Liver Transplantation, Department of Anesthesia

Children’s Hospital of Michigan

Preoperative Assessment

PMH

  1. Note etiology and stage of liver disease. Implications vary greatly between chronic liver failure and acute/fulminate failure.

Acute Fulminate Hepatic Failure (FHF)

  1. Risk of intracranial hypertension and severe encephalopathy.
  2. Risk of further increases in ICP:
  3. liver lifted by surgeon decreases venous drainage
  4. inadequate paralysis
  5. reperfusion stage
  6. Treatment of ↑ICP:
  7. elevate head of bed 15
  8. hyperventilation (PaCO2 25-30)
  9. osmotic diuretics (25% mannitol 0.5 gm/kg= 2cc/kg)
  10. barbiturates (pentobarbital 2-3 mg/kg/hr)
  11. avoid high doses of volatile agent (use high dose opioids instead)
  1. Cardiovascular- ↑CO and ↓SVR due to systemic vasodilatation.
  2. Pulmonary- hypoxia due to ascites/hepatosplenomegaly, A-V shunts, pulmonary HTN or pleural effusions.
  3. GI- ascites with ↓intravascular volume, esophageal varices, delayed gastric emptying, ↓glycogen stores, ↓clotting factors.
  4. Patients in renal failuremay need dialysis prior to transplantation.
  5. Metabolic disease requires special IV fluids & meds- check for documentation.

Laboratory studies

  1. Completed as part of initial evaluation
  2. full set of labs including CBC, LFTs, electrolytes, BUN/Cr, coags
  3. EKG
  4. CXR
  5. echocardiogram
  6. MRI of abdomen may be requested by the surgeon
  7. Immediately pre-op
  8. CBC
  9. Na< 124 may warrant cancellation
  10. coags, if INR >2.0 may need FFP, discuss with surgeon
  11. abdominal ECHO for vascular anatomy

.

Procedure set-up

Liver cart-access code is 1234

Airway- cuffed ETT

Medications

  1. Midazolam (1 mg/mL)- at least 3 vials
  2. Propofol (10 mg/mL)- 10 mL syringe (x2),
  3. if unstable etomidate (2 mg/mL)- 1 vial
  4. Rocuronium (10 mg/mL)- 1 vial or succinylcholine (20 mg/mL)- 1 vial
  5. Cisatracurium (2 mg/mL)- 3 vials
  6. obtain from pyxis (5 available)
  7. infusion- 10 mL syringe with tubing
  8. second choice- vecuronium (10 mg)- 3 vials
  9. Fentanyl (50 mCg/mL)
  10. CaCl2 (10 mg/mL)- 10 mL syringe, on cart
  11. NaHCO3 (1 meq/mL)- 50 mL bottle, on cart
  12. THAM 500 mL bottle
  13. obtain from wake-up pyxis, only as needed
  14. Lasix 20 mg vial- on cart
  15. D10 250 mL bag- on cart
  16. Epinephrine (100 mCg/mL)- 10 mL syringe, on cart
  17. 10 mL syringe (10 mCg/mL)
  18. if <10 kg- additional 10 mL syringe (1 mCg/mL)
  19. Phenylephrine (40 mCg /ml), 250 mL bag,provided by pharmacy
  20. 10 mL syringe
  21. Mannitol 25%- 50 mL vial, on cart

Lines/ Monitors

  1. Cardiac tree
  2. A-line set up- 2.5F, 5 cm catheter, heparin solution autochecked in order set
  3. Double-lumen CVP- heparin solution and maintenance solution autochecked in order set
  4. Small peripheral IV from floor- D545, on cart
  5. Large IV #1- Hotline w/Normosol, on cart
  6. Large IV #2- Level One or Belmont, w/Normosol (x2), on cart
  7. Pulse-ox (x2)
  8. Foley catheter
  9. Salem sump OGT

Thermoregulation

  1. Warm room to 75-850F
  2. Esophageal and rectal or urinary temp probe
  3. Bair Hugger- upper, lower and under body as appropriate
  4. HME
  5. Plastic wrap for covering head

Labs

  1. GEM- room 2
  2. iStat machine (in workroom, instruction sheet on cart)
  3. iStat cartridges (x5) from Stat lab (next to blood bank, in walk in refrigerator- upper shelf, yellow bin), obtain more as needed
  4. Warm cartridges for 5 min at room temp prior to use then must remain at room temp
  5. Expiration date (14 days after warming) must be written on remaining cartridges.

