*3.2.2. Vasoactive substances and inotropes*

Peripheral nerve stimulation and depth of block can be assessed using single twitch, train of

Other parameters monitored during liver transplantation include the following:

• coagulation parameters via rotational thromboelastometry (ROTEM).

**3.2. Haemodynamic management during the three phases of liver transplantation**

Even if bleeding risk has decreased over time, it still can induce a volemic stress.

Ever since the first successful liver transplantation in 1960, the surgery has been associated with significant bleeding and an increased amount of blood products transfused [28]. Blood products used during liver transplantation have declined significantly in the last 20 years.

Clamping of the inferior vena cava during the second phase (anhepatic) of the liver transplantation leads to an important decrease in preload, CO and arterial pressure which need a quick diagnosis and management. Normal response of right ventricle (RV) and left ventricle (LV) to stress does not take place due to all the substances released from the liver in the

Continuous assessment of patient's volemic status and the amount of perfused fluids represent the key to a successful liver transplantation. This can be done using dynamic measurements of CVP and pulmonary capillary wedge pressure (PCWP), but these parameters do not correlate with changes in CO [29]. Another way of assessing fluid responsiveness is the use of stroke volume variation (SVV) and global end-diastolic volume index (GEDI). Inadequate fluid therapy can lead to pulmonary oedema, abnormal gas exchange, congestion, a decrease

This study does not offer an answer for the ideal monitoring system and guiding of fluid therapy [31]. In our clinic, the guidance of fluid management is done with the pulmonary

Using adequate vasoactive substances, which protect the brain, heart and kidney, led to a greater haemodynamic stability, adequate CO and renal perfusion [31]. The CVP can also be

Specific fluid management during liver transplantation can be described according to the

thermodilution technique and pulse contour wave analysis via the PiCCO system.

correlated with the severity of the post-reperfusion syndrome [32].

four, tetanic stimulation and double burst stimulation.

218 Organ Donation and Transplantation - Current Status and Future Challenges

• hourly diuresis,

• electrolytes,

• haemoglobin and haematocrit,

• base excess and lactate,

*3.2.1. Volemic resuscitation*

anhepatic phase.

three surgical phases:

in perfusion and oedema of the graft [30].

*3.1.5. Other parameters monitored during liver transplantation*

There are a variety of substances that can be used when haemodynamic instability takes place during liver transplantation. Noradrenaline is most often used, followed by adrenaline and dobutamine. Indications are shown in **Table 3**.


One of the most important elements released from the graft is potassium as a result of the portal venous congestion. All these substances can contribute to postoperative ischaemia and reperfusion lesions [45]. Another theory is represented by the pro-inflammatory cytokines (IL 1B, IL 2, IL 8, TNF-α) produced by ischaemia and released during the reperfusion of the graft leading to a marked inflammatory response and cellular death. They also have vasodilation and negative inotropic effect. The amount of pro-inflammatory cytokines released does not

Anesthesia for Liver Transplantation http://dx.doi.org/10.5772/intechopen.75167 221

• donor-related: age, obesity, hypernatraemia (>155 mEq), hepatic steatosis, prolonged in-

• myocardial depression (due to cold solutions released in circulation, abnormal acid base

Studies have shown that patients who had PRS have a higher risk of postoperative renal dys-

• adequate graft perfusion; vasodilators are rarely used (calcium channel blockers,

• give ephedrine bolus 5 min before unclamping of the IVC in order to obtain a MAP of

• liver graft wash with flush fluid of albumin 5% before IVC unclamping,

correlate with the duration of cold ischaemia time (CIT) [46].

Factors that may predict PRS are the following:

• intraoperative factors: duration of the surgery,

• patient's volemic status before reperfusion,

tensive care unit (ICU),

Risk factors include

• a decrease in CO,

status),

• cold ischaemia time exceeding 6 h.

• severity of metabolic acidosis.

function and 15 days of mortality [43].

• a decrease in arterial pressure and SVR,

Therapeutic options include the following:

• adequate haemodynamic management,

• correction of hypocalcaemia and hyperkalaemia,

Postreperfusion syndrome leads to

• a moderate increase in PAP,

• optimizing volemic status,

prostaglandins),

85–100 mmHg [47].

• frequent malignant arrhythmias.

**Table 2.** Fluid therapy decisional tree.

#### *3.2.3. Postreperfusion syndrome*

Liver reperfusion takes place in the neohepatic phase and is the most unstable period during liver transplantation, representing a real challenge for the anaesthetist. The postreperfusion syndrome is defined as a 30% decrease in the mean arterial pressure that lasts for at least a minute and appears in the first 5 min after the unclamping of the inferior vena cava (IVC) [41].

