Hemodynamic Optimization Strategies in Anesthesia Care for Liver Transplantation

Abstract

In this chapter, aspects of hemodynamic regulation in the end-stage liver disease (ESLD) patient, factors, contributing to the hemodynamic profile, coagulation-related problems, blood products transfusion tactics and problems, and hemodynamic optimization strategies during different stages of liver transplantation procedure-specifically what, when, and how to correct, with special attention to vasoactive agents use, will be discussed.

Nonischemic Cardiomyopathy in Liver Transplant Recipients

“…The clinical manifestations of cirrhosis-related myocardial dysfunction are becoming evident during liver transplantation surgery, when the hemodynamics are affected by numerous factors that include blood loss and fluid shifts with substantial third space formation, mechanical ventilation, large vessel clamping (specifically portal vein and IVC), and effects of anesthesia. In severe cases, heart failure manifests in significant reduction in the cardiac output [66,67]. The problem is that, considering the baseline abnormally increased CO (up to 10-12 L/min), a gradual decrease to 4-5 L/min may not be immediately perceived as such and interpreted as a sign of ongoing myocardial decompensation.…”

“…Patients with preexisting cardiomyopathy, mostly impaired left ventricular function, express a limited ability to generate an adequate CO. These patients, too, may benefit from the ameliorative effect of the preload, associated with VVB, throughout the whole of liver transplant surgery, but particularly during anhepatic and postreperfusion stages [67].…”

“…Different drug combinations have been tested and recommended for rapid hemodynamic recovery after liver graft reperfusion. Vasopressin in small boluses, 1-2 U, may be highly efficient in opposing the significant and rapid decrease of SVR, and calcium chloride, up to 1000 mg, may enhance inotropic effects of epinephrine [67,80]. Methylene blue, 2 mg/kg, has been reported as very efficient and "last resort" drug for prolong and profound hypotension, refractory to treatment with other vasoactive drugs [81].…”