Perioperative Manage

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<ul><li> 1. Perioperative Management of Liver Transplant Patients January 22, 2007 Geoffrey Schultz, MD </li> <li> 2. Topic Objectives <ul><li>1. Overview of indications &amp; selection for liver transplantation. </li></ul><ul><li>2. Identification &amp; treatment of complications associated with liver disease in the preoperative period. </li></ul><ul><li>3. Identification &amp; treatment of complications following orthotopic liver transplantation. </li></ul><ul><li>4. Induction of immunosuppressive pharmacotherapy following transplantation. </li></ul><ul><li>5. Diagnosis &amp; treatment of graft rejection. </li></ul></li> <li> 3. Orthotopic Liver Transplantation <ul><li>1 st orthotopic liver transplantation 1963. </li></ul><ul><li>Approximately 5,000 orthotopic liver transplantations annually for 17,000 in need. </li></ul></li> <li> 4. Indications for Liver Transplantation in Adults: Etiologies of End-Stage Liver Disease <ul><li>1. Fulminant Hepatic Failure </li></ul><ul><li>2. Alcoholic Liver Disease </li></ul><ul><li>3. Chronic Hepatitis C </li></ul><ul><li>4. Chronic Hepatitis B </li></ul><ul><li>5. Non-alcoholic steatohepatitis </li></ul><ul><li>6. Autoimmune Hepatitis </li></ul><ul><li>7. Primary Biliary Cirrhosis </li></ul><ul><li>8. Primary Sclerosing Cholangitis </li></ul><ul><li>9. Hepatic tumors </li></ul><ul><li>10. Metabolic and genetic disorders </li></ul></li> <li> 5. Indications for Liver Transplantation in Adults <ul><li>Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation </li></ul><ul><li>Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life </li></ul><ul><li>Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one-year patient survival and 70% five-year survival) </li></ul></li> <li> 6. Manifestations of End-Stage Liver Disease <ul><li>Progressive jaundice </li></ul><ul><li>Intractable ascites </li></ul><ul><li>Spontaneous bacterial peritonitis </li></ul><ul><li>Hepatorenal Syndrome </li></ul><ul><li>Encephalopathy </li></ul><ul><li>Variceal bleeding </li></ul><ul><li>Intractable pruritus </li></ul><ul><li>Chronic fatigue (such as resulting in loss of gainful employment) </li></ul><ul><li>Bleeding diathesis or coagulopathy </li></ul></li> <li> 7. Selection Criteria for Organ Allocation <ul><li>United Network for Organ Sharing (UNOS) governing body for organ allocation utilizes MELD score. </li></ul><ul><li>Model for End Stage Liver Disease (MELD) Score </li></ul><ul><li><ul><li>0.957 x loge (creatinine) + 0.378 x loge (bilirubin mg/dL) + 1.12 x loge (INR) + 0.643 x 10 </li></ul></li></ul><ul><li><ul><li>Range from 10 to 40 </li></ul></li></ul><ul><li><ul><li>Special considerations, amendments for HCC, renal failure. </li></ul></li></ul></li> <li> 8. Preoperative management of complications associated with hepatic failure &amp; decompensated cirrhosis <ul><li>Hepatic Encephalopathy </li></ul><ul><li>Cerebral Edema </li></ul><ul><li>Acute Renal Failure </li></ul><ul><li>Infection &amp; Sepsis </li></ul><ul><li>Metabolic Derangements </li></ul><ul><li>Malnutrition </li></ul><ul><li>Coagulopathy </li></ul><ul><li>Portal Hypertension </li></ul></li> <li> 9. Hepatic Encephalopathy <ul><li>Etiology: Attributed to increased serum ammonia levels secondary to metabolism of nitrogenous substances in the gut. </li></ul><ul><li>Symptoms: Range from euphoria to coma. </li></ul><ul><li>Treatment: lactulose, decreased intake of nitrogen containing compounds, oral neomycin. </li></ul></li> <li> 10. Cerebral Edema <ul><li>Etiology: Unknown </li></ul><ul><li>Swelling of brain results in increased ICP &amp; herniation. </li></ul><ul><li>Invasive monitoring with goal of ICP &lt; 20 mmHg &amp; CPP &gt; 50 mmHg. </li></ul><ul><li>Treatment: Anxiolysis, HOB elevation, hyperventilation, avoidance of overhydration, mannitol diuresis, HD if compromised renal function. </li></ul></li> <li> 11. Acute Renal Failure <ul><li>Etiology: Toxin induced, Derangements in systemic &amp; intrarenal hemodynamics. </li></ul><ul><li>Treatment: Prevention of hypotension, treatment of infection, avoidance of nephrotoxic agents. </li></ul><ul><li>Once established, renal failure in this setting is often irreversible. Early utilization of renal replacement therapy is indicated. </li></ul></li> <li> 12. Infection &amp; Sepsis <ul><li>Etiology: Immunologic derangements including complement deficiency, reduced opsonins, WBC dysfunction. </li></ul><ul><li>Treatment: Frequent cultures, including ascites. Broad spectrum antibiotics, including anti-fungals. </li></ul></li> <li> 13. Metabolic Derangements <ul><li>1. Hypokalemia </li></ul><ul><li><ul><li>Increased sympathetic tone promotes cellular uptake of K. Decreased serum K promotes production of ammonia by the kidney. </li></ul></li></ul><ul><li>2. Hyponatremia </li></ul><ul><li>3. Hypoglycemia </li></ul><ul><li><ul><li>Secondary to decreased hepatic glycogen stores &amp; decreased gluconeogenesis. </li></ul></li></ul></li> <li> 14. Coagulopathy <ul><li>Etiology: Compromised synthetic function, deficiency of coagulation factors, platelet dysfunction. </li></ul><ul><li>Contribute to GI