It can have severe consequences due to a decrease in cardiovascular function with haemodynamic instability, abnormal acid base balance and metabolic abnormalities. Haemodynamic instability is the consequence of severe vasodilation, negative inotropic effects and massive bleeding which may appear during surgery. Graft reperfusion can have fatal consequences such as severe arrhythmias or asystole [42].

The incidence of PRS varies between 5.9 and 60% due to different surgical techniques, haemodynamic intraoperative differences and geographic factors (in some countries, the number of reduced donors led to marginal graft use-expanded criteria donors) [43].

Causes of PRS are not yet clear, but there are several theories. Dyselectrolytemia, cold solutions used for graft preservation and severe vasodilation due to NO release may contribute to PRS. Unclamping of the inferior vena cava leads to vasoactive pro-inflammatory substance released from Kupffer cells and which are the result of the postischaemic graft [44].


**Table 3.** Main indications of inotropes during liver transplantation.

One of the most important elements released from the graft is potassium as a result of the portal venous congestion. All these substances can contribute to postoperative ischaemia and reperfusion lesions [45]. Another theory is represented by the pro-inflammatory cytokines (IL 1B, IL 2, IL 8, TNF-α) produced by ischaemia and released during the reperfusion of the graft leading to a marked inflammatory response and cellular death. They also have vasodilation and negative inotropic effect. The amount of pro-inflammatory cytokines released does not correlate with the duration of cold ischaemia time (CIT) [46].

Factors that may predict PRS are the following:


#### Risk factors include

*3.2.3. Postreperfusion syndrome*

**Table 2.** Fluid therapy decisional tree.

**CI < 3 l/min/m2** GEDI <700 ml/m<sup>2</sup>

**CI > 3 l/min/m2** GEDI <700 ml/m<sup>2</sup>

such as severe arrhythmias or asystole [42].

Ephedrine Arterial hypotension

Liver reperfusion takes place in the neohepatic phase and is the most unstable period during liver transplantation, representing a real challenge for the anaesthetist. The postreperfusion syndrome is defined as a 30% decrease in the mean arterial pressure that lasts for at least a minute and appears in the first 5 min after the unclamping of the inferior vena cava (IVC) [41]. It can have severe consequences due to a decrease in cardiovascular function with haemodynamic instability, abnormal acid base balance and metabolic abnormalities. Haemodynamic instability is the consequence of severe vasodilation, negative inotropic effects and massive bleeding which may appear during surgery. Graft reperfusion can have fatal consequences

or ITBI <850 ml/m<sup>2</sup> GEDI >700 ml/m<sup>2</sup>

or ITBI <850 ml/m<sup>2</sup> GEDI >700 ml/m<sup>2</sup>

ELWI <10 ml/m<sup>2</sup> ELWI >10 ml/m<sup>2</sup> ELWI <10 ml/m<sup>2</sup> ELWI >10 ml/m<sup>2</sup> Administer fluids Administer fluids No measure Fluid restriction

ELWI <10 ELWI >10 ELWI <10 ELWI >10

Vasopressor

Administer fluids Administer fluids (limited)

220 Organ Donation and Transplantation - Current Status and Future Challenges

or ITBI >850 ml/m<sup>2</sup>

or ITBI >850 ml/m<sup>2</sup>

Fluid restriction

Vasopressor Vasopressor

5–25 mg i.v. bolus every 10 min

The incidence of PRS varies between 5.9 and 60% due to different surgical techniques, haemodynamic intraoperative differences and geographic factors (in some countries, the number of

Causes of PRS are not yet clear, but there are several theories. Dyselectrolytemia, cold solutions used for graft preservation and severe vasodilation due to NO release may contribute to PRS. Unclamping of the inferior vena cava leads to vasoactive pro-inflammatory substance

released from Kupffer cells and which are the result of the postischaemic graft [44].

reduced donors led to marginal graft use-expanded criteria donors) [43].

Noradrenaline Arterial hypotension 0.2–1 μg/kgc/min Adrenaline Asystole, severe arterial hypotension 0.01–0.5 μg/kgc/min Dobutamine Cardiogenic shock 2.5–10 μg/kgc/min

**Substance Indications Dose**

Before unclamping IVC

**Table 3.** Main indications of inotropes during liver transplantation.


Studies have shown that patients who had PRS have a higher risk of postoperative renal dysfunction and 15 days of mortality [43].

Postreperfusion syndrome leads to


Therapeutic options include the following:

