**4. Anesthesia for non-transplant surgery in liver-transplanted patients**

Liver transplant recipients may return to the operating room for reexploration, which is frequently for biliary reconstruction. In these cases, liver usually functions normally, leading

**Impaired liver function tests:** Within the first 48-72 hours, inadequate perfusion of the graft, venous congestion and edema may lead to functional impairment. However, in the following period coagulopathy improves, whereas aminotransferase, alkalene phosphatase

**Malnutrition:** The patients with end-stage liver disease are often malnourished and have depleted protein stores. Following transplantation protein catabolism occurs, leading to a negative nitrogen balance within a month. This protein catabolism results in an increase in

**The primary non-functioning of donor graft:** The increase in the levels of liver enzymes within 1 week after transplantation refers to acute cellular rejection, which requires biopsy for the definitive diagnosis. Retransplantation is necessary before the other organs are

**Sepsis:** Most of the patients are transfered back to the ICU because of sepsis, following their discharge from ICU. Selective intestine decontamination may limit bacterial infections,

**Others:** Bile leak, thrombosis of hepatic artery and portal vein may be major complications during this period. Moreover, hyperglycemia, renal insufficiency and neurologic

Obesity (30-40%), hyperlipidemia (30%), diabetes (13-30%), osteoporosis and malignancy

• Prolonged mechanical ventilation

• Impaired Liver Function Tests

• The primary non-functioning of donor graft

urinary 3-methylhistidine levels, revealing this catabolism originates from muscle.

however non-bacterial organisms contribute to a major problem.

impairments may also occur, as side-seffects of immunsuppressive therapy.

may occur due to the long-term immunsuppressive therapy (Lopez et al, 2006).

• Bleeding • Hypertension

• Sepsis • Others

• Obesity

• Diabetes • Osteoporosis • Malignancy

**4. Anesthesia for non-transplant surgery in liver-transplanted patients** 

Liver transplant recipients may return to the operating room for reexploration, which is frequently for biliary reconstruction. In these cases, liver usually functions normally, leading

Table 4. Postoperative Adverse Events after liver transplantation

• Hypothermia

• Malnutrition

• Hyperlipidemia

and bilirubin levels start to decrease.

**3.8.2 Late complications (Table 4)** 

**Early Complications** 

**Late Complications** 

affected.

to anesthetic considerations including regional techniques such as epidural catheters similar to any abdominal procedure (Baker et al, 2005). The liver grafts that are functioning appropriately can metabolize the drugs effectively, however this functioning should be assessed. Coagulation abnormalities should be treated with vitamin K or FFP, ascites with diuretics or paracenthesis and encephalopathy should be avoided with lactulose administration and careful use of sedatives; these may improve outcome in these patients. Renal functions should also be assessed, moreover hypertension may be a common problem in these patients. Stress dose of corticosteroids may be required for patients who receive chronic supplementation. Because of the powerful immunsuppressive therapy, steril conditions should be optimized for the placements of venous and epidural catheters. Drugs that may decrease hepatic blood flow should be avoided (Steadman, 2004).

#### **5. References**


Biancofiore G, Critchley LAH, Lee A, Bindi L, Bisà M, Esposito M, Meacci L, Mozzo R,

Brown BR, Frink EJ. (1993)Anesthesia considerations in patients with liver disease.

BurtenshawAJ, Isaac JL. (2006) The role of trans-oesophageal echocardiography for

Chen CL, Chen YS, de Villa VH, Wang CC, Lin CL, Goto S, Wang SH, Cheng YF, Huang TL,

Chibber A, Dziak J, Kolano J, Norton JR, Lustik S. (2007) Anesthesia care for adult live donor

Choi SJ, Gwak MS, Ko JS, Kim GS, Ahn HJ, Yang M, Hahm TS, Lee SM, Kim MH, Joh JW.