Blood Replacement

  1. 5% Albumin, 250 mL bottle, on cart
  2. Cell saver- per perfusion
  3. Blood products on call to OR(PRBC and FFP stay ahead by 2 units)
  4. Pt <20 kg: 3 units PRBC, 3 units FFP, 1 unit plt
  5. Pt 20-40 kg: 4 units PRBC, 4 units FFP, 1 unit plt
  6. Pt >40 kg: 8 units PRBC, 8 units FFP, 2 units plt
  7. Cautious use of cryo. Discuss with surgeon before administering

"PEDS anesthesia- liver transplant" order set- MD to order as below:

Fluids for:

  • A-line and CVP pressure line- autochecked in order set
  • CVP pressor/drip line- autochecked in order set
  • Hydromophone (dilaudid)- autochecked in order set
  • gtt (40 mcg/mL)
  • to be delivered to ICU for postop pain management

Insulin gtt**for hyperGLYCEMIA** (not for hyperKALEMIA)

insulin in 0.9%NaCl (0.5 units/mL)

  • order as needed intraop (call 55277, ask for charge pharmacist)

Dopamine- order gtt based on weight (check one)

10 kg- 1.6 mg/mL (50 ml syringe) -or-

10-20 kg- 3.2 mg/mL (50 ml syringe) -or-

>20 kg- 3.2 mg/mL (250 ml premixed bag)

Epinephrine- order gtt based on weight (check one)

<5 kg- 0.01 mg/mL (50 ml syringe) -or-

5-20 kg- 0.05 mg/mL (50 ml syringe) -or-

>20 kg- 0.1 mg/mL (50 ml syringe)

NORepinephrine- order gtt based on weight (check one)

<10 kg- 8 mcg/mL (50 ml syringe) -or-

10 kg- 16 mcg/mL (50 ml syringe)

  • Vasopressin (1 unit/mL)- autochecked in order set
  • Phenylephrine (40 mCg/mL)- autochecked in order set

Aminocaproic acid (Amicar)

  • loading dose75 mg/kg (max 5 gms)
  • infusion 75 mg/kg/hr (max 1 gm/hr)

Insulin gtt**for hyperKALEMIA** (not for hyperGLYCEMIA)

insulin in 25% dextrose (0.05 units/mL)

  • order as needed intraop (call 55277, ask for charge pharmacist)

Intra-operative

(The surgeon will evaluate graft prior to making incision)

Premed- midazolam 1-2 mg if IV present. Avoid if encephalopathic

Positioning

  1. <10 kg: Supine with arms over head, pressure points well padded
  2. >10 kg: Supine with arms abducted (<90 degrees), pressure points well padded

Monitors/ Lines

  1. Large bore IV (x2) in upper extremities. Consider RIC in bigger pt.
  2. Hotline- Normosol
  3. Level Oneor Belmont- Normosol
  4. Small peripheral (placed on floor)
  5. D545 for glucose control
  6. designated syringe pumps (x2) for nurse administered meds
  7. Pulse-ox, upper extremities (x2)
  8. A-line- prefer upper extremity. If femoral then upper extremity NIBP.
  9. Central line- double lumen IJ
  10. OGT- change to NGT if Roux, caution with varices.
  11. Foley catheter
  12. Temp probe- rectal or urinaryand esophageal, caution with varices.
  13. Broviac- Gen. Surgery to place
  14. discuss timing of placement (before/ after procedure) with transplant surgeon
  15. <10 kg: single-lumen, subclavian vs. facial vein
  16. >10 kg: double-lumen, subclavian vs. facial vein
  17. heplock for post-op use

Induction

  1. No IV- inhalation with modified RSI
  2. IV present- RSI
  3. propofol2-5 mg/kg (if unstable etomidate 0.3 mg/kg)
  4. rocuronium (0.6-1.2 mg/kg) orsuccinlycholine(1-2 mg/kg)
  5. fentanyl (1-2 mCg/kg)
  6. Cuffed ETT

