Peri-operative Anesthetic Management in Liver Transplantation

Preface
Contents
About the Editors
1: The History of Liver Transplantation in India
1.1 Introduction
1.2 Background
1.3 Step I: Public Education
1.4 Step 2: Changing the Law
1.5 Step 3: The Initial Procedures
1.6 Step 4: Sustainable Programmes
1.6.1 Numbers
1.6.2 Statewise Distribution
1.6.3 The Situation in 2020
1.7 India Vs the World
1.8 Concerns
1.9 Recommendations
1.10 Conclusions
Part I: Basics Anatomy and Pathophysiology of Liver Disease
2: Physiological Role of Liver and Interpreting Liver Function Tests
2.1 Gross Anatomy of the Liver
2.1.1 Hepatic Blood Flow Regulation
2.2 Cellular Anatomy of the Liver
2.2.1 Models of Liver Microanatomy
2.3 Liver, the Immunological Gateway
2.3.1 Innate and Adaptive Immunity
2.3.2 Immune Tolerance
2.4 Hepatic Drug Metabolism
2.4.1 First Pass Effect
2.4.2 Phases of Drug Metabolism
2.4.3 Drug Extraction Ratio
2.5 Energy Metabolism
2.5.1 Glucose Homeostasis
2.5.2 Nitrogen Metabolism
2.5.3 Fatty Acid Metabolism
2.6 Role of the Liver in Coagulation
2.7 Hepatic Endocrine Function
2.8 Chronic Liver Disease
2.9 Interpreting Liver Function Tests
2.10 Tests Detecting Hepatocyte Injury
2.10.1 Serum Aminotransferases
2.10.2 AST to ALT Ratio
2.10.3 Lactate Dehydrogenase
2.11 Tests Detecting Injury to Bile Ducts
2.11.1 Alkaline Phosphatase
2.12 5′-Nucleotidase
2.13 Gamma-Glutamyl Transferase
2.14 Tests Assessing Biliary Organic Anion Transport
2.14.1 Serum Bilirubin
2.15 Tests Measure Hepatic Synthetic Capacity
2.15.1 Serum Proteins
2.16 Prothrombin Time and International Normalized Ratio
2.17 Tests Measuring Blood Flow and Metabolic Capacity of Liver
2.18 Pattern of Liver Test Abnormalities
2.19 Monitoring Liver Transplant
References
3: Surgical Anatomy of the Liver
3.1 Introduction
3.2 Ligaments of the Liver (Fig. 3.1)
3.2.1 Ligamentum Venosum (Arantius Ligament)
3.3 Lobar and Segmental Anatomy of the Liver
3.3.1 Functional Surgical Anatomy of the Liver
3.3.2 Bismuth’s Liver Segmentation
3.4 Caudate Lobe
3.4.1 Hepatocaval Ligament (Makuuchi Ligament)
3.4.2 Riedel Lobe (Fig. 3.8)
3.5 Hepatic Veins (Venous Outflow)
3.5.1 Right Inferior Hepatic Veins: RIHV (Fig. 3.11)
3.5.2 Inferior Phrenic Veins
3.6 Anatomical Relations Around the Hilum
3.6.1 Extrahepatic and Intrahepatic Vasculature
3.7 Portal Vein
3.8 Hepatic Artery
3.9 Biliary Anatomy
3.9.1 Intrahepatic Bile Duct Anatomy
3.9.2 The Right Hepatic Duct
3.9.3 The Left Hepatic Duct
3.9.4 Extrahepatic Biliary Anatomy
3.9.5 Biliary Ductal Anomalies
3.9.6 Bile Duct Blood Supply
3.10 Gallbladder and Cystic Duct
3.10.1 The Calot’s Triangle (Fig. 3.19)
References
4: Pathophysiology of Chronic Liver Disease
4.1 Introduction
4.2 Cellular Anatomy of the Liver
4.3 Etiology of Chronic Liver Disease
4.4 Pathophysiology of Chronic Liver Disease
4.4.1 Basics of Liver Inflammation
4.4.2 Cells Involved in Liver Inflammation
4.4.3 Repair of the Damaged Liver
4.5 Cirrhosis and Portal Hypertension
4.5.1 Hemostasis
4.5.2 Cardiac Manifestations
4.5.3 Renal Dysfunction
4.5.4 Pulmonary Complications
4.5.5 Hepatic Encephalopathy
4.5.5.1 Ammonia Hypothesis
4.5.5.2 Impaired Neurotransmission Hypothesis
4.5.6 Ascites
4.5.7 Varices
References
5: Pharmacokinetics and Pharmacodynamics of Drugs in Liver Disease
5.1 Introduction
5.2 The Normal Liver
5.3 Role of Liver in Drug Metabolism
5.4 Consequences of Liver Disease on Pharmacokinetics
5.5 Drug Absorption
5.6 Plasma Protein Binding and Drug Distribution
5.7 Metabolism
5.8 Biliary Excretion
5.9 Drugs Undergoing Renal Excretion
5.10 Consequences of Liver Disease on Pharmacodynamics
5.11 Assessment of Liver Function
5.12 Child-Pugh Scoring System
5.13 Conclusion
References
6: Viral Markers and Their Relevance in Liver Disease and Transplantation
6.1 Introduction
6.2 Hepatitis A Virus (HAV)
6.3 Hepatitis E Virus (HEV)
6.4 Hepatitis B Virus (HBV)
6.4.1 Epidemiology
6.4.2 Transmission
6.4.3 Serology/Serological Markers
6.4.4 Occult Hepatitis B Infection (OBI)
6.4.5 Transplantation for Hepatitis B
6.4.5.1 Risk Factors for HBV Recurrence after Liver Transplant
6.4.5.2 Prophylaxis for Prevention of Hepatitis B Virus (HBV) Graft Recurrence Following Liver Transplantation
Antiviral Monotherapy
6.4.5.3 Prophylaxis for Prevention of Hepatitis B Virus (HBV) Graft Recurrence Following Liver Transplantation (LT)
Combination Prophylaxis
6.4.6 Antiviral Monotherapy
6.5 Hepatitis D Virus (HDV)
6.5.1 Laboratory Diagnosis
6.5.2 Liver Transplantation in Patients with Hepatitis D Virus Liver Cirrhosis
6.6 Hepatitis C Virus (HCV)
