**2. Anesthetic management of the living donors**

In order to permit successful transplantation of the liver, it is necessary to provide excellent conditions for the donor while preserving optimal hemodynamic parameters (Pickett et al, 1994; Lutz et al, 2003). However anesthetists may face severe hemodynamic instability, which is frequently seen in donors especially during the harvesting period when organs are removed (Pickett et al, 1994). Hemodynamic stability can be achieved by maintaining sufficient organ perfusion, adequate cardiac output, avoiding excessive bleeding, keeping hematocrit at about 30% and preventing coagulopathies (Lutz et al, 2003).

Invasive monitoring is obligatory to ensure sufficient organ perfusion and cardiac output, because of the major hemodynamic, hematologic and metabolic disturbances associated with hemorrhages and electrolyte imbalances that may be seen especially in right hepatectomy procedures (Lutz et al, 2003). During the operation, a central venous pressure (CVP) below 5 cm H20 is suggested in many liver transplantation protocols to decrease blood loss and graft edema. Chen et al. found a correlation between CVP and blood loss during resection of liver; however, Chhibber et al. reported no significant decrease in blood loss in patients with low CVP (Chen et al, 2000; Chhibber et al, 2007). Balci et al. has recommended an acute intraoperative normovolemic hemodilution technique and fluid restriction in a group of live donors (Balci et al, 2008).

The type of the intravenous solutions are also important in liver transplantation as well as their amount. Although there is no definitive data about a detrimental effect, 0.9% saline is known to be associated with hypercloremic metabolic acidosis. The Ringer's lactate solution is contraindicated because lactate metabolism will be disrupted as the liver is resected, furthermore serum lactate levels increase after resection. Plasmalyte may be an alternative being devoid of lactate, however there is no clear data that it is superior to other crystalloids. Despite the absence of definitive data about adverse outcome, since hydroxyethyl starch solutions are known to effect the coagulation system, they should be used with caution. 5% albumin can be used after hepatectomy, but it has also no proven benefit (Hwang and McCluskey, 2010).

Preventing major life threatening bleeding during transsection of liver requires extraordinary attention by the surgical team. Preparation of autologous blood and hemodilution in operating room may prevent transfusion complications (Merritt et al, 2004).

Anesthetic management of living donors is maintained with general anesthesia. Commonly used anesthetic agents such as modern inhalational anesthetics, sufentanil, fentanyl, remifentanil, propofol, cis-atracurium and vecuronium have no adverse effects on liver functions. In live donor hepatectomies, Rabie et al. investigated the effects of propofol or isoflurane, both of which were similar in terms of perioperative hemodynamics, blood loss, duration of surgery and hospital stay (Rabie et al, 2006).

Appropriate antibiotic prophylaxis (at least 20 minutes before skin incision) including a third-generation cephalosporin and metronidazol covering anaerobic infections, in addition to venous thromboembolism prophylaxis including subcutaneous heparin or low-molecular weight heparin with pneumatic compression stockings should be administered. Prior to donor graft perfusion 1000-5000 IU intravenous heparin is administered and its reversal is often not needed (Hwang and McCluskey, 2010).

Considering the rapid recovery from anesthesia and difficulties in pain control, general anesthesia combined with epidural anesthesia seems to be effective; a mid thoracic epidural application may be the best form of pain relief during early postoperative period. However, despite the data that epidural analgesia seems to be safe in spite of postoperative coagulation disorders in hepatectomy operations (Choi et al. 2007), it has been discouraged because of postoperative unpredictable coagulation profile and epidural hematoma risk of

sufficient organ perfusion, adequate cardiac output, avoiding excessive bleeding, keeping

Invasive monitoring is obligatory to ensure sufficient organ perfusion and cardiac output, because of the major hemodynamic, hematologic and metabolic disturbances associated with hemorrhages and electrolyte imbalances that may be seen especially in right hepatectomy procedures (Lutz et al, 2003). During the operation, a central venous pressure (CVP) below 5 cm H20 is suggested in many liver transplantation protocols to decrease blood loss and graft edema. Chen et al. found a correlation between CVP and blood loss during resection of liver; however, Chhibber et al. reported no significant decrease in blood loss in patients with low CVP (Chen et al, 2000; Chhibber et al, 2007). Balci et al. has recommended an acute intraoperative normovolemic hemodilution technique and fluid

The type of the intravenous solutions are also important in liver transplantation as well as their amount. Although there is no definitive data about a detrimental effect, 0.9% saline is known to be associated with hypercloremic metabolic acidosis. The Ringer's lactate solution is contraindicated because lactate metabolism will be disrupted as the liver is resected, furthermore serum lactate levels increase after resection. Plasmalyte may be an alternative being devoid of lactate, however there is no clear data that it is superior to other crystalloids. Despite the absence of definitive data about adverse outcome, since hydroxyethyl starch solutions are known to effect the coagulation system, they should be used with caution. 5% albumin can be used after hepatectomy, but it has also no proven benefit (Hwang and

Preventing major life threatening bleeding during transsection of liver requires extraordinary attention by the surgical team. Preparation of autologous blood and hemodilution in operating room may prevent transfusion complications (Merritt et al, 2004). Anesthetic management of living donors is maintained with general anesthesia. Commonly used anesthetic agents such as modern inhalational anesthetics, sufentanil, fentanyl, remifentanil, propofol, cis-atracurium and vecuronium have no adverse effects on liver functions. In live donor hepatectomies, Rabie et al. investigated the effects of propofol or isoflurane, both of which were similar in terms of perioperative hemodynamics, blood loss,

Appropriate antibiotic prophylaxis (at least 20 minutes before skin incision) including a third-generation cephalosporin and metronidazol covering anaerobic infections, in addition to venous thromboembolism prophylaxis including subcutaneous heparin or low-molecular weight heparin with pneumatic compression stockings should be administered. Prior to donor graft perfusion 1000-5000 IU intravenous heparin is administered and its reversal is

Considering the rapid recovery from anesthesia and difficulties in pain control, general anesthesia combined with epidural anesthesia seems to be effective; a mid thoracic epidural application may be the best form of pain relief during early postoperative period. However, despite the data that epidural analgesia seems to be safe in spite of postoperative coagulation disorders in hepatectomy operations (Choi et al. 2007), it has been discouraged because of postoperative unpredictable coagulation profile and epidural hematoma risk of

hematocrit at about 30% and preventing coagulopathies (Lutz et al, 2003).

restriction in a group of live donors (Balci et al, 2008).

duration of surgery and hospital stay (Rabie et al, 2006).

often not needed (Hwang and McCluskey, 2010).

McCluskey, 2010).

living donors (Stamenkovic et al, 2011). On the other hand, since the kinetics of intravenous analgesics and opioids after liver resection have not been clarified yet, extra attention is required for the usage of these agents. Hwang and McCluskey reported that intravenous patient-controlled analgesia or intrathecal morphine may become an alternative for pain control in living donors. Regional techniques such as paraspinal blocks, transversus abdominus plane blocks, incisional field blocks are still investigated for their effect and safety in these patients (Hwang and McCluskey, 2010).
