Living Donor Liver

Transplant
Anaesthesia team
Consultants: Dr. Satyaprakash, Dr. Senthilnathan
SR: Dr. Jeevasri
JR: Dr. Afshan
 PART 01
PREOPERATIVE PERIOD
 HISTORY
• 45 year old male presented to hospital with initial complaint of nose bleed and on evaluation was
diagnosed to have chronic liver disease

• He was on regular follow up since then for chronic liver disease

• He had an episode of melena and an episode of jaundice in the intervening period

• He experienced one episode of hematemesis one and a half years ago which was managed
conservatively

• He was admitted in view of low sugars and urinary tract infection last year

• He was also admitted last year with abdominal distention, urinary tract infection and altered sensorium
last year

• He was evaluated for liver transplant and referred to JIPMER

 HISTORY
• There is no history of previous jaundice episodes/hepatitis infections

• No history of reduced urine output

• No history of exertional breathlessness/palpitations/syncope/orthopnoea

• There is no history of any other illnesses/known allergies/past surgeries

• No history of fever/URI/LRI

• Effort tolerance more than 4 METS.

 PAST/PERSONAL HISTORY
• He is also a known case of Type 2 Diabetes Mellitus for past 8 years, and he was not compliant to
medications

• Four years ago he was started on insulin but he again defaulted treatment

• He has been compliant to medications for past one year

• He experiences occasional paresthesias on walking

• He is a known alcoholic and smoker for the past twenty years, stopped alcohol consumption one and a
half years ago, and stopped smoking six months ago
 TREATMENT HISTORY
• He has been on regular follow up for past 12 years in view of chronic liver disease

• Two years ago, esophageal varices were noted on routine UGIE, and banding was done

• One a half years ago, he had an episode of hematemesis which was managed conservatively

• Last year he was admitted once in view of hypoglycemia and UTI

• He was also admitted in view of Spontaneous Bacterial Peritonitis (SBP)/sepsis/AKI/hepatorenal

syndrome/Hepatic encephalopathy and large volume paracentesis was done (around 2L ascitic fluid was
tapped)

• He was continued on Rifaximine and propanolol

 MEDICATION HISTORY
• T. Metformin 500 mg 1-0-1

• Inj. Actrapid 14-10-8 IU s/c

• Inj. Glargine 10 IU s/c hs

• T. Rifaximine 410 mg TDS

• T. Carvedilol 3.125 mg BD
 EXAMINATION
• On general examination, he is conscious, oriented to time, place and person
• Weight 74 kg
• no pallor/icterus/cyanosis/lymphadenopathy/edema
• Grade 2 clubbing is present

• Vitals: BP 110/70 mm Hg, PR 64/min, SpO2 99% on RA

• CVS: S1, S2 heard, no murmurs
• RS: Bilateral air entry equal, normal vesicular sounds heard
lifting all 3 balls on incentive spirometry, BHT>50s
• CNS: sensorium intact, no focal deficits
• P/A: no dilated veins, no distention, no hepatosplenomegaly, no shifting dullness

• Airway: MO>3FB, MMP III, neck movements full range, SLUX +1, no loose teeth/dentures
 INVESTIGATIONS
• 13/10
Hb TLC Plt U/Cr Na/K/Ca TB/DB TP/Alb AST/ AL
ALT P
13.1 5.79k 71k 29/1.21 137/4.03/9.74 1.8/0.58 6.51/3.33 65/42 90

• (13/10) PT/INR 15.2”/1.39, (7/23) APTT 41.3’

• (16/9) HbA1c 8.1%
• Sugar charting
AC PC BL AL BD AD
13/10 266 121 226 227 234
14/10 121 287 219 123 138 272
 INVESTIGATIONS
• ABG 13/10
pH pO2 pCO2 HCO3 Na/K/Ca Lactate Hb
7.41 96.2 (on 37.9 23.6 137/3.53/ 1.76 14
RA) 0.961

• ECG (10/23) NSR 64/min

• CXR (8/23) normal

• ECHO (7/23) normal

• Stress MPI (8/23) normal LV, LVEF>65%, No evidence of stress induced ischemia/scar
 INVESTIGATIONS
• Body plethysmography - normal lung capacities

• Fundus: no e/o diabetic retinopathy

• CECT (5/23) nodular liver, left lobe hypertrophied, right lobe atrophied, no focal lesion.
Multiple periportal and perisplenic collaterals, mild splenomegaly