Costa MG, Della Rocca G, Chiarandini P, Mattelig S, Pompei L, Barriga MS, Reynolds T,

Dawwas MF, Lewsey JD, Watson CJ, Gimson AE. (2005) The impact of serum potassium

De Boer MT, Molenaar IQ, Hendriks HGD, Slooff MJ, Porte RJ. (2005) Minimizing blood loss

Della Rocca G, Costa MG, Chiarandini P, Bertossi G, Lugano M, Pompei L, Coccia C, Sainz-

liver surgery. *Br J Anesth* 2009; 102:47–54. ISSN: 0007-0912.

*Anesthesiol Rev* 1993; 20 (6):213-220. ISSN: 0093-4437

use? *J Am Coll Surg* 1998; 186:683-690. ISSN: 1072-7515

ISSN: 1527-6465 (Print) ISSN: 1527-6473 (Electronic)

54-8 ISSN: 1527-6465 (Print) ISSN: 1527-6473 (Electronic)

22:265-75. ISSN: 0253-4886 (Print) ISSN:1421-9883 (Electronic)

2008; 22:681–687. ISSN: 1053-0770 (Print) 1532-8422 (Electronic).

ISSN: 0041-1345

(Electronic)

1527-6473 (Electronic)

DeSimone P, Urbani L, Filipponi F. (2009) Evaluation of an uncalibrated arterial pulse contour cardiac output monitoring system in cirrhotic patients undergoing

perioperative cardiovascular monitoring during orthotopic liver transplantation.*Liver Transpl* 2006; 12:1577–1583. ISSN: 1527-6473 (Electronic). Chari RS, Gan TJ, Robertson KM, Bass K, Camargo CA Jr, Greig PD, Clavien PA. (1998)

Venovenous bypass in adult orthotopic liver transplantation: routine or relective

Jawan B, Cheung HK. (2000) Minimal blood loss living donor hepatectomy. *Transplantation*. 2000 27; 69:2580-6. ISSN: 0041-1337. Electronic ISSN: 1534-0608. Chen JP, Jawan B, Chen CL, Wang CH, Cheng KW, Wang CC, Concejero AM, Villagomeza

E, Huang CJ. Comparison of postoperative morphine requirements in healthy living liver donors, patients with hepatocellular carcinoma undergoing partial hepatectomy, and liver transplant recipients.*Transplant Proc*. 2010 Apr; 42 (3):701-2.

hepatectomy: our experiences with 100 cases. *Liver Transpl.* 2007 ; 13:537-42. ISSN:

(2007) The changes in coagulation profile and epidural catheter safety for living liver donors: a report on 6 years of our experience. *Liver Transpl*. 2007 ; 13:62-70.

Cecconi M, Pietropaoli P. (2008) Continuous and intermittent cardiac output measurement in hyperdynamic conditions: pulmonary artery catheter vs lithium dilution technique. *Int Care Med* 2008; 34:257–263. ISSN: 1525-1489 (Electronic) Davis CL, Gonwa TA, Wilkinson AH. (2009) Identification of patients best suited for

combined liver-kidney transplantation. Part II *Liver Transpl* 2004; 10 (10 Supll 2) S

concentration on mortality after liver transplantation: a cohort multicenter study. *Transplantation* 2009; 88:402–410. ISSN: 0041-1337 (Print) ISSN: 1534-0608

in liver transplantation: progress through research and techniques.*Dig Surg* 2005;

Barriga M, Pietropaoli P. (2008) Arterial pulse cardiac output agreement with thermodilution in patients in hyperdynamic conditions. *J Cardiothor Vasc Anesth*


Henriksen JH, Bendtsen F, Sorensen TIA, Stadeager C, Ring-Larsen H (1989). Reduced

Homvises B, Sirivatanauksorn Y, Limsrichamrern S, Pongraweewan O, Sujirattanawimol K,

Jullien T, Valtier B, Hongnat Jm Dubourg O, Bourdarias JP, Jardin F (1995). Incidence of