Prior to incision

  1. Send full set of labs including TEG.
  2. Solumedrol (20mg/kg, max 500 mg)
  3. Ampicillin (50 mg/kg, IVP), cefotaxime (50 mg/kg, max 2 mg, IVP)
  4. If penicillin allergic: clindamycin (10 mg/kg, max 900 mg), gentamicin (2 mg/kg)
  5. Aminocaproic acid (Amicar)
  6. loading dose 75 mg/kg (max 5 gms) over 15 mins
  7. infusion 75 mg/kg/hr (max 1 gm/hr)

Maintenance

  1. Isoflurane (agent of choice). Air-oxygen. No nitrous after induction.
  2. Pressure controlled ventilation, PEEP 5
  3. Cisatacurium (relaxant of choice) or vecuronium:
  4. bolus: 0.1-0.2 mg/kg
  5. gtt: 0.1-0.2 mg/kg/hr
  6. Fentanyl (5-10 mCg/kg),then 1-2 mCg/kg/hr
  7. Mean BP70
  8. Volume
  9. CaCl 10 mg/kg IVP
  10. Phenylephrine 1 mCg/kg IVP
  11. NORepinephrine starting at 0.1 mCg/kg/min- 1st choice
  12. Vasopressin starting at 0.5 milliunits/kg/min- 2nd choice
  13. Dopamine starting at 5 mCg/kg/min
  14. Epinephrine starting at 0.05 mCg/kg/min

  1. CVP 5-10, may increase upper limit when IVC cross clamped
  2. Normothermia is essential

Labs

  1. Q1 hr and beginning of anhepatic phase, 15 min prior to and 5-15 min after reperfusion
  2. Full set of labs include:
  3. CBC (lab)
  4. ABG (Gem, room 2)
  5. PT, INR (iStat)
  6. TEG
  7. postinduction, anhepatic phase, and after reperfusion of new liver
  8. 1.8 mL in blue top tube to lab
  9. will be analyzed by Hematology- if Hematology not available, do not analyze
  10. Acceptable labs
  11. pH> 7.3
  12. Na+ 130-145
  13. K+5
  14. iCa++ >1.2
  15. blood sugar (BS) 70-250
  16. INR~2.0
  17. HCT 20-25, ideal Hgb 7
  18. plts~ >20,000
  19. Treatment of metabolic disturbances
  20. Acidosis
  21. NaHCO3 1 meq/kg
  22. THAM- (1 meqNaHCO3 = 3 mL THAM),located in PACU Pyxis
  23. beneficial if CO2 elevated
  24. avoid if Na+ >145
  25. follow lactate. Will decrease with reperfusion if liver functioning well.
  26. Na+ <130 meq or >145 meq
  27. Na+ <130- correct slowly, at risk of Central Pontine Myelinolysis
  28. Na+ >145- limit NaCl, avoid albumin (contains Na+ 145 meq)
  29. Do not treat hypokalemia
  30. HYPERkalemia
  31. K+5
  32. hyperventilate
  33. NaHCO3 1meq/kg + CaCl 10 mg/kg
  34. consider lasix 0.5-1 mg/kg
  35. K+6 or EKG changes
  36. insulin in 25% dextrose infusion (0.05 units/mL), in liver txp order set
  37. 250 mL bag- infuse at 0.05 units/kg/hr (1 mL/kg/hr)
  38. IV infusion pump- "PICU- continuous HYPERKALEMIA- insulin "
  39. iCaCl 1.2:CaCl 10 mg/kg
  40. HYPOglycemia
  41. treat blood sugar <70
  42. D102.5 mL/kg, over 2 min

  1. HYPERglycemia
  2. BS >250 for 2 consecutive measurements-start insulin gtt
  3. insulin 125 units/250 mL 0.9%NaCl (0.5 units/mL)- in order liver txp order set
  4. IV infusion pump- "PICU- continuous insulin- 0.5 units/ml"
  5. starting rate: 0.02 units/kg/hr
  6. increase/decrease by 0.01 units/kg/hr q30min to maintain BS 150-250.
  7. STOP insulin when BS falls below 150
  8. restart when BS>250 again and follow aboveprocedure.

