Liver Transplant

[coccygodynia]

Well - I almost got to do a liver transplant this afternoon ... right up until the s*it hit the fan. The man was a 54 yo with cryptogenic cirrhosis, hx of DVT and PE(was on coumadin), EF of 50%. Probably had around 2-3 liters in his abdomen. Got a short arm cordis, LIJ cordis/Swan, RIJ perfusion cath, Lfem 16g catheter and an a-line ... all meticulously deaired. PA's 20's/10's and CVP around 10. Of course, his CI was 4.0.

Induced with STP/SCh, easy intubation, Iso on. About 30 min after induction, his BP went from 93 to 43 within a matter of seconds. Gave 100mcg of epi, neo wide open, and he was already getting plenty of volume (blood, FFP) through the rapid infuser. His ETCO2 didn't change (32-33), sat stayed >97% and HR was sinus tach in the 110's. Both cuff and A-line correlated and within about 1 minute from the drop, he started having ventricular ectopy. CXR showed no PTX, Swan was in good position. His pressure finally came up within about 3 minutes (seemed like a lot longer) to the low 90's. PA's are now in the low 50's and CVP about 18. My attending refloated the swan and we got a 2D echo - all it showed was ascites ... no PFO.

So the transplant surgeon decides to cancel ... now he's in the unit tubed with a propofol gtt because of the 10mg of pavulon we gave after induction. What do you all think might have happened? I won't be back until next week, but I'll be calling to check in. Would love to hear your thoughts!

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[chicamedica]

Well - I almost got to do a liver transplant this afternoon ... right up until the s*it hit the fan. The man was a 54 yo with cryptogenic cirrhosis, hx of DVT and PE(was on coumadin), EF of 50%. Probably had around 2-3 liters in his abdomen. Got a short arm cordis, LIJ cordis/Swan, RIJ perfusion cath, Lfem 16g catheter and an a-line ... all meticulously deaired. PA's 20's/10's and CVP around 10. Of course, his CI was 4.0.

Induced with STP/SCh, easy intubation, Iso on. About 30 min after induction, his BP went from 93 to 43 within a matter of seconds. Gave 100mcg of epi, neo wide open, and he was already getting plenty of volume (blood, FFP) through the rapid infuser. His ETCO2 didn't change (32-33), sat stayed >97% and HR was sinus tach in the 110's. Both cuff and A-line correlated and within about 1 minute from the drop, he started having ventricular ectopy. CXR showed no PTX, Swan was in good position. His pressure finally came up within about 3 minutes (seemed like a lot longer) to the low 90's. PA's are now in the low 50's and CVP about 18. My attending refloated the swan and we got a 2D echo - all it showed was ascites ... no PFO.

So the transplant surgeon decides to cancel ... now he's in the unit tubed with a propofol gtt because of the 10mg of pavulon we gave after induction. What do you all think might have happened? I won't be back until next week, but I'll be calling to check in. Would love to hear your thoughts!

Well, I know it's probably protocol to abort surgeries after an intraop code resuscitation (happened to one of the patients I was following on my CCM rotation). However, i had the opportunity to help out on a liver transplant on the anesthesia side a couple days ago, and before the new liver was in place and completely perfused, two residents and an attending were scrambling to keep the patient stable, expecting her to crash at any second. After the reperfusion, the patient got considerably more stable, still needed some blood once in a while, but it was like 2 completely different cases!

If the OP's patient recovered stability, my uneducated, unexperienced guess (as an MS4) is that the patient might possibily have been better off had they gone ahead and transplanted the liver. The patient remains just as sick as before (if not sicker), the new liver went to waste, and such an event might happen again the next time, especially since it's not known why this happened.

 

[militarymd]

Sounds like anaphylasis vs anaphylactoid reaction.....

Blood
Hespan
ffp

all of which can cause this problem.

 

[SleepyTime]

test. I apologize for the test.

 

[Noyac]

Besides the anaphyalxis, other thoughts are Cardiac Tamponade (what's PFO, anybody, I hate abreviations). Did echo show any pericardial fluid? Equal pressures in all chambers?

I agree with Chica. He's worse off now. I think he might have had to be dead for me to cancel.

 

[coccygodynia]

Besides the anaphyalxis, other thoughts are Cardiac Tamponade (what's PFO, anybody, I hate abreviations). Did echo show any pericardial fluid? Equal pressures in all chambers?

I agree with Chica. He's worse off now. I think he might have had to be dead for me to cancel.

We wanted to go on ... the transplant surgeon had the opposite opinion. No pericardial fluid, no equalization of pressures. PFO - patent foramen ovale (a thought with the lack of pulm signs and major CV signs).

 

[militarymd]

Any follow up on this patient?