceptualized as consisting of three
phases:
1). hepatectomy (liver removal, Pre-anhepatic) phase,
2). Anhepatic (no liver) phase, and
3). post implantation(Post anhepatic) phase.

34. Pre-anhepatic phase: Begins with surgical incision and ends with cross-clamping of the
portal vein, the suprahepatic inferior vena cava(IVC), the infrahepatic
IVC, and the hepatic artery. This phase involves dissection and
mobilization of the liver. Drainage of ascitic fluid
Hemodynamic instability
Transection of large varices
Surgical manipulation
obstructing venous return
 Hypotension is initially due to drainage of ascites, resulting in
hypovolemia.
Hypovolemia should be treated in an anticipated fashion with colloid
containing fluid to minimize changes in preload . (Ringer acetate
solution + Albumin is on the vasopressor of choice in maintaining the
 No evidence to date administered routinely at 10 mL/ kg/ h.)
blood pressure during OTLX. Epinephrine, norepinephrine &
dopamine have all been
Used.

35.  In this period of liver transplantation
the primary issue is surgical bleeding.
Degree of pre-existing coagulop
Severity of portal hypertension
Complexity of the surgical proc
 Several approaches have been applied to manage this
problem:
1) Pre-operative autologous blood donation,
2) Erythropoietin administration,
3) Intra-op isovolemic hemodilution,
4) Blood salvage techniques
5) Maintenance of low intra-op central venous pressure(CVP < 5 cm
H2O)
 6) Preventing hypothermia-induced coagulation abnormalities and
Monitoring coagulation parameters by PT, APTT, fibrinogen
platelet counts & thromboelastography(TEG).
 The administration of FFP, RBCs, platelets, & cryoprecipitate
remains the mainstay of therapy .
 Excessive treatment of coagulopathy is not usually recommended at
this phase unless bleeding is extreme .Aggressive correction of the
coagulation status may lead to hypervolaemia & diilutional
coagulopathy.

36.  Red blood cells are transfused to maintain a haematocrit around
30%. FFP is given to maintain the prothrombin time below 1.2-1.5
times normal and
platelets are kept above 50X109 L-1.
 Diuretics can be used to maintain euvolemic conditions and reduce
transfusion requirements.
 Mannitol
20% IV bolus (0.3–0.5 g/kg) prior to venous clamping,
with its potential for free radical scavenging and antioxidant properties,
helps to remove free water in the abdominal organs & provides renal
protection.
 Overall use of blood products during liver transplantation has been
significantly reduced in recent years because of improved surgical
technique, intra-op management, and patient selection.

37. Anhepatic phase:
Starts with the occlusion of blood inflow to the liver and ends with
graft reperfusion, when the IVC and portal vein clamps are removed
with or without unclamping of the hepatic artery.(interpositional
anastomosis) cava is occluded
Inferior vena
VENOVENOUS BYPASS
(VVB) overcomes the pro
 If VVBP is not used, volume loading
with a target CVP of 10 to 20 mm Hg &
small doses of vasopressors are
↓ CO and hypotension
needed before the infrahepatic and
↑ Distal venous pressure suprahepatic venacaval clamps are
placed to prepare for the anhepatic
phase.
Increase bleeding,
Loss of venous return
Renal hypoperfusion
The majority of patients will tolerate IVC clamping for a period of about one
hour.
MAP is usually maintained for up to 1 h because of increased heart rate and a
compensatory increase in SVR.

38. Venovenous Bypass (VVB): This involves the extracorporeal divertion of blood from the venous
system below the caval clamps (inferiormesenteric and femoral
veins) to the central veins (axillary or internal jugular veins) via a
centrifugal pump and heparin bonded tubing.
 In the past, a greater than 50% reduction in cardiac output after
vena cava clamping was considered an indication for VVBP. The
decision of using VVB depends on medical team experiences,
preferences
Disadvantages:Advantages:- and judgement.
1) Improved hemodynamic stability,
2) Improved perfusion of organs
during anhepatic phase,
3) Decreased RBCs and fluid
requirements
4) Renal protection,
5) Reduced incidence of pulmonary
edema.
1) No evidence that it improves
outcome 2) Vascular access
related complications
- pneumothorax,
- lymphoceles,
- hematoma formation,
- air embolism,
- major vascular/ nerve injury,
- vessel thrombosis