• UGIE (7/23) one column medium sized varix, two columns small sized varices, mild portal
gastropathy

• Child-Turcotte-Pugh score 6 points (CHILD A)

• MELD-Na score 16 points (<2% estimated 90d mortality)
BASELINE TEG
 BASELINE TEG
Parameter Value Normal
R (min) 9.1 4-8
K (min) 2.9 0-4
Angle 49.1˚ 47-74
MA (mm) 46 54-72
LY30 25.8% 0-8
 PREOP EVALUATION
• Clearances obtained from:

• Cardiology - RCRI score 2, intermediate risk

• Pulmonary medicine - ARISCAT 38 points, intermediate risk

• Psychiatry

• MGE

• Endocrine

• Nephrology

• Dental
 PREOP ADVICE
• NPO orders, AST, XST
• Crossmatch and reserve PRBC, 10 FFP
• ICU ventilator bed
• Early morning BUSE
• sugar charting
• Baseline TEG

• Preop medications on the night before surgery

- T. famotidine 20 mg PO
- T. Lorazepam 2 mg PO
- Inj. actrapid 8IU s/c , T. Mf 500 mg PO
- skip glargine insulin
-T. Carvedilol 3.125 mg PO
• Preop medications on the morning of surgery
- T. famotidine 20 mg PO
- T. Lorazepam 2 mg PO
- T. perinorm 10 g PO
- Skip all insulin, OHA, skip carvedilol
 PART 02
INTRAOPERATIVE PERIOD
 INDUCTION
• Patient shifted and standard monitors attached - ECG, NIBP, pulse oximeter

• Baseline vitals: BP 126/70 mm Hg, PR 62/min, SpO2 99% on RA

• 16 G iv line secured in left hand

• Patient preoxygenated with 100% O2 for three minutes

• Premedicated with Inj. midazolam 5 mg iv, Inj. Morphine 15 mg iv

• Induced with Inj. Thiopentone 150 mg iv, and after check ventilation, Inj. vecuronium 8 mg iv given

• Intubated with 8.5# PVC ETT, fixed at 20 cm after confirming equal bilateral air entry
 INDUCTION
• Two arterial lines secured - Right radial artery and right femoral artery

• Under USG guidance, Right IJV cannulated with 12Fr triple lumen CVC (Certofix HF Trio) and 7Fr
triple lumen CVC

• Additional monitors attached - Cardiac output monitor FloTrac sensor to radial artery for IBP and to
16G distal lumen of certofix CVC for CVP

• Temperature probe attached, warmers placed

• BIS monitor placed

• Rapid flow infusor attached to 12G lumen of certofix CVC

• Patient positioned
CERTOFIX HIGH FLOW TRIO - 12Fr

Distal lumen - yellow, 16G,

minimum flow 65cc/min

medial and proximal lumens - 12G, minimum

flow 225 cc/min
 MEDICATIONS
• Prophylactic antibiotics
- Inj. Teicoplanin 400 mg (to be repeated BD)
- Inj. Piptaz 4.5 g iv (to be repeated TDS)
- Inj. Metronidazole 500 mg iv (to be repeated TDS)
- Inj.Fluconazole 200 mg iv (OD dose)

• Inj. Morphine 15 mg iv repeated before incision

• Anaesthesia maintained with N2O, O2 and Isoflurane with MAC 0.7-1

• Infusion Atracurium 30 mg/hr i.v

• Infusion Tranexamic acid 1 g over 1 hr followed by 1mg/kg/hr

• Infusion NAC 400 mg/hr (5mg/kg/hr , free radical scavenging)

• Infusion Albumin 20% at 15-25 cc/hr

 MEDICATIONS
• Infusion Calcium gluconate 10% at 10-25 cc/hr (titrated according to ABG, targeting Ca 1-1.2 mmol/L)

• Infusion Sodium Bicarbonate 15-25 mEq/hr (titrated according to ABG, targeting HCO3 22-26 mEq/L)

• Infusion Terlipressin 0.5 mg over 2 hours during preanhepatic phase (splanchnic vasoconstriction, to
relieve portal pressure)

• Infusion Insulin 1.5-2 IU/hr (titrated according to sugars, targeting 140-180 mg/dL)

• Infusions noradrenaline and adrenaline used minimally as required

• Inj. methylprednisolone 10 mg/kg given during anhepatic phase

• Inj. Mannitol 20 g iv during neohepatic phase (free radical scavenging)

• Inj. Morphine 15 mg iv repeated end operatively

SURGICAL PHASES
 PREANHEPATIC
• Starts with incision and ends with clamping of the hepatic vessels (the hepatic artery, portal veins, and the
suprahepatic and infrahepatic inferior vena cavas).

