Liver transplantation
Stem
A 52-year-old man, 90 kg, with alcohol-related cirrhosis is having a deceased-donor orthotopic liver transplant tonight. He has tense ascites and grade 1 encephalopathy. Sodium is 128, potassium 4.9, creatinine 1.8, INR 2.4, platelets 48,000 and fibrinogen 110 mg/dL. A recent right heart catheterization showed a mean pulmonary artery pressure of 31 mmHg. He has known grade 2 esophageal varices.
Question
What is your anesthetic plan for him, phase by phase?
Ideal answer
HeadlineThree phases, three threats: bleeding in dissection, low output and acidosis when anhepatic, collapse at reperfusion.1 I prepare for massive transfusion.
- Access before incision. Large-bore lines, rapid infuser, arterial line, and a central line above the diaphragm so caval clamping does not affect it.1
- Rapid sequence induction for the ascites; PA catheter, TEE. TEE carefully, because varices are only a relative contraindication.1
- Dissection: red cells and plasma about 1:1. He can lose two to five blood volumes; calcium chloride for citrate; coagulopathy by viscoelastic testing, not the INR.1
- Anhepatic: less volume; fix potassium, ionized calcium, acidosis. Output falls with caval clamping and lactate builds; I correct before the clamps come off.1
- Reperfusion: calcium and epinephrine drawn up, because a fall in mean pressure of more than 30% is common.2
Watch for: I keep him warm throughout and never raise his sodium quickly.
Breaking down the answer
- Screen the pulmonary circulation — with portopulmonary hypertension, a mean PAP above 35 mmHg should be treated before transplant and 45 or more is an absolute contraindication.3 At 31 he proceeds, with a PA catheter for reperfusion.1
- Transfuse by goals — thromboelastography and rotational thromboelastometry run in the OR and help separate surgical bleeding from coagulopathy after reperfusion.1
- Caval clamping and bypass — without venovenous bypass cardiac output falls by about 50% in the anhepatic phase, and about 30% with it; the piggyback technique preserves caval flow and causes little change.1
- Why less volume when anhepatic — overloading him then congests the new graft.1
- Why correct before unclamping — cold, acidotic, potassium-rich blood and preservation fluid reach the heart at reperfusion; optimizing potassium and calcium beforehand is the one thing I control.1
Follow-up question
The portal vein is unclamped. Within two minutes his heart rate falls to 38, mean arterial pressure drops from 75 to 40 mmHg, the T waves peak, and the potassium on the blood gas is 6.9. What do you do?
Follow-up answer
HeadlineSevere postreperfusion syndrome with hyperkalemia. I tell the surgeon, ask them to hold off further unclamping or compress if that helps, and call for help.
It is a mean pressure more than 30% below the anhepatic baseline within five minutes of reperfusion.2 Calcium chloride stabilizes the myocardium and epinephrine boluses treat the bradycardia and pressure,2 then bicarbonate, insulin with dextrose and increased ventilation move potassium into cells. If he arrests, CPR and ACLS. TEE shows whether the right ventricle is dilated or holds clot or air, and I start a vasopressor infusion. I recheck potassium, ionized calcium and a gas every few minutes, and get a viscoelastic test, because fibrinolysis often follows.
Pitfalls that cost points
- Placing the only central line in the femoral vein.
- Giving plasma before incision to correct the INR.
- Correcting his sodium rapidly with large bicarbonate or saline loads.
Rapid-fire
Q: Why does metabolic alkalosis develop after a good reperfusion? A: The working graft metabolizes the citrate from transfused blood.1
Q: How common is postreperfusion syndrome? A: Reported between 6 and 77% depending on the definition.2
Q: What drives the hypotension at reperfusion? A: Cold, acidic fluid, cytokines from Kupffer cell activation causing vasodilation, myocardial depression and loss of preload to the refilling graft.2
Q: When are platelets and cryoprecipitate held? A: Until he is off venovenous bypass, if it is used.1
Numbers to know
| Item | Value |
|---|---|
| Postreperfusion syndrome | MAP fall >30% within 5 min, lasting ≥1 min2 |
| Dissection blood loss | 2–5 blood volumes1 |
| Anhepatic cardiac output fall | ~50% without bypass, ~30% with1 |
| Portopulmonary hypertension | mPAP >35 treat first; ≥45 contraindication3 |
| Red cells to plasma | ~1:11 |
Links
- Cirrhosis and the patient with liver disease, Massive hemorrhage and transfusion, hyperkalemia, Pulmonary hypertension and right ventricular failure, Perioperative hypothermia and coagulopathy
- Atlas: The 11 TEE views
- International Liver Transplantation Society guidance on portopulmonary hypertension
Sources
- 1.Adult Liver Transplantation: Anesthetic Considerations · OpenAnesthesia · openanesthesia.org
- 2.Postreperfusion Syndrome · OpenAnesthesia · openanesthesia.orgAggarwal 1987 definition; reported incidence 6–77% depending on definition.
- 3.Macitentan Improves Risk Categorization for Liver Transplant Mortality in Patients With Portopulmonary Hypertension · Liver Transplantation 2020;26(7):935-940, 2020 · pmc.ncbi.nlm.nih.govCites ILTS: mPAP >35 treat before transplant; mPAP ≥45 absolute contraindication.
Facts on this page were checked against these sources on Oct 16, 2026. Guidelines change; confirm doses against current institutional protocols.