Blood Products

  1. Avoid overtransfusionafter new liver perfused
  2. Ideal Hgb 7
  3. Plts <20,000- discuss with surgeon before transfusing (<50kg- 1 unit/10 kg)
  4. INR >2.0, discuss FFP with surgeon
  5. No cryo
  6. 1 part PRBC + 1 part liquid= HCT ~28

Stages of Operation

Procedures

  1. Piggybacks (splits and living donors)- run dry.
  2. End-to-end (deceased donors)- give volume when cross clamp removed.

Pre-anhepatic phase (hepatectomy)

  1. Volume
  2. large blood loss
  3. CVP 5-8
  4. HCT 25, stay 2 units ahead in OR refrigerator
  5. urine output>1 mL/kg/hr
  6. beware of persistent bleeding from posterior dissection, AV shunts
  7. hemodynamically unstable when ascites drained. Replace

5% albumin- 25gm (500 mL)/ Lascites drained

  1. Coagulopathy- send full set oflabs, transfuse as above after discussion with surgeon
  2. Correct electrolytes disturbances
  3. Maintain temperature
  4. Document times of hepatic artery and portal vein ligation.

Anhepatic phase

  1. Begins with hepatectomy; ends with vascular anastomosis to IVC then to portal vein (document times of anastomoses)
  2. ↓CO,↓BP, ↓CVPand ↑SVR (due to ↓venous return from clamping IVC)
  3. ↓ETCO2 due to ↓pulmonary perfusion from ↓IVC return
  4. avoid volume overload
  5. watch for acid base imbalance,↓Ca, hypothermia,and citrate toxicity(hypocalcemia, hypomagnesemia, high anion gap metabolic acidosis followed by metabolic alkalosis)
  6. Cautious use of volatile agent(BP sensitive to isoflurane), give midazolam as needed
  7. Sendfull set of labsincluding TEG at beginning of anhepatic phase then full set of labs only (no TEG) Q30 min.
  8. Keep MAP >70

  1. Prior to reperfusion
  2. 15 min prior send full set of labs(shortly after flushing portal vein)
  3. increase minute ventilation
  4. NaHCO3 (1 meq/kg)
  5. CaCl (20 mg/kg)
  6. have vasopressors, inotropes available
  7. Document time of liver out of ice.

Neohepatic phase- begins withhepatic artery anastomosis

  1. *The new liver does not like volume*- cautious use of fluids
  2. hepatic artery thrombosis (HAT) from overcorrection of coags, hypertransfusion
  3. HAT responsible for failure in ~5-10% of recipients
  4. maintain HCT 20-25%, aim for Hgb 7
  5. discuss platelets and FFP with surgeon prior to transfusing
  6. Reperfusion syndrome
  7. bradyarrhythmias, ↓BP, ↓SVR, pulmonary HTN
  8. ↑K+, acidosis, ↓Ca++ (lack of citrate metabolism)
  9. hyperventilate with 100% O2, give CaCl, andNaHCO3
  10. start inotropes as needed (prefer norepinephrine, vasopressin before dopamine, epinephrine)
  11. temp may ↓1-2 degrees with graft insertion
  12. 5-15 min after reperfusion, send full set of labsincluding TEG
  13. associated with hyperglycemia
  14. monitor for coagulopathy
  15. Watch for venous air emboli
  16. Keep MAP >70, U/O >1 cc/hr
  17. Good graft function will quickly clear acidosis, follow lactate
  18. Document times of hepatic artery (aka “liver”) reperfusion

Post-operative

To ICU, intubated

PCA- Hydromorphone (Dilaudid) (40 mcg/mL)

  1. Order from "PEDS anesthesia- liver transplant" order set
  2. To be delivered to ICU for postop pain management.
  3. Patient less than 6 yrs: "Continuous Opioid Infusions- Peds Pain" order set.
  4. choose "nurse titratable"
  5. check both titration instructions and medication solution (2-8 mcg/kg/hr)
  6. Patient 6 yrs and older: “PEDS PAIN- Patient Controlled Analgesia” order set.
  7. Place dilaudid order and patient sticker on pain service list and indicate "to be started in ICU".

Estimated times

  • Goal <8 hours cold ischemia time for donor liver
  • Start recipient ~2 hrs after donor incision
  • Recipient incision to start of liver reanastomosis ~30 min
  • X-clamp time ~45 min

- 1 -11/7/2018