6.6.1 Epidemiology
6.6.2 Clinical Features
6.6.3 Diagnosis
6.6.4 Screening Test: (Anti-HCV Antibody)
6.6.5 Treatment Strategies and End-Stage Liver Disease
6.6.6 Liver Transplantation for HCV-Related Liver Disease
6.6.6.1 Hepatitis C Virus Infection After Liver Transplantation
6.6.6.2 Treatment Strategies for HCV
6.7 Donors with Viral Hepatitis
6.7.1 Hepatitis B Virus
6.7.2 Approach to the Isolated HbcAb-Positive Donor
6.7.3 Approach to Use of HbsAg or HBVNAT-Positive Donors
6.8 Hepatitis A and E Virus
6.9 Conclusion
References
Part II: Liver Transplantation: Indications, Pre-operative Assessment and Optimization
7: Indication and Contraindications for Liver Transplantation
7.1 Indications
7.1.1 Acute Liver Failure
7.1.2 Chronic Liver Disease
7.1.2.1 Viral Hepatitis
7.1.2.2 Alcoholic Liver Disease
7.1.2.3 Cholestatic Liver Disease
Primary Sclerosing Cholangitis (PSC)
Inclusion Criteria for Liver Transplantation in PSC
Exclusion criteria for Liver Transplantation in PSC
Primary Biliary Cirrhosis (PBC)
7.1.2.4 Malignancy
Hepatocellular Cancer (HCC)
Cholangiocarcinoma
Intrahepatic Cholangiocarcinoma
Hilar Cholangiocarcinoma (H-CCA)
Metastatic Neuroendocrine Tumours
7.1.2.5 LT in Metabolic Liver Disease
7.1.2.6 Vascular Causes
7.2 Liver Transplantation in Paediatric Patients
7.3 Contraindication
7.4 Contraindications for Live Liver Donors as per OPTN (Organ Procurement and Transplantation Policy) [34]
7.5 Summary
References
8: Disease Severity Scoring System in Chronic Liver Disease
8.1 Introduction
8.2 Clinical States in Cirrhosis
8.3 Different Scoring Systems in Cirrhosis
8.3.1 CTP Score
8.3.2 Modified CTP Score
8.3.3 MELD Score and Its Modifications
8.3.4 Alcoholic Liver Disease
8.3.5 Primary Biliary Cirrhosis
8.3.6 Primary Sclerosing Cholangitis
8.4 Acute on Chronic Liver Failure
8.4.1 APASL AARC Definition
8.4.2 EASL CLIF-C Definition
8.4.3 CLIF-C AD Score
8.4.4 CLIF-C ACLF Score
8.5 Conclusion
References
9: Preoperative Assessment and Optimization of Liver Transplant Patient: Ascites and Hydrothorax
9.1 Introduction
9.2 Pathophysiology of Ascites in Cirrhosis [4, 5]
9.3 Standard Diagnostic Steps
9.3.1 History
9.3.2 Physical Examination
9.3.3 Laboratory Assessment
9.3.4 Abdominal Ultrasound
9.3.5 Diagnostic Paracentesis
9.3.6 Analysis of Ascitic Fluid in a Cirrhotic Patient
9.4 Management: Depends on the Grade of Ascites
9.5 Management of Patient with Grade II Ascites [5, 6]
9.5.1 Diuretics
9.6 Management of Grade III Ascites/Tense Ascites
9.6.1 Refractory Ascites (RA)
9.6.1.1 Management of Patient Refractory Ascites
9.6.1.2 Large Volume Paracentesis (LVP)
9.6.1.3 Transjugular Intrahepatic Portosystemic Shunt (TIPS)
9.6.1.4 Peritoneovenous Shunt
9.6.1.5 Pharmacological Therapies
9.6.1.6 Indwelling Peritoneal Catheters
9.6.2 CART—Cell Free Concentrated Ascites Reinfusion Therapy
9.6.2.1 Peritoneal Urinary Drainage (Alfa Pump System)
9.7 Hepatic Hydrothorax
9.7.1 Uncomplicated Hepatic Hydrothorax [45]
9.7.2 Management
References
10: Preoperative Assessment and Optimization of Liver Transplant Patients: Cardiac Issues in Liver Disease
10.1 Hemodynamic Changes in Patients with Cirrhosis
10.2 Preoperative Cardiac Evaluation of Liver Transplant Candidates
10.3 Systemic Disease That Affect Both Heart and Liver
10.4 Management of Stenotic CAD
References
11: Preoperative Assessment and Optimisation of Liver Transplant Patients: Renal Issues
11.1 Introduction
11.2 Definition of Acute Kidney Injury
11.3 Pathophysiology of Renal Dysfunction in Liver Impairments
11.4 Evaluating Criteria
11.5 Management
References
12: Preoperative Assessment and Optimization of Liver Transplant Patients: Pulmonary Issues
12.1 Introduction
12.2 Hepatopulmonary Syndrome
12.3 Epidemiology and Pathophysiology
12.4 Portopulmonary Hypertension
12.5 Epidemiology
12.6 Pathophysiology
12.7 Diagnosis
12.8 Hepatic Hydrothorax
12.9 COPD and Smoking
12.10 Obstructive Sleep Apnea
12.11 Interstitial Lung Disease
12.12 Alpha1 Antitrypsin Deficiency
12.13 Arteriovenous Malformations (AVM)
12.14 Pulmonary Nodules
12.15 Preoperative Assessment
12.15.1 History
12.15.2 Physical Examination
12.15.3 Laboratory Investigations
12.16 Management
12.16.1 HPS
12.17 Portopulmonary Hypertension
12.18 Specific Therapy
12.18.1 PAH-Specific Therapy Includes
12.19 Hepatic Hydrothorax
12.20 Summary
References
13: Coagulation in Liver Disease
13.1 Introduction
13.2 Haemostasis in Health
13.3 Coagulation in Chronic Liver Disease
13.4 Coagulation in Acute Liver Failure
13.5 Procoagulant Factors
13.6 Fibrinogen
13.7 von Willebrand Factor (vWf)