39.  Close observation of serum electrolytes (Sodium, pottasium & ionised ca
& ABG is essential and should be kept within normal limits.
 Calcium
chloride administration during the absence of hepatic
functions avoids citrate intoxication related hypocalcemia associated
with infusion of citrate rich blood products.
 Acid metabolites originating from intestine cannot be cleared in the
absence of liver, resulting in progressive acidosis. Sodium
bicarbonate therapy should be guided by ABG analysis, because
excessive administration may result in hypernatremia,
hyperosmolality and metabolic alkalosis.
 Due to absence of a liver produced plasminogen activator inhibitor,
fibrinolysis may begin during this phase. During this phase platelets
and coagulation factors continue to decrease.
 Antifibrinolytic strategies differs among centers, used if there is
evidence of fibrinolysis and there are no contraindications for its use.
.
Epsilon aminocaproic acid
Tranexamic acid

40. Post Anhepatic Phase:-(Reperfusion phase)
 The onset of this phase is heralded by the unclamping of the portal
vein and IVC , with reperfusion of the new liver.
 The most critical part of the reperfusion phase is the period
immediately after the vascular clamps are removed from the liver graft.
Significant hemodynamic
instability like bradycardia, ventricular dysrhythmias and cardiac
arrestmajor anaestheticseconds to minutes of unclamping.
 The can occur within issue during this phase is that of
“postreperfusion syndrome.” The hallmark of the postreperfusion
syndrome (PRS) is systemic hypotension(at least 30% decrease) for
more than 1 min with or without pulmonary hypertension occurring
within the first 5 minutes after reperfusion of the graft and anesthetic
management is directed at maintaining or recovering cardiovascular
stability.
 These changes are provoked by the rapid infusion of effluent from
the transplanted liver, which is high in potassium and low in pH &
temperature.

41. Some steps to manage the cardiovascular instability
1- Continuous Monitoring of BP.
2- Norepinephrine infusion to be started.
3- Blood and colloid infusion by rapid infusion system.
Retrograde flushing with the recipient's blood by the surgeon prior to
reperfusion(`blood flush') reduces the potassium concentration and
acid content of the effluent(Flushing has been shown to decrease the
incidence of post reperfusion cardiac arrest).
4- Epinephrine and atropine should be at hand for treatment of
bradycardia.
5- Calcium chloride should also be continued.
6- Sodium bicarbonate, dextrose 25% and insulin should be readily
available to
rapidly treat acidaemia and hyperkalaemia.
7- After complete revascularization of the allograft,
methylprednisolone
(10mg/Kg) is administered as immunoinduction.
8- Maintenance of temperature is important because it plays a vital
role in optimizing the function of the coagulation system.

42.  Prostaglandin E1 is administered at a rate of 0.3-0.6 mg/kg/h in the
post anhepatic portion of the surgery as a hepatic and renal
cytoprotective agent, improving blood flow to the graft..
 This reperfusion of the graft is associated with restoration of
electrolyte and acid base balance.
 Signs of liver function which may be seen in the operating room are
decreased calcium requirements, improvement in acidosis,
increased urine output, rising core temperature and biliary output
from the graft.
 As the graft begins functioning the coagulopathy gradually improves.
Fibrinolysis and heparin effect ceases within 2 hours, coagulation
factors and platelets begin to increase toward baseline levels; PT and
APTT reach their baseline values within a few days.

43. EXTUBATION: Postoperative tracheal intubation is no longer mandatory as long as
significant respiratory compromise or concern for airway protection is
absent, and established criteria for extubation are fulfilled.
 „Fast-tracking‟ defined as extubation at the conclusion of surgery before
leaving
the operating room in selected patients has shown to improve early graft
function and reduce duration of stay in the ICU and nosocomial infectio
 Selection of patients for early extubation depends on duration of the
surgery, coagulation profile, amount of blood and products
transfused, patients‟ pre-operative status (MELD score), and status
of the graft.
 Regardless of whether the patient is extubated in the operating room,
most
centers admit patients to the ICU for close monitoring purposes.

44. Postoperative Care: Frequent assessment of cardiac and pulmonary function, serum
glucose and electrolytes, renal and liver functions , coagulation status
and the blood count is crucial.
 Adequate Pain control , prevention of shivering & hypothermia
to avoid excessive sympathetic nervous system stimulation.
 The requirements for blood transfusion continues also in the
postoperative
Period. If ongoing bleeding, despite correction of coagulopathy &
rewarming of the patient especially if hemodynamic instability &
oliguria are present, the patient should undergo immediate reoperation
to identify and stop the ongoing
Liver Function-Favourable signs regarding hepatic function in the immediate
bleeding. Haematocrit maintained between following:
postoperative period include the 0.26 & 0.32.
.
1. Hemodynamic stability
2. Clearance of lactate
3. Resolution of hypoglycaemia
4. Normalization of coagulation profile
5. Resolution of elevated liver enzymes.
6. Good renal function