Kim SH, Cho SY, Lee KW, Park SJ, Han SS (2009). Upper midline incision for living donor right hepatectomy. *Liver Transpl* 2009; 15: 193-8 ISSN: 1527-6473 (Electronic). Kim WR, Biggins SW, Kremers WK, Wiesner RH, Kamath PS, Benson JT, Edwards E,

transplant waiting list. *N Engl J Med* 2008; 359:1018–1026. ISSN: 0028-4793 Krowka MJ, Plevak DJ, Findlay JY, Rosen CB, Wiesner RH, Krom RA (2000). Pulmonary

Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, Bridges CR,

Lee EM, Kang JK, Yun SC, Kim KH, Kim SJ, Hwang KS, Lee SG (2009). Risk factors for

Liu H, Gaskari SA, Lee SS (2006). Cardiac and vascular changes in cirrhosis:pathogenic mechanisms. World J Gastroenterol 2006; 12:837–842 ISSN 1007-9327 Lopez PM, Martin P. Update on liver transplantation: indications, organ allocation, and long-term care. Mt Sinai J Med. 2006 Dec; 73 (8):1056-66. ISSN: 0027-2507 (Print) Lukanovic NP (2008). Hot topics in liver anesthesia. *Transplant Proc*. 2008; 40 (4):1187-9.

Lukin C, Hein HAT, Swygert TH, Gunning TC, Valek TR, Donica SK, Nelson RB 3rd,

Lutz JT, Valentín-Gamazo C, Görlinger K, Malagó M, Peters J (2003). Blood-transfusion

Ramsay MA. (1995) Duration of vecuronium induced neuromuscular blockade as a predictor of liver allograft dysfunction. *Anesthesia Analgesia* 1995; 80 (3):526-533.

requirements and blood salvage in donors undergoing right hepatectomy for living related liver transplantation. *Anesth Analg*. 2003; 96 (2):351-5. ISSN: 0003-2999.

ISSN: 1087-2418 (Print) ISSN: 1531-7013 (Electronic)

6 ISSN: 0012-3692 (Print); ISSN: 1931-3543 (Electronic).

2000; 6:443-50. ISSN: 1527-6473 (Electronic).

5085

(Electronic)

9913 (Electronic)

ISSN: 0041-1345

ISSN: 0003-2999

central blood volume in cirrhosis. *Gastroenterology* 1989; 97:1506–1513. ISSN: 0016-

Raksakietisak M (2008) The minimal flush volume for washout of preservation fluid in liver transplantation. *Transplant Proc* 2008; 40:2123–2126 ISSN: 0041-1345 Hwang GS, McCluskey SA. (2010) Anesthesia and outcome after partial hepatectomy for

adult-to-adult donor transplantation. *Curr Opin Organ Transplant* 2010; 15; 377-382

Tricuspit regurgitation and venacaval backward flow in mechanical ventilated patients. A color Doppler and contrast echocardiographic study. *Chest* 1995; 9: 301-

Therneau TM (2008). Hyponatremia and mortality among patients on the liver-

hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation. *Liver Transpl*.

Haan CK, Svedjeholm R, Taegtmeyer H, Shemin RJ; Society of Thoracic Surgeons Blood Glucose Guideline Task Force. (2009) The Society of Thoracic Surgeons practice guideline series: blood glucose management during adult cardiac surgery. *Ann Thorac Surg* 2009; 87:663–669. ISSN: 0003-4975 (Print) ISSN: 1552-6259

central pontine and extrapontine myelinolysis following orthotopic liver transplantation. *Eur Neurol* 2009; 62:362–368. ISSN: 0014-3022 (Print) ISSN: 1421-


Nasraway SA, Klein RD, Spanier TB (1995). Hemodynamic correlates of outcome in patients

Niemann CU, Eilers H. (2010) Abdominal organ transplantation. *Minerva Anesthesiol* 2010;

O'Connor CJ, Roozeboom D, Brown R, Tuman KJ. (2000) Pulmonary thromboembolism

Ozier Y, Klinck JR. (2008) Anesthetic management of hepatic transplantation*. Curr Opin Anesthesiol* 2008 21: 391-400 ISSN: 0952-7907 (Print). ISSN: 1473-6500 (Electronic) Park GR, Evans TN, Hutchins J, Borissov B, Gunning KE, Klinck JR (2000). Reducing the

Peterfreund RA, Allain RM (2003). *Liver Transplantation*. In: Yao&Artusio's Anesthesiology

Pickett JA, Wheeldon D, Oduro A (1994). Multi-organ transplantations: donor management.