13.8 Platelets
13.9 Anticoagulant Factors
13.10 Fibrinolytic and Antifibrinolytic System
13.11 Disseminated Intravascular Coagulation (DIC)
13.12 Hypercoagulability
13.13 Assessment and Correction of Coagulation Status Before Invasive Procedures
13.14 Coagulation and Infection
13.15 Portal Hypertension and Bleeding
13.16 Conclusion
References
14: Nutrition in Chronic Liver Disease
14.1 Introduction
14.2 Prevalence and Causes of Malnutrition in Cirrhosis
14.3 Causes of Under-Nutrition
14.4 Screening for Malnutrition in Patients with Chronic Liver Disease
14.4.1 History
14.4.2 Physical Examination
14.4.3 Anthropometry, Biochemical Measures and Rapid Screening Tests for Nutritional Status
14.5 Assessment and Implications of Sarcopenia
14.6 Recommendations
14.7 Effect of Obesity on Cirrhosis
14.8 Summary
References
Part III: Intra-operative Course and Management
15: Intra-operative Management of Transplant Recipient: An Overview
15.1 Introduction
15.2 Preoperative Preparation
15.3 Preoperative Fasting Guidelines and Preparation
15.4 Conduct of Anaesthesia
15.5 Haemodynamic Monitoring
15.5.1 Central Venous Pressure (CVP) Monitors
15.5.2 Cardiac Output Monitors (Table 15.1)
15.5.2.1 Can We Derive Fluid Responsiveness?
15.5.2.2 Induction Agents
15.5.3 How Do I Intubate a Patient with CLD for Transplant? Is RSI Mandatory?
15.6 Depth of Anaesthesia Monitoring During Liver Transplant Surgery
15.7 Fluid Management in Liver Surgery
15.8 Coagulation Monitoring and Guidelines for Product Transfusion
15.8.1 Fast Tracking in Liver Transplant
15.9 Conclusion
References
16: Ischemia–Reperfusion Injury
16.1 Introduction
16.2 Pathophysiology
16.2.1 Ischemia
16.2.2 Reperfusion
16.3 Global Effects of Hepatic Ischemia–Reperfusion Injury
16.4 Measures to Ameliorate Hepatic Ischemia–Reperfusion Injury
16.4.1 Pharmacological Measures
16.4.2 Surgical
16.5 Summary
References
17: Hemodynamic Monitoring in Liver Transplantation
17.1 Blood Pressure
17.2 Central Venous Pressure
17.3 Invasive Cardiac Output Monitoring
17.4 Minimally Invasive Cardiac Output Monitoring
17.5 Transesophageal Echocardiography
References
18: Intraoperative Coagulation Monitoring in Liver Transplant Surgery
18.1 Introduction
18.2 Intraoperative Changes in Each Phase
18.2.1 Dissection Phase
18.2.2 Anhepatic Phase
18.2.3 Post-reperfusion/Neohepatic Phase
18.3 Monitoring Coagulation During Liver Transplant Surgery
18.3.1 Standard Laboratory Tests
18.3.2 Prothrombin Time (PT)
18.3.3 International Normalized Ratio (INR)
18.3.4 Activated Partial Thromboplastin Time (aPTT)
18.3.5 Thrombin Time [13]
18.3.6 Platelet Count
18.3.7 Fibrinogen
18.3.8 Fibrinogen Degradation Products (FDPs) and D-Dimer (Tests of Fibrinolysis)
18.3.9 Limitations of Conventional Tests
18.4 Point-of-Care Coagulation Testing
18.4.1 Functional Assay of Monitoring Heparin Anticoagulation [13]
18.4.1.1 Activated Clotting Time (ACT)
18.4.2 Platelet Function Monitoring
18.4.2.1 Platelet Function Analyser-100
18.4.3 Near-Patient Clotting Factor Test
18.4.4 Viscoelastic Measures of Coagulation
18.4.4.1 TEG/ROTEM: Introduction
18.4.4.2 Thromboelastography (TEG)
18.4.4.3 Decrease in Amplitude Measurement A30 and A60 [22]
18.4.4.4 Clot Pro
18.4.5 Rotational Thromboelastometry (ROTEM)
18.4.5.1 Diagnostic Power of TEG/ROTEM [11]
18.4.6 The Sonoclot
18.4.6.1 Principle
18.4.7 Use of Standard/Conventional Tests in Liver Transplant
18.4.8 Use of Point-of-Care (POC) Devices in Liver Transplant
18.4.8.1 Pre-transplant Liver Failure Patients
18.4.8.2 Intraoperative Use of TEG During Liver Transplant
18.4.8.3 Sonoclot in Liver Transplant
18.4.8.4 Application of Platelet Function Testing in Liver Transplant [8]
18.4.9 Limitations [23]
18.5 Conclusion
References
19: Fluid Therapy in Liver Transplant
19.1 Vascular Component Approach for Guiding Fluid Therapy: A Novel and Critical Way of Volume Status Assessment [16]
19.2 Restrictive vs. Liberal Strategy
19.3 Composition of Fluids and Its Impact on Outcome
19.4 Monitoring of Volume Status and Perioperative Fluid Management
19.5 Fluid Assessment in ICU
19.6 Special Considerations
19.6.1 LDLT vs. Cadaveric
References
20: Role of Vasopressors in Liver Transplant Surgery
20.1 Introduction
20.2 Aetiopathogenesis
20.3 Haemodynamic Changes During LT Surgery
20.3.1 Anaesthesia-Related Factors
20.3.2 Surgery-Related Factors [1, 2]
20.4 Vasoactive Agents Used During Orthotopic Liver Transplant (OLT) [3, 4, 6]
20.4.1 Norepinephrine
20.4.2 Phenylephrine
20.4.3 Epinephrine
20.4.4 Ephedrine
20.4.5 Dopamine
20.4.6 Dobutamine
20.4.7 Isoproterenol
20.4.8 Vasopressin and Analogues
20.5 Nonadrenergic Agents
20.6 Complications of Vasopressor Use
20.7 Conclusion
References
21: Minimizing Blood Loss in Recipient Surgery
21.1 Introduction
21.2 Why to Minimize Transfusion?
21.3 Coagulation Derangements (Preoperative and Intraoperative)
21.4 Risk Factors (Recipient, Surgery and Graft-Related Risk Factors)
21.5 Prevention of Excessive Bleeding