• In patients with a large amount of ascites, removal of the ascites can result in significant hypotension,
necessitating aggressive fluid resuscitation.

• Volume expansion can be achieved with crystalloids, albumin, and blood products. Crystalloids that
require hepatic metabolism, such as lactated ringers, should be avoided.

• Other concern is hemorrhage, worsened by pre-existing coagulopathy, portal HTN

• Anaesthetic focus is on maintaining hemodynamic stability, addressing coagulopathy, maintaining baseline

CVP and managing electrolytes in preparation for the anhepatic stage
 PREANHEPATIC
• The standard technique of clamping the inferior vena cava (IVC) results in an extreme loss of preload, with
subsequent hypotension.

• Optimization for this clamping technique requires involves volume loading, administration of vasoactive
medications, and correction of hypocalcaemia.

• If the patient cannot tolerate IVC clamping, either a piggyback technique or veno-venous bypass or side
clamping of IVC can be done

In our case, based on preoperative TEG report, tranexamic acid was started at the beginning itself
Based on ABG, calcium and HCO3 infusions were titrated
Patient was stable during preanhepatic phase, without significant bleeding
Terlipressin helped maintain hemodynamics
 ANHEPATIC
• removal of the native liver and re-anastomosis of the transplanted liver graft, but prior to vascular
unclamping and reperfusion.

• Patients (especially with conventional anastomosis technique) are essentially hypovolemic due to
reduced preload.

• Some volume resuscitation if needed, and maintain haemodynamics with vasopressors and inotropes
(such as norepinephrine).

• While functionally anhepatic, the patient may rapidly develop worsening acidosis and hypocalcaemia
(due to the lack of lactate and citrate metabolism) - increasing lactate

• Acidaemia and anuria leads to increasing hyperkalaemia, which must be aggressively treated in
preparation of hepatic reperfusion.

• No production of clotting factors can cause worsening of coagulopathy, increased fibrinolysis (absence
of PAI), reduced gluconeogenesis
 ANHEPATIC
• Treating hyperkalaemia and acidosis - with diuretics, CRRT, minimizing blood transfusions, as well as
potentially washing blood products in cell saver devices to reduce the potassium load.

• Transient hyperkalaemia can be further countered with insulin, glucose, and bicarbonate infusions.

• Acute acidosis can be further stabilised with hyperventilation.

• Existing coagulopathy will worsen in proportion to duration of anhepatic period, especially in the
presence of acidosis, hypothermia, and electrolyte imbalances.

In our case, patient did not experience reduction in preload as side clamping of IVC was done, and
therefore maintained hemodynamics. ABG was repeated every 30 minutes and infusions of HCO3 and
Calcium were titrated - acidosis, hypocalcemia, hyperkalemia was prevented
 REPERFUSION
• Prior to graft reperfusion, the IVC is unclamped, restoring preload to the heart.

• Reperfusion of the transplanted liver begins when the portal vein is unclamped.

• On unclamping, desaturated blood from portal circulation and inflammatory mediators, are rapidly
flushed into the patient’s circulation.

• These ischemic components commonly result in hemodynamic instabiliy - sudden decrease in BP, HR,
SVR and CO. Sudden Hyperkalemia, acidosis can also occur, which needs to be treated aggressively

• Acute physiologic changes can quickly result in a worsening of pulmonary hypertension and right heart
failure.

• A sustained 30% decrease in mean arterial blood pressure for more than 1 minute during the first 5
minutes after reperfusion is defined as Post-Reperfusion Syndrome (PRS).

• The risk of PRS increases proportionally with prolonged cold ischemic time.
 NEOHEPATIC
• After reperfusion, the remainder of the vascular anastomoses must be completed, including the hepatic
artery and the bile duct.

• Immunosuppression, usually in the form of a steroid bolus, is usually administered at or just before
reperfusion of the liver.

• During the neohepatic phase, the function of the new liver can be variable, so the anaesthetist must
carefully monitor and appropriately treat any acidosis, coagulopathy, and temperature disturbances
while hepatic function returns.