bleeding in conjunction with portal hypertension. </li></ul><ul><li>Treatment: Prevention with H2 blockers, PPI. Judicious use of Factor VIIa &amp; FFP. </li></ul></li> <li> 15. </li> <li> 16. Post-operative complications &amp; management of liver transplant patients <ul><li>Right pleural effusion </li></ul><ul><li><ul><li>May affect ventilation, necessitating drainage. </li></ul></li></ul><ul><li>Hepatic edema secondary to aggressive resuscitation &amp; increased intravascular volume. </li></ul><ul><li><ul><li>Goal CVP 6-10. Minimize increased hepatic vein pressures, sinusoidal congestion that impair graft perfusion &amp; exacerbate reperfusion injury. </li></ul></li></ul></li> <li> 17. Post-operative complications &amp; management of liver transplant patients <ul><li>Renal failure </li></ul><ul><li><ul><li>Elevation of creatinine &amp; BUN observed in nearly all transplant patients secondary to ATN, hepatorenal syndrome. Usually self-limiting. May necessitate therapy with loop diuretics, renal replacement therapy. </li></ul></li></ul></li> <li> 18. Post-operative complications &amp; management of liver transplant patients <ul><li>Electrolyte Derangements </li></ul><ul><li><ul><li>Recovering graft increases demand for magnesium &amp; phosphorous. </li></ul></li></ul><ul><li><ul><li>Transfusion of citrate rich blood products results in decreased serum magnesium &amp; calcium. </li></ul></li></ul><ul><li><ul><li>Rapid correction of chronic hyponatremia with isotonic solution can have severe neurological consequence. Judicious use of hypotonic solutions with goal of serum Na 125-130 advised. </li></ul></li></ul></li> <li> 19. Post-operative complications &amp; management of liver transplant patients <ul><li>Thrombocytopenia </li></ul><ul><li><ul><li>Preoperative portal hypertension results in splenomegaly &amp; platelet sequestration. Generally improves as graft recovers. May necessitate replacement if bleeding is encountered or invasive procedures are planned. Splenectomy is rarely indicated. </li></ul></li></ul><ul><li><ul><li>Platelet dysfunction secondary to renal &amp; hepatic failure may be improved acutely with DDAVP. </li></ul></li></ul></li> <li> 20. Post-operative complications &amp; management of liver transplant patients <ul><li>Biliary leak </li></ul><ul><li><ul><li>RUQ pain, fever, persistent elevation of bilirubin, liver enzymes. Biloma on CT. Treated with endoscopic stent, percutaneous drainage. Possible surgical revision if duct is ischemic. </li></ul></li></ul><ul><li>Hepatic artery thrombosis </li></ul><ul><li><ul><li>Persistent elevation or increasing liver enzymes, poor graft function. Diagnosed with U/S, CT angiography, MRA. Treated with immediate revascularization. </li></ul></li></ul></li> <li> 21. Induction of Immunosuppression <ul><li>Triple therapy </li></ul><ul><li><ul><li>Calcineurin inhibitor (tacrolimus, cyclosporine), anti-proliferative agent (mycophenolate), corticosteroid taper. </li></ul></li></ul><ul><li><ul><li>Initiated immediately following transplantation. </li></ul></li></ul><ul><li><ul><li>Levels followed daily in immediate post-operative period &amp; with decreasing frequency once stabilized in desired range. </li></ul></li></ul><ul><li>Agents vary according to etiology of liver disease. </li></ul><ul><li><ul><li>Thymoglobulin &amp; Hb Ig utilized in hepatitis patients along with entecavir &amp; prograf to limit viral replication &amp; to avoid coritocsteroid usage. </li></ul></li></ul></li> <li> 22. Allograft rejection <ul><li>Hyperacute rejection </li></ul><ul><li><ul><li>Secondary to preformed Ab to graft antigen. Extremely rare. Necessitates retransplantation. </li></ul></li></ul><ul><li>Acute Cellular Rejection </li></ul><ul><li><ul><li>70% of patients 5 to 14 days following transplant. </li></ul></li></ul><ul><li><ul><li>Heralded by fever, jaundice, elevation of liver enzymes. </li></ul></li></ul><ul><li><ul><li>Diagnosed by liver biopsy. Demonstrates endothelialitis &amp; non-suppurative cholangitis. </li></ul></li></ul></li> <li> 23. </li> <li> 24. <ul><li>Althaus SJ, Perkins JD, Soltes G, Glickerman D. Use of a Wallstent in successful treatment of IVC obstruction following liver transplantation. Transplantation. 1996 Feb 27;61(4):669-72. </li></ul><ul><li>Kim BW, Won JH, Lee BM, Ko BH, Wang HJ, Kim MW. Intraarterial thrombolytic treatment for hepatic artery thrombosis immediately after living donor liver transplantation. Transplant Proc. 2006 Nov;38(9):3128-31. </li></ul><ul><li>Cotler, Scott J , MD UptoDate Treatment of acute cellular rejection in liver transplantation </li></ul><ul><li>Brown , Robert S., MD, MPH , Dove, Lorna M, MD, MPH UptoDate Patient selection for liver transplantation </li></ul><ul><li>Eric Goldberg, MD , Sanjiv Chopra, MD UptoDate Overview of the treatment of fulminant hepatic failure </li></ul><ul><li>Bussutil RW, Klintmalm GB, Transplantation of the Liver, WB Saunders Company, Philadelphia. 1996 </li></ul><ul><li>Peter J. Friend; Charles J. Imber Transplantation Immunology. Current Status of Liver Transplantation pp. 29 46, MAR 2006 </li></ul><ul><li>http://med.stanford.edu/shs/txp/livertxp </li></ul></li> </ul>