Liver Transplant

[IveGotTwins]

New CA2. I just finished my first liver transplant and it was awesome.

Pt was late 60s hx of chronic Hep C and met colon CA to liver s/p resection 7 yrs ago. Diabetes, HTN but normal heart.
Case went great despite lasting 9 hrs and losing 2L of blood since it was a re-operation. "Usual" case length is 4-5 hours. 6 units of PRBCs, 5 units FFP, 6pk platelets, some cryo, 1L albumin, and 2.5L crystalloid. We went upstairs with normal ABG and no pressors.

The set-up was a beast but thank dog there was a protocol for me to follow. Ours calls for bilateral radial art lines(one for vigileo) and triple lumen CVC (CVP/FMS/drips). Induction is standard (fent/prop/roc). Drips include epi, norepi, dopamine, sufent, nimbex, CaCl, plus/minus bicarb, phenylephrine, mannitol. Drugs that are to be at the ready include CPR meds (atropine, lido, CaCl, pressors, etc.), amicar, cold albumin for flushing the donor liver, solumedrol given while anhepatic, and basiliximab given after reperfusion.

The reason I posted was to see if anyone else who regularly does liver transplants has a set-up they rely upon. I did a search I didn't see anything.

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[BobBarker]

A TLC is not enough access. Mac Catheter next time.

 

[urge]

Maybe they had good peripheral access.

BTW, what is FMS on the central line?

 

[Idiopathic]

New CA2. I just finished my first liver transplant and it was awesome.

Pt was late 60s hx of chronic Hep C and met colon CA to liver s/p resection 7 yrs ago. Diabetes, HTN but normal heart.
Case went great despite lasting 9 hrs and losing 2L of blood since it was a re-operation. "Usual" case length is 4-5 hours. 6 units of PRBCs, 5 units FFP, 6pk platelets, some cryo, 1L albumin, and 2.5L crystalloid. We went upstairs with normal ABG and no pressors.

The set-up was a beast but thank dog there was a protocol for me to follow. Ours calls for bilateral radial art lines(one for vigileo) and triple lumen CVC (CVP/FMS/drips). Induction is standard (fent/prop/roc). Drips include epi, norepi, dopamine, sufent, nimbex, CaCl, plus/minus bicarb, phenylephrine, mannitol. Drugs that are to be at the ready include CPR meds (atropine, lido, CaCl, pressors, etc.), amicar, cold albumin for flushing the donor liver, solumedrol given while anhepatic, and basiliximab given after reperfusion.

The reason I posted was to see if anyone else who regularly does liver transplants has a set-up they rely upon. I did a search I didn't see anything.

i wonder if by TLC you mean a triple lumen MAC catheter - im not sure what FMS means either, but I agree with this, you need not just access, but RELIABLE access. if your OLT goes south and you are putting blood volumes in every hour, then yes, your bilateral 14g PIVs can handle the volume, but I wouldnt trust them to stay good over time.

we typically use a MAC +/- PAC and a RIC in the AC, bilateral radial art lines and another PIV for platelets. dopamine is a fine pressor/inotrope, not sure about sufenta. if you guys have a fast track pathway that allows you to extubate rapidly, then perhaps its ideal, we allow ours to rest overnight and so we wouldnt benefit much from running sufenta intraoperatively versus fentanyl bolus. same with nimbex.

 

[BobBarker]

FMS=Fecal Management System around here.

 

[sevoflurane]

Best case in anesthesia world... I wish I still did them.

 

[sevoflurane]

Great case for some AC RIC catheters.

Make sure you place a TEE before you unclamp.

My favorite part.

 

[IveGotTwins]

Yes. It was a triple lumen MAC. FMS is fluid management system; just an acronym for Belmont that gets used.

 

[IveGotTwins]

We don't rotate through the transplant ICU so I don't know for sure about a fast-track extubation pathway but the team did discuss extubation within the next 6 hours so it is likely.

 

[lazylikeapanda]

At our university hospital, our set up was a bit of an over kill since our liver transplant numbers weren't high. Our set up would be to double stick the IJ, Cordis + PAC and the second stick to place a 10 Fr cannula for possible veno-veno bypass, though we normally would just hook it up to a Belmont. 1 radial aline, one large bore iv, and a ricc. Also TEE. If the livers went well with minimal fluid/blood products and the field had good hemostasis, we'd extubate on the table. Other times, left them tubed and brought them to the unit still attached to the belmont.

