Orthotopic Liver Transplant
Patient phenotype
End-stage liver disease (cirrhosis, HCC, alcoholic, NAFLD, viral hepatitis). Hepatorenal syndrome, encephalopathy, coagulopathy, varices, hyperdynamic circulation often present. MELD ≥ 15 typical.
Procedure
Three phases: (1) PRE-ANHEPATIC — recipient hepatectomy, (2) ANHEPATIC — venous bypass or piggyback technique, donor implantation, (3) NEO-HEPATIC — reperfusion of new liver. 6–12 hours.
Anesthetic plan
GETA, often with 2 A-lines, large central access (Cordis/MAC), TEE essential. Massive transfusion infrastructure. ICU intubated overnight. Multidisciplinary team (transplant surgery, hepatology, OR nursing).
Setup
- ·TWO arterial lines (radial + femoral)
- ·Central access: 9 Fr Cordis OR MAC catheter for rapid transfusion + PA cath
- ·Two large-bore PIVs in addition to central
- ·TEE — RV function + reperfusion
- ·Belmont rapid infuser, Level 1 backup, fluid warmer
- ·Type & cross 10 units PRBC, FFP, platelets, cryo, factor concentrates
- ·TEG/ROTEM at bedside — guides product replacement better than INR
- ·Renal replacement therapy (CVVH) ready if hepatorenal
Biggest concerns by phase
Hyperdynamic circulation + low SVR + cardiomyopathy
Cirrhotic = high CO, low SVR baseline. Vasodilators dramatic effect. Cirrhotic cardiomyopathy: latent systolic + diastolic dysfunction, blunted β response. Stress test + ECHO required for waitlist. Don't trust 'normal EF' — under stress they crash.
Coagulopathy + thrombocytopenia + portal HTN bleeding risk
INR is unreliable in liver disease (rebalanced hemostasis). Don't transfuse based on INR alone — use TEG/ROTEM. Avoid high-volume crystalloid (worsens coag). Risk: variceal bleeding from any tube/airway manipulation.
Anhepatic phase — no metabolic clearance
No hepatic metabolism for hours. Avoid drugs metabolized by liver: morphine, midazolam, vecuronium accumulate. Use cisatracurium (Hofmann), remifentanil (esterase). Lactate accumulates. Glucose drops — start D5 infusion. Calcium drops with citrate (each PRBC).
Reperfusion syndrome — hyperkalemia, acidosis, cardiac arrest
Unclamping new liver dumps preservation solution + cold acidotic hyperkalemic blood centrally. Sudden K spike to 6+, pH drop to 7.1, BP collapse. Pre-reperfusion: K + acidosis correction, calcium 1 g, epi drawn for bolus, clear team. Be ready to do CPR.
Massive transfusion — TEG-guided component therapy
Average liver transplant: 6–12 units PRBC, similar FFP, multiple platelets, cryo. Factor concentrates (PCC, fibrinogen) replacing FFP at many centers. Replace in 1:1:1 ratio. TEG guides direction: low MA = platelets, low alpha = fibrinogen, prolonged R = FFP/PCC.
ICU management: allograft function, CVVH, immunosuppression
Direct to ICU intubated. Watch lactate trend (rising = poor allograft function or PV thrombosis), bilirubin trend, INR drop (good sign). Tacrolimus + mycophenolate + steroid started day 1. Close watch for primary nonfunction, hepatic artery thrombosis, biliary leak.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Mid-anhepatic phase. Patient has had 8 units PRBC, 6 FFP, 1 platelet pheresis. INR 1.8, fibrinogen 100, ionized Ca 0.85, K 5.5, pH 7.22. Surgeon is preparing to reperfuse the new liver in 5 min. What's your plan?
What an examiner probes for
- ▹Pre-reperfusion: correct K (insulin/dextrose, maybe albuterol nebulizer), correct acidosis (bicarb 50 mEq), give CaCl₂ 1 g
- ▹Correct fibrinogen (cryo or fibrinogen concentrate)
- ▹Vasopressor + epi drawn for reperfusion crash
- ▹Communication: clear room of nonessential people, full team focus
Reperfusion just happened. BP 60/30, HR 130 then drops to 40, ETCO₂ falls from 35 to 18, K reads 7.2 on the rapid analyzer. What do you do?
What an examiner probes for
- ▹Recognizes post-reperfusion syndrome with hyperkalemic cardiac arrest pattern
- ▹Action: CPR, calcium chloride 1 g IV push, epinephrine 1 mg, bicarb
- ▹Insulin 10U + D50 25g, albuterol nebulizer
- ▹Communicate with surgeon — flush graft, may need temporary clamp
Sources
- Miller's Ch 73 (transplant)
- AASLD Liver Transplant Guidelines
- ILTS Liver Anesthesia
Anatomy reference
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