21.5.1 Nonpharmacological Interventions
21.5.2 Pharmacological Interventions
21.5.2.1 Antifibrinolytics
21.5.2.2 Prothrombin Complex Concentrate (PCC)
21.5.2.3 Fibrinogen Concentrate
21.6 Others
21.6.1 Strategies
References
22: Veno-Venous Bypass in Liver Transplantation
22.1 Introduction and Historical Background
22.2 Indications for VVBP (Table 22.2)
22.2.1 Cardiovascular Instability
22.2.2 Renal Impairment
22.2.3 Acute Liver Failure (ALF)
22.2.4 Severe Portal Hypertension
22.2.5 Massive Bleeding During Hepatectomy and Other Indications
22.3 Contraindications
22.4 Insertion and Management of VVBP
22.5 Complications of VVBP (Table 22.3)
22.5.1 Vascular Access Related
22.5.2 Extracorporeal/Bypass Circuit Related
22.5.3 Post-Reperfusion Syndrome (PRS)
22.6 Caval Preserving Options
22.7 Selective Use of VVBP
22.8 Conclusion
References
23: Intraoperative Complications and Management
23.1 Massive Blood Transfusion in Liver Transplant
23.1.1 Preoperative Risk Factors for Massive Blood Transfusion
23.1.2 Intraoperative Risk Factors for Massive Blood Transfusion
23.2 The Role of Graft Function
23.3 Management of Massive Blood Loss
23.3.1 Fluid Management
23.4 Maintenance of Homeostatic Conditions for Clotting
23.4.1 Vasopressors
23.5 Coagulation Tests for Monitoring and Guiding Coagulation Management
23.5.1 Pharmacological Interventions
23.5.1.1 Antifibrinolytic Drugs
23.5.1.2 Fibrinogen
23.5.1.3 Prothrombin Complex Concentrate
23.5.1.4 Recombinant Activated Factor VII
23.5.1.5 Factor XIII
23.5.2 Protamine and the Heparin Like Effect
23.5.3 Fractionated Products vs. Fresh Components
23.5.4 Preparation for Massive Bleeding
23.5.5 Transfusion of Blood Components During Massive Blood Transfusion
23.5.5.1 Fixed Ratio Blood Products Vs. POC Directed Transfusion
23.5.5.2 Targets of Resuscitation in Massive Blood Loss
23.6 Intracardiac Thrombus (ICT) and Pulmonary Embolism (PE)
23.6.1 Incidence of Intraoperative Thromboembolic Events
23.6.1.1 Predisposing Factors
23.6.1.2 Role of Antifibrinolytics
23.6.1.3 Factor Concentrates
23.6.2 Management of ICT
23.6.2.1 Anticoagulation
23.6.2.2 Suggested Management of Intra Cardiac Thrombus
23.6.3 Intraoperative Vasoplegia
23.6.4 Methylene Blue [51]
23.6.5 Air Embolism During Liver Transplantation
23.7 Severe Post-Reperfusion Syndrome (PRS)
23.7.1 Dynamic LVOT Obstruction (LVOTO)
23.7.2 Pulmonary Hypertension
23.7.2.1 Arrhythmias
23.7.2.2 Treatment
23.7.3 Miscellaneous
23.8 Conclusion
References
Part IV: Donor Issues: Liver Donor Hepatectomy and Organ Donation
24: Peri-Operative Assessment and Management of Live Donor for Donor Hepatectomy
24.1 Introduction
24.2 Donor Evaluation
24.2.1 Phase 1
24.2.2 Phase 2
24.2.3 Phase 3
24.3 Multidisciplinary Team Assessment
24.4 Pre-Anaesthetic Assessment
24.5 Systemic Assessment
24.5.1 Assessment Day Before Surgery (Day −1)
24.6 Anaesthetic Management
24.6.1 Transfusion Requirement and Methods of Minimizing Blood Loss
24.6.1.1 Low Central Venous Pressure (CVP)
24.6.1.2 Acute Normovolemic Hemodilution (ANH)
24.6.1.3 Pre-Operative Autologous Blood Transfusion
24.7 Post-Operative Care
24.8 Pain Management
24.8.1 Abdominal Wall Blocks
24.8.2 Multi Modal Analgesia
24.9 DVT Prophylaxis
24.10 Remnant Liver: Monitoring Its Function
24.11 Robotic Donor Hepatectomy
24.12 Liver Regeneration
24.13 Complications
References
25: Brain Death and Organ Donation
25.1 Introduction
25.2 Organ Donation in India
25.3 Brain Death
25.3.1 Definition
25.3.2 Pathophysiology of Brain Death [5], (Fig. 25.4)
25.3.3 Cardiovascular Changes
25.3.4 Pulmonary Changes
25.3.5 Endocrine, Metabolic, and Stress Response
25.3.6 Diagnosis of Brain Death
25.3.6.1 Apnea Test [6]
25.3.6.2 Ancillary Tests
25.3.7 Clinical Observations Compatible with the Diagnosis of Brain Death
25.3.8 Certification of Brain Death
25.4 Care of the Psychological Issues for Organ Donor Family and Treating Staffs
25.5 Conclusion
Appendix
References
26: Donation After Circulatory Death
26.1 Definition of Death
26.2 Ethical and Legal Issues in Donation After Cardiac Death (DCD) [8–13]
26.3 Process of DCD [15, 16]
26.4 Acceptable Time Limits in DCD
26.5 Ischaemia Reperfusion Injury (IRI) and Organ Preservation After DCD [15, 17, 19–24]
26.6 Machine Perfusion (MP) [19–24]
26.7 Functional Assessment of Organs [21]
26.8 Classification of Perfusion Techniques Based on Preservation Temperature [22]
26.9 Hypothermic Machine Perfusion (HMP) (0–12 °C)
26.10 Midthermic Machine Perfusion (13–24 °C)
26.11 Subnormothermic Machine Perfusion (25–34 °C)
26.12 Normothermic Machine Perfusion (35–38 °C) [22–24]
26.13 Normothermic Regional Perfusion (NRP) [23]
26.14 International DCD Programmes [7]
26.15 Lessons from UK Success Story in Overcoming Ethical, Legal and Professional Challenges [25, 26]
26.16 DCD in India [4]
26.17 Outcomes From DCD [9]
26.18 Future Trends and Directions for DCD [9, 19, 24, 25]
Annexure: Major Ethical, Legal and Professional Publications on Deceased Organ Donation, United Kingdom [26]