At the private hospital we'd rotate through with significantly higher volumes, the set up routinely was one art line, one peripheral IV, a left subclavin triple lumen, right IJ MAC with PAC. The transplant surgeons routinely did piggy backs and didn't require veno-veno bypass. For the healthier transplants i.e those with PBC or HCC without much liver dysfunction, we dropped a TEE probe and didn't place a PAC.

 

[G0S2]

In residency I liked to double stick IJ with MAC and Edwards oximetric catheter if not floating a PAC. Agree with TEE. In PP just MAC. 5 mins to unclamp give 1amp bicarbonate and 1gm calcium. At unclamp 10mcg epi Great cases. Nice job.

 

[urge]

Why two radial a lines on most protocols?

What's special about livers? Hearts(no circ arrest), neuro, belly cases.... don't usually get two, but livers do? Why is that?

 

[IlDestriero]

In residency I liked to double stick IJ with MAC and Edwards oximetric catheter if not floating a PAC. Agree with TEE. In PP just MAC. 5 mins to unclamp give 1amp bicarbonate and 1gm calcium. At unclamp 10mcg epi Great cases. Nice job.

Starting the epi drip really low and a little epi kiss at unclamp seems to bypass a lot of drama.

 

[MTGas2B]

Why two radial a lines on most protocols?

What's special about livers? Hearts(no circ arrest), neuro, belly cases.... don't usually get two, but livers do? Why is that?

You can draw a gas from one and still see the pressure on the other. And if one craps out you're not scrambling to replace it.

 

[RemyMcswain]

Any good book chapters or review articles on Liver Tx you guys can recommend?

 

[Ignatius J]

No good volume line?

We usually do a double stick double lumen/introducer. Set the introducer up to the Belmont for rapid volume administration when we need volume quickly and use the others as our drips/CVP lines.

Just a single arterial line although I don't see any harm in two.

Also, I have an attending that likes to use THAM.

 

[MTGas2B]

Best case in anesthesia world... I wish I still did them.

Off pump double lung was my favorite. Lines, TEE, epidural, and the threat/challenge of CPB

 

[sevoflurane]

Off pump double lung was my favorite. Lines, TEE, epidural, and the threat/challenge of CPB

I fold.

Can't say I've done one, but I sure wish I had.
They sound pretty cool.

Clamshell incision is gnarly.

We used to have this giant board in the liver room that showed all labs/TEG results in the pre-hepatic, anhepatic and post-hepatic phase. Pretty fun stuff and def. some continuous management. A lot to learn with those cases.

Some of these patients were sick as $hit. I mean, hepatorenal, jaundiced to all get out, encephalopathic, bleeding like stink etc, etc....

The echo was always super cool. Pressors before reperfusing and big sticks of 50-100mcgs at a time as we re-established hepatic circulation and washed out Co2. That little button on the belmont is also pretty fun to use when you need it....

Double lung though... Pretty awesome MTgas2B

 

[Idiopathic]

did three of those as a resident, easily the most work ive done in an OR

 

[dhb]

Off pump double lung was my favorite. Lines, TEE, epidural, and the threat/challenge of CPB

During day time maybe but lungs are always at night.

 

[MTGas2B]

During day time maybe but lungs are always at night.

If you're gonna be awake at night beats an appy or a c-section.

 

[Idiopathic]

During day time maybe but lungs are always at night.

yep, they always started about 1030-11 and finished right as the next shift was coming in around 630

 

[ssmallz]

If you're gonna be awake at night beats an appy or a c-section.

Sure lets do the most challenging case when we're dead tired and need sleep the most....seems reasonable. No thanks, we all know the risks of sleep deprivation on cognitive abilities. Give me a few chip shot appys and c/s's and save the big cases for the morning when I'm actually awake.

 

[sevoflurane]

Some people live for those cases. I remember attendings talking amongst each other:

Dr. X: Hey, Dr. Y, you want me to do that case? It's going to go late.

Dr. Y: No that's alright, I can do it. (as he mentally gives him the finger for asking)

Dr. Z would then make his way into the room as the patient is being brought to the OR: Dr. Y, I'm on liver call today, so I think I'll take it over.