• Good graft function is suggested by production of bile, decreasing serum lactate, improving of acidosis,
normalization of serum calcium, increase in urine output, rise in core tempreature and resolution of CVS
instability

In our case, as reperfusion started, prophylactically, Inj. Adrenaline was kept at 0.2 mcg/kg/min and Inj.
Noradrenaline at 0.2 mcg/kg/min. Hypotension was avoided and inotropes tapered. Repeat ABG showed
no acidosis or hyperkalemia. Bilie output was noticed intraoperatively.
 GRAFT DETAILS
• Warm ischemia time (donor to cold perfusate) 1:40 pm to 1:45 pm

• Cold ischemia time 1:45 pm to 2:43 pm (58 min)

• Warm ischemia time (recipient) 2:43 pm to 3:53 pm (80 minutes)

• Portal flushing of graft done with 1L NS prior to anastomosis

• Portal bleed out was not performed.

• Reperfused at 3:53 pm

• Donor liver weight = 611g

• Graft:Recipient weight ratio (GRWR) = 0.82

TIME pH pO2 pCO2
ABG
HCO3 Na/K Ca Lac Glu Hb

10:10 am 7.459 189.3 30.6 21.2 137.8/ 1.02 2.79 122 12.7
3.82
12 pm 7.34 179.9 32.9 17.5 135.7/ 0.93 2.58 174 11.4
3.49
2 pm 7.37 208.7 38.2 21.8 137.1/ 0.94 4.28 233 12
4.26
3 pm 7.38 186 36.6 21.5 138.1/ 1.23 4.56 210 12.1
ANHEPATIC 4.09
3:40pm 7.39 190.5 37.9 22.7 137.3/ 1.3 4.95 204 12.4
ANHEPATIC 4.08
4:15pm 7.37 224 38.1 21.8 137.7/ 1.17 4.82 219 11.4
after 4.08
reperfusion
5:30 pm 7.34 184.5 39.6 21 132.4/ 1.35 3.68 212 12.5
3.96
 VENTILATOR SETTINGS
• Volume control mode

• TV 450 mL
• RR 14-15/min
• I:E 1:2
• PEEP 5 cm H20
• Ppeak 17-19 cm H2O
 VITALS
• Saturation maintained 100% on 35% FiO2

• BP maintained systolic 110-120 mm Hg, diastolic 60-70 mmHg. Transient requirement of Inj.
noradrenaline 0.01-0.08 mcg/kg/min and Inj. Terlipressin 0.5 mg over 2 hrs during preanhepatic
phase
Required minimal Norad 0.01-0.04 mcg/kg/min and Adr 0.02-0.08 mcg/kg/min transiently during
reperfusion

• Heart rate maintained between 68-75/min, ECG normal sinus rhythm

• Temperature maintained at 37˚C

• EtCO2 maintained 35-38 mmHg

• BIS maintained 48-52

• CVP maintained at 0-3 mm Hg (Baseline 1 mm Hg)

 INPUT/OUTPUT
• Total input = 3750 mL

Plasmalyte 3000 mL
5%D 500 mL (as carrying fluid for norad/adr)
Albumin 150 mL
Mannitol 100 mL

• Total output = 2200 mL

Urine output 1200 mL

Blood loss 1000 mL
 SHIFTING
• All infusions except Inj. NAC and Inj. Albumin stopped

• Patient not extubated and shifted to LTP ICU, where monitors were attached and Cardiac output
monitoring was continued

• Vitals after shifting:

