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Transplant — Liver, Kidney, Heart, Lung
TEXTSpecialty III · 10 min read
Each organ transplant has signature anesthetic challenges. Reperfusion syndrome, denervated heart, PA clamp RV failure — physiology matters.
After this lesson you can
2 min read8 sections- Plan liver transplant anesthetic management.
- Anticipate reperfusion syndrome.
- Manage denervated heart in cardiac transplant recipient.
- Identify acute rejection clues.
Liver transplant — reperfusion syndrome
Hyperkalemia (graft K release), acidosis, cold preservation fluid, vasodilation from cytokines + air emboli.
Hypotension, bradycardia, possible cardiac arrest within minutes.
Pre-medicate before unclamping: calcium chloride 1 g + bicarbonate + insulin if K elevated.
Epinephrine 10-100 mcg bolus ready.
Brief CPR sometimes required.
Recovery minutes.
Liver transplant phases
- preanhepatic (dissection — bleeding + coagulopathy management)
- anhepatic (cross-clamps applied — no liver function, calcium + glucose monitoring)
- neohepatic (reperfusion + reconstruction)
TEG/ROTEM goal-directed coagulation.
Massive transfusion common — 10+ units PRBC + plasma + platelets.
Veno-veno bypass in some centers for cardiovascular instability during anhepatic phase.
Kidney transplant
Avoid nephrotoxins (NSAIDs, contrast).
Cisatracurium NMB of choice (Hofmann elimination — no renal dependence).
Mannitol + furosemide common at unclamping per surgeon.
Pre-transplant dialysis status critical.
Anti-thymocyte globulin pre-op = anaphylactoid risk — prepare for management.
Heart transplant — denervated heart
Direct chronotropes only: atropine + glycopyrrolate INEFFECTIVE on HR.
Direct agonists (epinephrine, dobutamine, isoproterenol) work.
HR baseline 90-110 (no resting vagal tone).
Coronary autoregulation preserved.
Frank-Starling preserved.
Reinnervation partial over years.
Avoid reflex bradycardia treatments — they don't work.
Lung transplant — PA clamp + RV failure
Inhaled NO or epoprostenol vasodilates pulmonary bed.
Inotropic support (epinephrine, milrinone) for RV.
ECMO standby often required, sometimes pre-clamp.
Anesthetic management requires advanced cardiothoracic experience + multidisciplinary team.
Immunosuppression + ECMO bridge
Maintain per protocol.
Long-term immunosuppression affects future anesthetic management (infection risk, wound healing, drug interactions, opportunistic infection susceptibility).
- continuous anticoagulation (heparin to ACT 180-220)
- hemodynamic management balancing pump flow vs native cardiac output
- ventilator weaning during recovery
- mobilization on ECMO at advanced centers
Donor management — donation after brain death + DCD
Goals: optimize organ perfusion + viability.
Hormonal resuscitation (T3, vasopressin, methylprednisolone, insulin) per UNOS protocol.
Maintain MAP, normothermia (vs hypothermia for organ preservation timing per surgeon), normoxia, normocarbia.
Diabetes insipidus typical (vasopressin or DDAVP).
Brain-dead patients have no autonomic regulation — anesthesia not needed but NMB given for surgical relaxation.
DONATION AFTER CIRCULATORY DEATH (DCD): withdrawal of support in OR, then organ procurement post-cardiac arrest — comfort care during withdrawal, no NMB, no positive-pressure ventilation after declaration.
Pre-transplant assessment + risk
- dobutamine stress echo
- RHC for portopulmonary HTN
- hepatopulmonary syndrome workup
Heart transplant: VAD bridge common; assessment of right heart, PA pressure, secondary organ dysfunction.
- 6-min walk test
- oxygen requirement
- RV function
Kidney transplant: dialysis access, cardiac eval given high CV mortality in ESRD.
Drug-allergy + immunosuppression history.
Realistic discussion of risk + recovery with patient + family.
⚠ Common pitfalls
- Routine peripheral pulses on heart transplant recipient — denervated; respond to chronotropes directly.
- Standard sux dose post-liver transplant — coagulopathy + altered drug handling.
- Forgetting that immunosuppressants alter MAC and pseudocholinesterase.
- Letting CVP rise during liver recipient — hepatic congestion increases bleeding.
💎 Clinical pearls
- Liver transplant reperfusion syndrome: hypotension + bradycardia + hyperK at unclamping — pre-treat with calcium + epi + bicarb on hand.
- Heart transplant: direct chronotropes (epi, isoproterenol) work; atropine doesn't.
- Calcineurin inhibitors (tacro, cyclosporine) → nephrotoxic + hypomagnesemic; monitor.
- Sirolimus prolongs poor wound healing — surgical timing matters.
Recap
- Liver transplant reperfusion syndrome: hypotension + bradycardia + hyperK at unclamping — pre-treat with calcium + epi + bicarb on hand.
- Heart transplant: direct chronotropes (epi, isoproterenol) work; atropine doesn't.
- Calcineurin inhibitors (tacro, cyclosporine) → nephrotoxic + hypomagnesemic; monitor.
- Sirolimus prolongs poor wound healing — surgical timing matters.
Mark each section done to complete the module.