References
27: Management of Deceased Donor for Organ Donation
27.1 Introduction
27.2 Pathophysiological Changes Due to Brain Death
27.3 Approach to a Patient with Brain Death
27.4 General Care and Monitoring
27.5 Specific Management
27.6 Cardiovascular Support
27.6.1 Hypotension
27.6.1.1 Fluid
27.6.1.2 Monitoring
27.6.2 Hypertension
27.6.3 Arrythmias
27.7 Respiratory Care and Ventilatory Support
27.8 Acid-Base Balance
27.9 Renal Support
27.10 Endocrine Dysfunction
27.10.1 Central Diabetes Insipidus (CDI)
27.10.2 Hyperglycaemia
27.10.3 Thyroid Dysfunction
27.10.4 Cortisol Replacement Is Must. It Is Vital to Administer It as It
27.11 Temperature Regulation
27.12 Coagulation System
27.13 Infectious Disease Protection
27.14 Management of Nutrition
27.15 Ischaemia-Reperfusion Injury
27.16 Summary
References
28: Normothermic Machine Perfusion
28.1 Introduction
28.2 Evolution of NMP
28.3 Organ Preservation (Table 28.2)
28.3.1 Static
28.3.2 Dynamic
28.3.3 Hypothermic Machine Perfusion (HMP)
28.3.4 Subnormothermic Machine Perfusion (SMP)
28.3.5 Normothermic Machine Perfusion (NMP)
28.4 Machine
28.5 Patho-Physiology During Preservation
28.6 Human Trials
28.7 COPE Trial (Consortium for Organ Preservation in Europe)
28.8 Parameters Assessed for Viability of Organ
28.9 Conclusion
References
29: Role of ECMO in Liver Transplant
29.1 Introduction
29.2 ECMO Overview
29.3 ECMO Components [4]
29.4 Functions
29.5 ECMO Configurations: Fig. 29.4
29.5.1 Venoarterial ECMO (VA ECMO)
29.5.2 Venovenous ECMO (VV ECMO)
29.5.3 Management of Patient on ECMO
29.5.4 Complications
29.5.5 ECMO in Liver Transplantation
29.5.5.1 In Donors
29.5.5.2 In Recipients
29.6 ECMO for Transplant Donors
29.7 Brain Dead ECMO Patient as Potential Donor
29.7.1 Declaring Brain Death on ECMO [7–10] Can Be Considered Under the Following
29.8 Prerequisites for Testing for Brain Death
29.8.1 Establish Irreversible and Proximate Cause of Death
29.8.2 Correct Any Severe Electrolyte, Acid/Base, and Endocrine Disturbance
29.8.2.1 Neurological Examination
29.8.2.2 Apnoea Testing on ECMO: Fig. 29.5
29.8.2.3 Ancillary Tests
29.8.3 Role of ECMO in Deceased Donor Management
29.8.4 Donation After Cardiac Death (DCD) [14]
29.8.5 Challenges and Ethical Issues of EDCD [20]
29.8.6 Logistic, Economic, and Social Questions
29.8.7 Challenges in the Use of ECMO for Organ Donation Specific to India
29.8.8 ECMO in Liver Transplant Recipients: Who Would Benefit?
29.8.9 Acute Liver Failure
29.8.10 ECMO in Hepatopulmonary Syndrome
29.8.11 Perioperative ECMO
29.8.12 In Summary, When Should ECMO Be Offered for the CLD Patient Awaiting Liver Transplantation? [36, 37]
29.9 Conclusion
References
Part V: Acute Liver Failure
30: Critical Care Management of Acute Liver Failure
30.1 Introduction
30.1.1 Definition and Classification
30.2 Intracranial Hypertension (ICH), Hepatic Encephalopathy in ALF and Management
30.2.1 ICP Monitoring
30.2.2 Methods of ICP Monitoring
30.2.3 Therapeutic Interventions
30.2.3.1 General Supportive Strategies
30.2.4 Specific Strategies
30.2.4.1 Strategies to Reduce Hyperammonemia
30.2.5 Prophylactic Strategies
30.3 Specific Strategies to Reduce Cerebral Edema and ICH
30.4 Hemodynamic Derangement in ALF and Management
30.5 Nutritional and Metabolic Support in ALF
30.6 Respiratory Derangement in ALF and Management
30.7 Renal Derangement in ALF and Management
30.7.1 Renal Replacement Therapy
30.8 Hemostasis in ALF and Management
30.9 Infection and SIRS in ALF
30.9.1 Biomarkers
30.9.2 Prognosis and Liver Transplantation
30.10 Liver Support Devices in Acute Liver Failure [149]
30.11 Artificial Liver Support Devices (Non-cell Based)
30.12 Bio-Artificial Liver Support Devices (Cell-Based)
References
31: Assessment for Transplanting Acute Liver Failure Patient
31.1 Introduction
31.2 Assessing Patients with ALF for Liver Transplantation