Dr. Y: Nah, that's alright. I already spoke to the family and devloped a plan. Thanks though.

Then, Dr. Y would be like..... This would transpire at 8:45pm



I can relate to that.

 

[MoMoGesiologist]

Any updates to how people are doing their liver transplants? Are people still doing PA catheters and double central lines and two alines? Are people trending CVP or just using TEE? Has TEG changed how much and what you give product-wise? What are people’s recipes for reperfusion? I miss doing these cases from residency so just curious!

 

[Iso4ane]

Any updates to how people are doing their liver transplants? Are people still doing PA catheters and double central lines and two alines? Are people trending CVP or just using TEE? Has TEG changed how much and what you give product-wise? What are people’s recipes for reperfusion? I miss doing these cases from residency so just curious!

MAC line (Swan is nice but probably not necessary if TEE available)
One Arterial Line
TEE
Two IVs at least one being 16G or larger (RIC would be great)
Rapid Infuser

As for blood, start with MTP ratios, playing catch up with FFP and platelets is no fun.

For reperfusion several things I saw.
Premed with lido (1.5mg/kg) sometimes amio too, and stuff to increase inotrophu/HR/BP
Have Calcium, bicarbonate, and epi when the hit comes
If the RV is okay bolus of blood/fluid from the rapid infuser when the clamp comes off.
Low threshold for antifibrinlytics and cryo

 

[deleted126335]

Some people live for those cases. I remember attendings talking amongst each other:

Dr. X: Hey, Dr. Y, you want me to do that case? It's going to go late.

Dr. Y: No that's alright, I can do it. (as he mentally gives him the finger for asking)

Dr. Z would then make his way into the room as the patient is being brought to the OR: Dr. Y, I'm on liver call today, so I think I'll take it over.

Dr. Y: Nah, that's alright. I already spoke to the family and devloped a plan. Thanks though.

Then, Dr. Y would be like..... This would transpire at 8:45pm



I can relate to that.

Outside of young academic attendings it is Dr. Z who is going

 

[DM27]

Our liver setup, with my commentary in parenthesis is usually:

9Fr MAC Introducer (Useful/necessary)
18Fr V-v bypass cannula (Overkill since our bypass usage have dropped significantly, but it's def an amazing volume line)
PA Catheter (imo garbage for the most part)
Single a-line (Radial, Fem, w/e, necessary)
One good peripheral (used for induction)
Rapid infuser (largely necessary)

Reperfusion largely depends on the way ABGs are trending, but everybody gets Calcium chloride 1g or more and some dose of Epi. If the K+ is becoming an issue during the anhepatic portion I will give some degree of insulin + glucose and bicarb. I personally relatively hyperventilate most patients as reperfusion is approaching simply for an additional K+ drop.

 

[dchz]

I did about 40 livers in residency. Never once was it veno-veno bypass. Got to fellowship and see how much time they spend on the cutdown.

Never been so thankful to not do a case a certain way.

 

[DM27]

Veno-veno bypass is an odd thing in terms of who does it and who doesn't, I assume it ultimately stems from where they trained. In residency it was close to never used. Where I did fellowship it was used often. Where I work now it is used maybe 10% of the time and usually for < 30 minutes when it is.

 

[MoMoGesiologist]

Veno-veno bypass is an odd thing in terms of who does it and who doesn't, I assume it ultimately stems from where they trained. In residency it was close to never used. Where I did fellowship it was used often. Where I work now it is used maybe 10% of the time and usually for < 30 minutes when it is.

Do you find it helpful? Can’t you get the patient through with fluids and pressors?

 

[DM27]

Do you find it helpful? Can’t you get the patient through with fluids and pressors?

It is definitely "easier" from our end, but its generally not being done from issues on our management side. We have not had a case where v-v bypass was used due to hemodynamic or transfusion issues reported on the anesthesia end.

It has been used exclusively at the surgeons request. Typically it is when the surgeon is having a lot of trouble (usually during the end of the dissecting phase) being able to adequately visualize structures due to either bleeding, prior surgeries (TIPSS etc), or anatomic variations.

While excessive blood loss can be an indication, typically it is a surgical decision based on concerns or complexity from their end.