Puhl G, Schaser KD, Pust D, Köhler K, Vollmar B, Menger MD, Neuhaus P, Settmacher U.

Pvalizza EG, Raber MK, Ozaki CF, Lappin JA, Wood RP. (2001) Heparin effect after hepatic

Rabie M, Negmi H, Hammad Y, Al Oufi H, Khalaf H (2006). Living donor hepatectomy

Ramsay MA (2000). Perioperative mortality in patients with portopulmonary hypertension

Ramsay MAE, Swygert TG (1992). Anaesthesia for hepatic trauma, hepatic resection and

Ramsay MAE, Randall HB, Burton E. (2004) Intravascular thrombosis and

Reddy K, Mallett S, Peachey T. (2005) Venovenous bypass in orthotopic liver

Rossaint R, Slama K, Jaeger M, Konrad M, Pappert D, Bechstein W, Blumhardt G, Neuhaus

transplantation.*Transplant Proc*.1990; 22:1533–4. ISSN: 0041-1345.

76: 266-275 ISSN: 0375-9393 (Print) ISSN:1827-1596 (Electronic)

ISSN: 0265-0215 (Print) ISSN: 1365-2346 (Electronic)

Williams & Wilkins, ISBN 0-7817-3641-2, USA

*J Anesthesiol.* 2006 ; 18:743-56. ISSN: 0544-0440.

(Print) ISSN: 1527-6473 (Electronic)

*Curr Op Anaesthesiol* 1994; 7:80-83. ISSN: 0952-7907

1931-3543 (Electronic)

ISSN: 1526-7598 (Electronic)

1527-6465 (Print).

0003-2999

0950-3501

(electronic): 1527-6473.

undergoing orthotopic liver transplantation. Evidence for early postoperative myocardial depression. *Chest* 1995; 107:218–224. ISSN: 0012-3692 (Print); ISSN:

during liver transplantation: possible association with antifibrinolytic drugs and novel treatment options. *Anesth Analg* 2000; 91:296–299. ISSN: 0003-2999 (Print);

demand for admission to intensive care after major abdominal surgery by a change in anaesthetic practice and the use of remifentanil. *Eur J Anaesthesiol* 2000; 17: 111-9

problem-oriented patient management. 5th ed., Yao FSF. pp 485-509, Lippincott

Initial hepatic microcirculation correlates with early graft function in human liver transplantation, Liver Transpl 2005, 11:555–563. ISSN (electronic): 1527-6473. ISSN:

artery anastomosis during liver transplantation. *Anesth Analg* 2001; 93:798-804.ISSN

(LDH)--comparative study between two different anesthetic techniques. *Middle East* 

undergoing liver transplantation. *Liver Transpl*. 2000 ; 6:451-2. ISSN: 1527-6465

liver transplantation. *Bailliere's Clinical Anaesthesiology* 1992; 6 (4):863-894. ISSN:

thromboembolism during liver transplantation: antifibrinolytic therapy implicated. *Liver Transpl* 2004; 10:310–314. ISSN:1527-6465 (Print). ISSN: 1527-6473 (Electronic).

transplantation: Time for a Rethink? *Liver Transplantation* 2005; 11 (7):741-749. ISSN

P, Falke KJ. (1990) Fluid restriction and early extubation for successful liver


to serum sodium. *Transplantation* 1989; 48 (6):1006-12. ISSN: 0041-1337 (Print) ISSN: 1534-0608 (Electronic)

