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Transplant Anesthesia Rotation Guide ​

Most recently edited by Dominic Royster DO, July 2023

The primary focus of this month will be liver transplants, with time spent doing kidney transplants and high acuity general cases (i.e. Whipples & HIPECs). Liver transplant recipients have many major physiology derangements within multiple organ systems and the surgery often involves significant blood loss, coagulopathy, and hemodynamic instability. The high acute nature of liver transplants provides incredible insight into massive transfusion protocols, interpreting TEGs, and large bore line placement. You will be 1:1 with your attending for liver transplants and may have a liver transplant fellow that works with you.

Transplant Anesthesiology Attendings ​

  • Adrian Hendrickse MD (Fellowship Director)
  • Seth Aly MD
  • Fareed Azam MD
  • Cara Crouch MD
  • Ana Fernandez-Bustamante MD
  • Naveen Kukreja MD
  • Barbara Wilkey MD
  • Pat Henthorn MD

Rotation Breakdown ​

  • Typically, two residents on rotation sharing 24hr call every other day 7am-7am.
  • Non-call days usually in a high acuity general OR case (i.e. Whipples & HIPECs).
  • Keep your eye on the board and check in with OR charge before you leave for the day - you'll want to know if a transplant is added on later that evening. Typically charge or on-call attending will contact you.

Reading the relevant chapters regarding anesthesia for patients with liver disease and liver transplantation in any of the major anesthesia textbooks (M&M, Barash, Miller, etc) provides a great background and helps you understand the physiologic changes associated with liver disease. Recommend the Liver Transplant section of the Jaffe book to get a very basic idea of the surgical procedure.

If you are hard-pressed for time to read chapters, here are some great review articles:

When You Get Called for a Liver Transplant ​

  1. When the OR desk or on-call attending calls you on nights/weekends for a liver transplant, they will usually give you at least 3-4 hours' notice. Always call the desk again before heading into the hospital, as plans often change. Important information to get: patient name, MR#, donor procurement time (this gives you a better idea of the timeline), whether the attending has been notified.

  2. Before you leave your house, confirm that the case is still scheduled AND if so, go into EPIC or call the pharmacy and order your drips. This is especially important at night and on the weekends as the inpatient pharmacy is not as quick as the OR pharmacy. Have your drips tubed to the OR front desk. Use the guide on the Anesthesia Sharepoint website to figure out which drips to order, forget about antibiotics (low, intermediate or high risk- look at the protocol in the manual)!

Pre-op ​

  • Pre-op Note: Fill out the pre-op note as you normally would, always include TTE information and calculate a MELD (can use MDCalc), determine the risk category for blood products and antibiotics. There is a separate section for transplants on the pre-op note that should be filled out, titled "Transplant". It's fairly self-explanatory.

  • Consent: Usually the attendings like to consent the patient themselves, you can ask them this when you call to discuss the plan. If you do the consent: GA, arterial line, central line (+/- PA catheter), TEE (if planned), and possible post-op ventilation.

  • Pre-med: These patients will get Ativan instead of midazolam if premedication is used. Do not give any premedication until the UNOS time out has occurred in the OR.

  • Blood: The attending will order the initial blood products; you are responsible for confirming that the blood is in the room and checked prior to heading back to the OR. The nurses will usually check it for you, but always double-check that this has been done.

  • Always confirm that everyone is ready prior to heading back to the OR. Typically, you will be ready to roll and will have to wait for a green light from the surgical team (the organ must be confirmed as acceptable prior to heading back).

Intra-op ​

  • Chart: There is a separate macro for Liver transplants, again it should be self-explanatory.

  • Timeout: You will perform a UNOS timeout prior to induction, include this information in the Epic Record (there's a button for this).

  • Induction: RSI, all patients are presumed to have full stomachs. Succinylcholine for intubation, cisatracurium is the preferred drug for NMB maintenance (more rocuronium is now being considered on a case-by-case basis, discuss this with your attending). Do give lidocaine to patients with liver disease!

  • Lines: Discuss with your attending. Arterial line (typically right radial), two large bore PIVs (can convert one to a RIC), central access (usually a triple lumen CVC and/or a Cordis or Mahurkar). If you have not placed a RIC or Cordis before, or if it's been a long time since you last placed a central line, review these with a CA3 or a CA2 who has just finished transplant or cardiac to refresh your memory.

  • Connect your infusions (should all be connected to the manifold) to one of the central line ports, the CVP to another port and then crystalloid (can use the Level One tubing) to the third port.

  • The Belmont is usually connected to the RIC, Cordis or Mahurkar. Use caution when connecting the Belmont or Level One to PIVs, infiltration can occur and compartment syndrome can develop extremely quickly.

Liver Transplant Surgical Phases ​

There are three phases/stages to the surgical procedure, they are very briefly explained below. The guide on the Sharepoint website will go through the anesthetic goals of each stage and any textbook will walk you through the other important aspects of each stage.

1. Preanhepatic Phase (aka Dissection Phase) ​

  • Blood loss is your main concern during dissection. Keeping up with blood loss and maintaining hemodynamic stability are the major goals. Low CVP is preferred (≤5 mmHg if tolerated) to reduce blood loss. Monitor ABGs, usually at least every 30 minutes. Monitor and correct coagulopathy as needed.
  • Phase ends with clamping of the Suprahepatic + Infrahepatic IVC, portal vein, hepatic artery, and removal of liver.

