Anaesthesia for liver transplantation
- 1. Anesthesia for liver transplantation
- 2. History • 1963 First liver transplant Sir Thomas Starzl ( orthotopic liver transplantation) • 1967 First long survival • 1979 Cyclosporine-Sir Roy Calne • 1987 UWI solution for improved organ preservation • 1989 FK 506 • 1999 Living donor liver transplantation
- 3. History
- 4. Introduction • The treatment of end stage liver disease underwent dramatic transformation with the development of LT • LT is one of the most successful organ transplant after kidney transplant in terms of survival
- 5. Improved survival • Improvement in preservation techniques • Advances in Intraoperative management • Refinement of surgical techniques • Better immunosuppressive management
- 6. Background • genetic relationship • the anatomical site of the implantation • auto graft • isograft or syngeneic graft • allograft or homograft • xenograft or heterograft
- 7. Background • Orthotopic transplantation • Heterotopic transplantation
- 8. Blood type compatibility chart Blood Type Can receive liver from: Generally can donate a liver to O O O, A, B, AB A A, O A, AB B B, O B, AB AB O, A, B, AB AB
- 9. Liver transplantation activity in India • Estimated 200,000 patients suffer from liver disease • No viable long term bridging options exists • Approximately 60 liver transplants per year • First attempt at cadaveric LTx in 1994 at AIIMS • Organ procurement –ORBO and MOHAN organizations
- 10. Transplant team • Anesthetist • Hepatologist • Transplant surgeons • Transplant coordinator • Clinical dietician • Physiotherapists • Social worker
- 11. CVS changes • “Hyper dynamic circulation” • Elevated cardiac output • Decreased peripheral resistance • Hypotension • Vascular hypo reactivity • Splanchnic and systemic arteriolar vasodilatation • Cardiac dysfunction • “cirrhotic cardiomyopathy”
- 12. Respiratory changes • Gas exchange alterations • Hepatopulmonary syndrome • Porto pulmonary hypertension • Restrictive lung changes • Blood gas alteration
- 13. Coagulation Abnormalities • Liver plays a central role in haemostasis • Coagulopathy parallels the degree of liver failure • Reduced hepatic synthesis of coagulation factors • Malabsorption of vitamin K • Inadequate hepatic clearance of procoagulant factors • Platelet: – impaired aggregation – increased adhesiveness
- 14. Renal system • HRS - renal failure in the absence of intrinsic renal disease • Intarrenal vasoconstriction • Renal dysfunction is potentially reversible • Renal function is regained in 40% to 95%
- 15. Child – Pugh Classification of Cirrhosis Factor & Score 1 2 3 S. Bili mg/dl <2.0 2.0 – 3.0 > 3.0 S. Alb g/dl >3.5 3.0 – 3.5 < 3.0 Ascitis None controlled Poorly controlled PT prolongation 0 -4 4 – 6 > 6 INR (< 1.7) ( 1.7 – 2.3) ( > 2.3) Encephalopathy none grade 1 grade2-3
- 16. Physiologic consequences of cirrhosis • Increased C.O • Arterial hypotension • Decreased SVR • Increased total plasma volume • Increased activity of vasoconstrictor systems • Increased renal vascular resistance, decreased renal perfusion pressure • Dilutional hyponatremia
- 17. Pharmacokinetics & Pharmacodynamics • Due to changes in - Protein synthesis -Volume of distribution -Protein binding -Hepatic blood flow -Hepatic drug metabolism • Resulting in - Altered Serum levels - Elimination half life - altered hepatic extraction ratio - increased free drug levels
- 18. Preoperative assessment • Performed jointly by hepatologist,surgeon and anesthetist before listing
- 19. Indications for Liver Transplantation in Adults • Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation • Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life • Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one-year patient survival and 70% five-year survival)
- 20. Indications for Liver Transplantation in Adults • Chronic Hepatitis C • Chronic Hepatitis B • Cryptogenic cirrhosis • Hepatocellular carcinoma • Alcoholic Liver Disease • Fulminant Hepatic Failure • Wilson’s disease • Primary Biliary Cirrhosis • Metabolic and genetic disorders
- 21. Contraindications • Extra hepatic cancer • Active sepsis • Advanced cardiac disease • Advanced pulmonary disease • HIV with AIDS and low CD4 count
- 22. Goals of evaluation • Which patients require LT? • Which patients would benefit? • When such therapy should be undertaken?