31.2.1 Assessing the Need for Transplant
31.2.2 Assessing Various Organ Systems
31.2.2.1 Central Nervous System
31.2.2.2 Cardiovascular System
31.2.2.3 Respiratory System
31.2.2.4 Renal System and Acid-Base, Fluid, Electrolyte Balance
31.2.2.5 Coagulation System
31.2.2.6 Other Considerations
31.2.3 Assessment for Presence of Contraindications to LT
31.3 Conclusion
References
32: Bridging Therapies in Acute and Acute on Chronic Liver Failure
32.1 Introduction
32.2 Bridging Therapies
32.3 Therapeutic Plasma Exchange (TPE)
32.4 Liver Support System/Assist Devices
32.5 Molecular Adsorbent Recirculating/Recycling System
32.6 Fractionated Plasma Separation and Adsorption (Prometheus)
32.7 Single-Pass Albumin Dialysis
32.8 Extracorporeal Liver Assist Device
32.9 Experimental Regenerative and Cell-based Therapies
32.10 Bone Marrow-derived Stem Cells (In Vivo)
32.11 Hepatocyte Transplantation
32.12 Mesenchymal Stem Cell (MSC) Therapy
32.13 Role in ALF
32.14 Role in ACLF
32.15 Conclusion
References
33: Anaesthetic Management of Acute Liver Failure for Liver Transplant
33.1 Background
33.2 Specific Concerns
33.3 Central Nervous System
33.4 Cardiovascular System
33.5 Coagulation
33.6 Renal Function
33.7 Too Sick To Be Considered for Liver Transplant
33.8 Shifting from ICU to Operating Room
33.9 Anaesthetic Management
33.10 Vascular Access
33.11 Hemodynamic Monitoring and Management
33.12 Neurologic Monitoring and Management
33.13 ICP Monitoring
33.14 Strategies to Reduce Intracranial Pressure
33.15 Pre-emptive Hepatectomy
33.16 Venovenous Bypass (VVB) and IVC Clamping
33.17 Managing the Coagulopathy
33.18 Metabolic Derangement
33.19 Renal Function Management
33.20 Use of Intraoperative CRRT
33.21 Postoperative Management
References
Part VI: Paediatric Liver Transplant
34: Anesthetic Issues in the Management of Pediatric Liver Transplantation
34.1 Introduction
34.2 Indications
34.3 Basis for Allocation
34.4 Timing of Transplantation
34.5 Pathophysiological Changes, Pre-operative Concerns, and Anesthetic Implications
34.5.1 Pulmonary
34.5.2 Cardiovascular
34.5.3 Central Nervous System
34.5.4 Renal
34.5.5 Gastrointestinal
34.6 Pre-operative Workup
34.7 Pre-operative Medication and Theater Preparation
34.8 Intraoperative Management
34.8.1 Induction
34.8.2 Intravenous (IV) and Intraarterial (IA) Access
34.8.3 Maintenance of Anesthesia
34.8.4 Temperature Management
34.8.5 Metabolic Management
34.8.6 Hemodynamic Management
34.8.7 Hematological Management
34.9 Stages of Liver Transplantation and the Specific Anesthetic Considerations
34.9.1 Dissection Phase- (Pre-hepatic Stage)
34.9.2 Anhepatic Phase
34.9.3 Neohepatic Phase
34.9.4 Elective Ventilation Vs. on Table Extubation
34.9.5 Early Post-operative Course
34.10 Pediatric Liver Transplantation: Special Circumstances
34.10.1 Acute Liver Failure
34.10.1.1 Management of PAL
34.10.2 Primary Hyper Oxaluria
34.10.3 Maple Syrup Urine Disease (MSUD)
34.11 Conclusion
References
35: Challenges in Pediatric Liver Transplant
35.1 Introduction
35.2 Journey till the Transplant
35.3 Challenges in Pediatric Liver Transplant
References
36: Intensive Care Issues in Post-operative Pediatric Liver Transplantation
36.1 Introduction
36.2 General Principles
36.3 Post-op Ventilation and Oxygenation
36.4 Fluids and Hemodynamics
36.5 Electrolytes and Metabolic Issues
36.6 Pulmonary Issues
36.7 Post-operative Hematological Issues: Bleeding and Coagulopathy
36.8 Gastrointestinal (GI) Concerns
36.9 Neurological Issues
36.10 Acute Kidney Injury (AKI)
36.11 Immunosuppression
36.12 Infections
36.13 Nutrition
36.14 Early Post-operative Complications Specific to Liver Graft
36.14.1 Primary Graft Failure
36.14.2 Size Discrepancy of Graft
36.14.3 Rejection
36.14.4 Vascular Issues
36.14.5 Biliary Issues
36.15 Conclusion
References
Part VII: Post-operative Issues
37: Fast Tracking in Liver Transplantation