BP 120/70 mm Hg
PR 70/min
SpO2 100%

• Infusions 20 % albumin and NAC was continued in the ICU

POST-OPERATIVE
PERIOD
 POD 1

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• Antibiotics - piptaz TDS, Metrogyl
• Conscious, oriented • BP 130/70 to 150/80 • O2 by FM TDS, Teicoplanin BD, fluconazole
• No fever/pain • i.v fluids OD
mm Hg • Immunosuppression - Inj.
• Hoarseness of voice plasmalyte/
• PR 64-70/min 10%D + 10U Methypred 500 mg iv OD,
post extubation • SpO2 100% on O2 T. Tacrolimus 1 mg PO OD
insulin (2:1)
• urine output 75-100 100cc/hr • No analgesic required
ml/hr 6L/min
• RR 20-24/min • Extubated 10:30 • Ipravent neb q8h
• RBS 270-330mg/dL am • Neb Adr q6h
• CVS/RS right side • NIV (PS 10) • Neb Salbutamol q6h
basal entry reduced, q2h • Inj. Actrapid according to sliding
NVBS • Certofix CVC scale
and femoral AL • Inj. MgSO4 1g, Inj. Ca 1 g
removed • Inj. NAC 100 mg/hr
• Inj. Albumin 20% 10 cc/hr
 USG DOPPLER
• POD 1 - USG graft - normal, mild free fluid in subhepatic region, right lung mild pleural fluid and basal
atelectasis, left side thin rim of pleural fluid
Doppler - hepatic artery patent, colour flow present, portal vein patent, turbulent
flow with preserved phasicity, right hepatic vein - patent
POST OP TEG (POD1)
Parameter Value Normal
R (min) 9.1 4-8
K (min) 3.6 0-4
Angle 46.2˚ 47-74
MA (mm) 40.8 54-72
LY30 6.9% 0-8
 POD 2

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• Conscious, oriented • BP 160/90 to 190/90 • O2 by NP 2L/min • Antibiotics
• No fever/pain • i.v fluids • Immunosuppression
mm Hg •
• Hoarseness of voice plasmalyte 100 No analgesic required
• PR 64-70/min cc/hr • Neb Adr q6h
persistent • SpO2 100% on O2 • 10%D + 10U • Neb Salbutamol q6h
• Mobilised to insulin 50cc/hr • Inj. Actrapid according to sliding
washroom 92% on RA
• RR 20-24/min • NIV (PS 10) q4h scale
• urine output 100 • Oral semisolids • Inj. MgSO4 1g, Inj. Ca 1 g iv
ml/hr • CVS/RS auscultation - started • T. Amlo 5 mg PO stat
• RBS 270-320 mg/dL NAD • NIV q4hr • Inj. Albumin 5% at 10 cc/hr
• Lifting two balls on
incentive spirometry
POST OP CXR
 POD 3

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• Conscious, oriented • BP 130/80 mm Hg • O2 by NP 2L/min • Antibiotics
• No fever/pain • PR 68-74/min • i.v fluids • Immunosuppression
• Hoarseness of voise plasmalyte 100 • No analgesic required
• SpO2 100% on O2 cc/hr • Neb Adr q6h
improving 95% on RA • NIV (PS 10) q8h • Neb Salbutamol q6h
• urine output 200-400 • Oral solids • Inj. Actrapid according to sliding
• RR 20-24/min
ml/hr tolerating scale
• RBS 270-320 mg/dL • CVS/RS auscultation -
• CVC, AL and • Inj. MgSO4 1g, Inj. Ca 1 g iv
• Mobilising well NAD CBD removed • T. Amlo 5 mg PO stat
• Lifting two balls on
incentive spirometry
TIME pH pO2 pCO2
ABG
HCO3 Na/K Ca Lac Glu

16/10 9pm 7.29 200 49 23.5 136/4.0 1.25 2.97 225

SIMV, 50% FiO2
17/10 7 am 7.39 202 34.7 21.4 128/3.3 0.58 2.77 273
SIMV, 50%FiO2
17/10 12 pm 7.39 206 32.1 19.5 136/3.1 0.68 4.06 268
NIV, 40% FiO2
18/10, 7:15 am 7.45 151 33.1 23.5 135/3.5 0.92 3.16 312
O2 by FM,
44%FiO2
18/10, 5pm 7.46 73.7 32.3 23.4 142/3.0 0.78 2.53 278
room air
19/10, O2 by NP, 7.47 190 34.5 25.4 134/3.1 0.68 1.83 292
28% FiO2
 INVESTIGATIONS
Date Hb TLC Plt U/Cr Na/K/Ca TB/DB TP/Alb AST/ALT ALP
preop 13.1 5.79k 71k 29/1.21 137/4.03/9.74 1.8/0.58 6.51/3.33 65/42 90
16/10 12.1 68k 36/1.31 139/4.37 4.65/2.21 -/2.98 248/210 65
17/10 10.3 14.18k 44k 61/1.48 143/3.92 2.87/1.25 424/258 46
18/10 9.7 13.5k 46k 64/1.4 143/3.89 2.89/1.28 385/244 43
19/10 10.2 11.58k 46k 58/1.16 140/3.65 3.68/1.49 5.7/3.86 312/254
THANK YOU