2. Anhepatic Phase ​

  • The stage begins with the applications of multiple vascular clamps: 1) Hepatic artery 2) Portal vein 3) Infrahepatic Vena Cava 4) Suprahepatic Vena Cava. The mobilized liver is removed. Steroids will be given once fully anhepatic (confirm timing with surgeons).
  • Ice-cold liver graft is placed in the field. 3 anastomoses are then completed:
    1. Suprahepatic vena cava
    2. Infrahepatic vena cava
    3. Portal vein - critical for providing flow into the liver
  • Prepare for reperfusion, the surgeons will often give you a 3-5 min warning. Discuss with your attending how to best prepare for reperfusion.

3. Neohepatic Phase ​

  • Monitor for new graft function, avoid hepatic congestion, ensure hemodynamic stability to prepare for case end. Monitor ABGs and correct coagulopathy as needed (discuss continued lab draw timing with your attending).
  • The surgeons will place a Yankauer in the abdomen, pack it and leave for about 30-45min (pay attention to the blood loss during this period). They will come back and re-inspect for any continued bleeding and fix any issues.

Post-op ​

  • Extubation: The goal is to wake up/extubate these patients at the end of the case. If this occurs, they usually go to PACU. It's a good idea to stick around for a little bit to make sure there's no significant bleeding or other issues which would require immediately returning to the OR.

  • Post-op intubation: If the patient has significant unresolved hemodynamic instability or very high blood loss, they may be left intubated and will therefore go to the STICU.

  • It is always a good idea to go see these patients the next morning, not only will it give you feedback for your management but also good to know ahead of time if there are any complications.

  • Remember, if they return to the OR you are returning to the OR!

Live Donor Liver Transplant ​

These cases are a bit different, they will be scheduled and the patients are usually not as sick. Here are a few specifics of these cases but this is a constantly evolving protocol and may change.

Living Donors ​

  • The living donor is managed by an attending (LT2) and an APP
  • These patients are very important - complications in these cases are the type of thing that ends up on the news. It's not the type of media attention you want!

Recipients ​

  • The recipient will be managed by the LT1 attending and the resident.
  • These patients tend to be slightly healthier than patients who are receiving deceased donor organs, as they usually are not sick enough to get on the waitlist for a deceased donor organ.

Coordination between the two surgical and anesthesia teams is very important, communicate with the other room!

Liver Transplant Setup ​

Drugs to have ready at case start ​

  • Bicarb x 1
  • CaCl x 3
  • Epinephrine x 2
  • Phenylephrine x 2
  • Norepinephrine x 1
  • Vasopressin x 1
  • Protamine x 1

Infusions set up on left side of patient (see image - Alaris pumps) ​

  • Epinephrine
  • Norepinephrine
  • Vasopressin
  • Calcium (use 25% - Currently not available at UCH)
  • Albumin

Antibiotics ​

Please call pharmacy (x86132) to order appropriate antibiotics for your patient. Continue antibiotic infusions until surgery end.

Transplant Box (obtain from pyxis) contents ​

  • CaCl 1g (x3)
  • Epinephrine 1mg (x2)
  • Vasopressin 20 units (x1)
  • Phenylephrine 100mcg (x2)
  • Norepinephrine 4mg (x1)
  • DDAVP 20mcg (not always used)

Transplant Emergency Syringes Bag (obtain from pyxis) contents ​

  • Epinephrine 100mcg/mL (x2)
  • Phenylephrine 100mcg/mL (x2)
  • Ephedrine 5mg/mL (x2)
  • Atropine 0.4mg/mL (x2)
  • Glycopyrrolate 0.2mg/mL (x2)
  • Metoprolol 5mg vial (x2)

Equipment to set up in the room ​

  • Belmont (Wet down with 0.9% NS or Albumin)
  • Level 1 (Attending dependent - most prefer Belmont so put outside room)
  • Cell saver (discuss with attending whether to have it set up in the room or available outside the room)
  • Rapid infuser
  • TEE (if planning to place PAC)
  • Defibrillator pads (have pads in the room, discuss with your attending whether or not to put them on prior to case start)
  • HD machine (for patients who will need intraoperative HD, the dialysis RN will set up the machine in the room next to the belmont/next to cell saver). All orders for HD will be placed by your attending.
  • Cooler with ice
  • Lab tubes (pre-filled out blue top tubes, a few purple top tubes and at least 2 light green top tubes)

Lines ​

All patients get an arterial line and at least one central line, sometimes two, discuss which lines to have ready with your attending:

  • RIC (most common line placed)
  • Cordis
  • Arrow MAC
  • Triple lumen
  • Mahurkar
  • PA Catheter

During dissection phase the frequency of further lab draws will vary by case and attending, discuss this with your attending.

*** 15 minutes after reperfusion of the hepatic artery: PT/INR, PTT, Fibrinogen (one blue top tube)*

Definition of Ischemia Times and Operative Variables ​

A timeline of different phases of ischemic injuries for organs procured after cardiac death:

  • Donor warm ischemia time (DWIT) is defined as the interval from withdrawal of life support to initiation of cold organ preservation
  • Graft cold ischemia time (CIT) is defined as the interval from initiation of donor in vivo cold organ preservation to removal of the graft from 4°C cold storage
  • Graft warm ischemia time (WIT) is defined as the interval from removal from cold storage to establishment of reperfusion of the liver graft.

Donor operative variables after withdrawal of life support were:

  • Organ hypoperfusion (OH), defined by a mean arterial pressure lower than 60 mm Hg
  • Tissue hypoxemia (TH), defined by tissue oxygen saturation less than 70%

What the hell is "piggy-back"? ​

A "piggy-back" refers to partial occlusion of the IVC intra-operatively, with an end-to-side anastomosis, instead of insertion of donor IVC.