37.1 Introduction
37.2 Definition and Evolution of Fast Tracking in LT
37.3 To Fast Track or Not? That’s the Question
37.3.1 Be Careful Before You Fast Track
37.3.2 Benefits of the Fast Track Approach
37.4 Anesthesia For Fast Tracking
37.5 Fast Tracking in the LDLT Setting
37.6 Criteria For Fast Tracking
37.7 Future Prospects
References
38: Early Post-operative Care of Liver Transplant Recipient
38.1 Introduction
38.2 General Considerations
38.3 Cardiovascular and Hemodynamics
38.4 Respiratory System
38.5 Renal and Electrolyte Balance
38.6 Graft Function Assessment
38.7 Neurological Management
38.8 Pain Management
38.9 Infection Prophylaxis
38.10 Nutrition Management
38.11 Physiotherapy
38.12 Psychosocial Management
38.13 Conclusion
References
39: Assessment of Early Graft Function and Management of Early Graft Failure
39.1 Incidence, Predictors, and Outcome of PGD
39.2 Assessment of Early Graft Function
39.3 Scoring Systems for Assessment of Graft Function Post-LT
39.4 Management of a Failing Graft
39.4.1 Deteriorating Recipient Physiology in PGD
39.4.2 General Principles of Management
39.4.3 Meticulous Surgical Care
39.4.4 ICU Management
39.5 General Supportive Care
39.5.1 Neurological Support
39.5.2 Mechanical Ventilation
39.5.3 Cardiovascular Support
39.5.4 Renal Support
39.5.5 Infection Prevention and Control
39.5.6 Nutritional Support
39.5.7 Immunosuppression
39.6 Specific Interventions
39.6.1 Use of N-Acetyl Cysteine
39.6.2 Role of Plasma Exchange in Graft Failure
39.6.3 Other Artificial Liver Support Systems in PGD
39.7 Use of Prostaglandins
39.8 Other Experimental Strategies
References
40: Postoperative Renal Dysfunction in Recipient
40.1 Objective
40.2 Preamble
40.3 Definition of AKI
40.3.1 RIFLE Criteria
40.3.2 Acute Kidney Injury Network (AKIN) Classification
40.3.3 KIDGO Revision of RIFLE and AKIN Criteria
40.4 Why Do We Need to Change the Conventional Diagnostic Criteria for AKI?
40.5 Assessment of Renal Function Before and After Liver Transplantation
40.6 Biomarkers of AKI
40.7 Burden of Renal Dysfunction After Liver Transplantation
40.8 Risk Factors for Postoperative Acute Kidney Injury After Orthotopic Liver Transplantat
40.8.1 Pre-transplantation Risk Factors
40.8.2 Hyponatremia
40.8.3 Hypoalbuminemia
40.8.4 Hyperbilirubinemia
40.8.5 Liver Disease Severity
40.9 Strategies to Reduce Pre-transplantation Risk Factors
40.9.1 Studies Evaluating the Effect of Terlipressin in HRS
40.9.2 Role of Nonpharmacological Therapies
40.9.3 Role of Simultaneous Liver and Kidney Transplant
40.10 Intraoperative Risk Factors
40.11 Strategies to Reduce Intraoperative Risk Factors
40.12 Postoperative Risk Factors
40.12.1 Strategies to Reduce Postoperative Risk Factors
40.13 Early Renal Protection Strategies Post-OLT (0–6 Months)
40.13.1 Induction Therapy to Delay CNI Initiation
40.13.2 Polyclonal Induction Therapy with Anti-thymocyte Globulin (ATG)
40.13.3 Monoclonal Antibody Induction Therapy (Daclizumab, Basiliximab)
40.14 Reduced CNI Exposure
40.14.1 MMF Plus Reduced Dose Tacrolimus
40.14.2 Use of mTOR Inhibitors (Sirolimus/Everolimus)
40.15 Factors Affecting Renal Function in Long-Term Survivors
40.16 Renal-Sparing Strategies (Long Term, >6 Months Post-OLT)
40.16.1 CNI Minimization/Withdrawal
40.16.2 Role of Renal Biopsy
40.16.3 Modification of Risk-Factors Other Than CNIs
40.16.3.1 Hypertension
40.16.3.2 Diabetes Mellitus
40.16.3.3 Dyslipidemia
40.16.3.4 Management of HCV Recurrence
40.16.3.5 Referral to Nephrology
40.17 Conclusion
References
41: Immunosuppression
41.1 Introduction
41.2 Immunosuppressive Agents
41.3 Classification of Immunosuppressive Agents Based on Mechanism of Action
41.3.1 Corticosteroids: Methylprednisolone/Prednisolone
41.3.2 Calcineurin Inhibitors (CNI):Cyclosporin(CyA), Tacrolimus (Tac)
41.3.3 Antimetabolites
41.3.4 mTOR inhibitors: Sirolimus/Rapamycin (SRL) Everolimus (EVR)