- 23. Goals of evaluation • Understanding the underlying liver disease • Development of complications • Remote organ dysfunction (cardiac, pulmonary and renal) • Optimization of nutritional and medical therapy
- 24. Preoperative assessment • AIM :identify physiological abnormalities :attempt to improve and optimize :preoperative assessment is tailored to accommodate the clinical needs of the patient
- 25. Liver Transplantation-evaluation • Medical history– -Symptoms such as fatigue, itching, swelling, changes in mental status and GI bleeding – Other medical problems – Medications – Includes alcohol use and drug use history • Physical examination • Blood tests • Determine current functional status of the liver
- 26. Liver Transplantation-evaluation • Concomitant medical problems – Heart – Lung – Kidney – Bone thinning
- 27. Liver Transplantation-evaluation • Determine cause of liver disease • Document severity of liver disease • Determine survival and functional ability • Concomitant medical problems • Psychiatric evaluation • Social Evaluation
- 28. Assessment of the patient • Does the patient need transplant at this time • Will the patient survive the procedure • Will the patient meet the 50% 5yr survival criterion • Does the patient understand the implications of transplantation
- 29. Cardio respiratory assessment • CAD – resting 2D echo and DSE - best strategy unclear • Respiratory – room air ABG - PFT’s - HPS – indication for Tx - PPS – defer Tx
- 30. Liver donation • Conventional adult deceased donor procurement • Nonheart beating donors and • Insitu splitting the deceased donor liver • Living related organ donors
- 31. How Much Liver Do You Need? • Liver = 2% body weight • Optimal: > 1% liver weight/body weight ratio • Liver remnant volume -30-40% of total liver volume • Minimum graft volume -40% of standard liver mass
- 32. Theatre preparation • Consultant and assistant anesthetists • Perfusionist • Lines and physiological monitoring • Infection control • Immunosuppression • Blood loss and replacement • Biochemical monitoring
- 33. OT Preparation Checklist • OT Preparation Checklist -Warm OT to 21 – 26°C -Fluid warmers (e.g.Hotline) -Airway heater / humidifier -Convective warming device -Fluid pressurizing device -Cell saver -Stat lab availability -Blood availability Packed cells FFP RDP or SDP -Drugs -Anaesthetic and general -Monitoring devices WWarmarm TTouchouch PPatientatient wwarmingarming SSystemystem
- 34. Vascular access • Large bore IV cannulae • 8.5F catheters placed in the antecubital fossa • 8.5F (two) placed in right IJV • Rapid infusion system • Veno-venous bypass catheters • Arterial access
- 35. Monitoring • Complete invasive monitoring is mandatory • CVS – ECG, direct arterial pressure, CVP and CO • RS – EtCO2, ABG, pulmonary artery pressure • Coagulation – platelet count, INR, fibrinogen and TEG • Liver – ammonia, lactate, bicarbonate, potassium, glucose and temperature • CNS – ICP • Renal – urine output
- 36. Induction of anesthesia • ECG and arterial pressure monitoring are commenced • Invasive cardiovascular monitoring pre/post induction • ALF patients – shift with ICP bolt monitoring • Induction drugs tailored to maintain CVS stability • Rapid sequence induction technique : -reflux and ascitis -short notice
- 37. Maintenance of anaesthesia • Analgesia and muscle relaxants – Remifentanil/fentanyl Atracurium/Vecuronium • Supportive drugs – dextrose infusion,calcium - sodium bicarbonate - antifibrinolytics (aprotinin,tranexamic acid) - N-acetylcysteine (mucomix) • Vasopressor/inotropes – noradrenalin (adrenor) - dopamine
- 38. Intraoperative management • Severe coagulopathy • Metabolic disturbances • Massive fluid shifts • Blood loss • Temperature derangement • Heamodynamic instability and • Renal dysfunction
- 39. Intraoperative management - principles • Surgery falls into three phases – -Phase I-dissection phase (skeletonization of the native liver) -Phase II-an hepatic phase (removal of the liver) -Phase III- reperfusion phase (graft reperfusion, haemostasis and completion of arterial anastomosis and Biliary drainage)
- 40. Intraoperative Crisis • Cardiac rhythm disturbances • Hyperkalaemia • Reperfusion syndrome • Pulmonary hypertension
- 42. Harvested liver
- 45. Ischemic-reperfusion injury • Decrease in >30% of MAP occurring within 5mins of graft reperfusion and lasting 1minute • Heamodynamic changes include: -reduction in MAP -reduction in SVR and -reduction in myocardial contractility
- 46. Postoperative management • Heamodynamic support • Ventilatory support • Metabolic support • Haemostasis support • Renal support • Prevention of infections • Early nutritional therapy
- 47. Postoperative care • Ventilatory support for 6-12hrs • Sedation and analgesia (propofol and fentanyl) • Tight glycemic control • Coagulation and full blood count tests • Hct between 24-30 • Immunosuppression at the earliest • Frequent doppler assessment of the graft
- 48. Post-operative complications • Primary nonfunction (5%) • Right pleural effusion • Hemorrhage • Renal failure • Electrolyte Derangements • Thrombocytopenia • Biliary leak • Hepatic artery thrombosis
- 49. Induction of Immunosuppression • Triple therapy – Calcineurin inhibitor (tacrolimus, cyclosporine), anti-proliferative agent (mycophenolate), corticosteroid – Initiated immediately following transplantation.
- 50. Liver Transplantation-Outcomes • 1-year survival ~90-94% • 5-year survival ~75-80%
- 51. Anesthesia for non-transplant surgery • Preserve hepatic blood flow • Avoid hepatotoxic medications • Correction of coagulation abnormalities • Monitor postoperative liver function • High suspicion of infection at an early stage • Providers at high risk for hepatitis
- 52. •The entire goal of organ transplantation is to save another human life
- 53. Success