41.3.5 Antibodies/Biological Immunosuppressive Agents
41.4 Choice of Immunosuppressive Agents in Specific LT Population
41.4.1 Immunosuppression in Patients with Renal Impairment
41.4.1.1 Recommendations of Immunosuppressive Agents in Patients with Renal Dysfunction
41.4.2 Immunosuppression in HCV Liver Transplant Patients
41.4.2.1 Role of Immunosuppression in HCV Recurrence
41.4.3 Immunosuppression in Patients with HCC
41.4.4 Immunosuppression in Paediatric Patients
41.4.5 Immunosuppression in Pregnant Patients
41.5 Can Immunosuppression Be Withdrawn After LT?
References
Part VIII: Special Situations
42: Anesthesia for Interventional Radiology in CLD and Transplanted Patient
42.1 Introduction
42.2 Basic Considerations for Providing Anesthesia for IR
42.2.1 Anesthesia for Interventional Radiology for the Pre-Transplant Patients
42.2.1.1 Transjugular Intrahepatic Portosystemic Shunt (TIPS)
42.2.1.2 TIPS Procedure
42.2.1.3 Indication and Contraindications
42.2.1.4 Complications
42.2.1.5 Anesthesia
42.2.1.6 Preoperative
42.2.1.7 Anesthesia Technique
42.2.1.8 Radiofrequency Ablation
42.2.1.9 Anesthesia
42.2.1.10 Monitored Anesthesia Care
42.2.1.11 General Anesthesia
42.2.1.12 Epidural Anesthesia
42.2.1.13 Thoracic Paravertebral Block
42.2.2 Anesthesia for Interventional Radiology for Post-Liver Transplant Patients
42.2.2.1 Hepatic Artery Complications
42.2.2.2 Portal Vein Complications
42.2.2.3 Biliary Complications
42.3 Conclusion
References
43: Acute on Chronic Liver Failure: An Update
43.1 Introduction
43.2 Definitions of ACLF
43.3 Pathogenetic Basis of ACLF (Fig. 43.1)
43.3.1 Systemic Inflammation
43.3.2 Immunodysfunction in Patients with ACLF
43.3.3 Intestinal Inflammation and Gut Dysbiosis
43.3.4 Infections
43.4 The Concept of Tolerance in ACLF
43.4.1 Assessment of Liver and Extrahepatic Organs in Patients with ACLF
43.4.1.1 Liver Failure
43.4.1.2 Coagulation Failure
43.4.1.3 Kidney Dysfunction or Failure
43.4.1.4 Spectrum of AKI in ACLF
43.4.1.5 Prediction of AKI in ACLF
43.4.1.6 Diagnosis of AKI in Patients with ACLF
43.5 Role of Biomarkers
43.5.1 Biomarkers of Glomerular Injury
43.5.1.1 Cystatin C
43.5.2 Biomarkers of Proximal Tubular Damage
43.5.2.1 Kidney Injury Molecule (KIM-1)
43.5.2.2 Liver Fatty Acid Binding Protein (L-FABP)
43.5.2.3 Interleukine-18
43.5.3 Biomarkers of Distal Tubular Damage
43.5.3.1 Neutrophil Gelatinase-Associated Lipocalin
43.5.4 Studies Assessing Markers of Tubular Injury in Patients with ACLF
43.5.4.1 Management of AKI
43.5.4.2 Cerebral Failure
43.5.4.3 Circulatory and Respiratory Failure
43.6 Management of Patients with ACLF (Fig. 43.3)
43.6.1 Albumin
43.6.2 Renal Replacement Therapy
43.6.3 Extracorporeal Liver Support Systems
43.6.4 Therapeutic Strategies Targeting Liver Regeneration in ACLF
43.6.5 Role of Anti-Oxidants in ACLF
43.6.6 Liver Transplantation in ACLF
43.6.7 Assessing Futility in Patients with ACLF
43.6.8 Need of Dynamic Prognostic Models
43.7 Conclusion
References
44: Combined Liver and Kidney Transplant
44.1 Introduction
44.1.1 Renal Function, Liver Disease, and Liver Transplantation
44.1.2 Why Is CKLT Important?
44.1.3 Who Benefits from CKLT?
44.2 Anesthetic Considerations
44.2.1 Preoperative
44.2.2 Intraoperative
44.2.2.1 Renal Replacement Therapy
44.2.3 Postoperative
44.3 Conclusions
References
45: ABO-Incompatible Liver Transplantation
45.1 Introduction
45.2 History of ABO-I Liver Transplantation
45.3 Need of ABO-I Transplant in Setting of Living Donor
45.4 Current Strategies for ABO Incompatibility in LDLT Worldwide
45.4.1 Rituximab
45.4.2 Plasmapheresis
45.4.3 Mycophenolate Mofetil
45.4.4 Intravenous Immunoglobulin (IVIG)
45.5 Outcomes and Long-Term Survival After ABO-I Liver Transplant
References
46: Non-Transplant Surgery for Post-Transplant Patient
46.1 Introduction
46.2 Surgeries in Post-LT Recipients
46.3 Anaesthesia Concerns and Considerations
46.3.1 Preoperative Assessment of Transplant Recipients
46.3.2 Physiology of LT Recipient
46.3.2.1 Liver Functions
46.3.2.2 Portal Hypertension
46.3.2.3 Renal Functions in the Post-LT Recipient
46.3.2.4 Cardiorespiratory System
46.4 Immunosuppression
46.4.1 Side Effects of Immunosuppressive Therapy
46.4.2 Drug Interactions of Immunosuppressive Therapy
46.5 Preoperative Evaluation
46.5.1 Premedication
46.5.2 Considerations for General Anaesthesia
46.5.3 Monitoring
46.5.4 Airway Management
46.5.5 General Anaesthesia
46.5.6 Inhalation Agents
46.5.7 Intravenous Induction Agents like
46.5.8 Neuromuscular Blockers
46.5.9 Opioids
46.5.10 Regional Anaesthesia
46.5.11 Postoperative Management
46.6 Conclusion
References