What intraoperative anesthetic problems occur during liver transplantation?

In the future, might liver transplantation become a viable option for this patient? what intraoperative anesthetic problems occur during liver trans-plantation?

Liver transplantation is viewed as a viable treatment option for patients with ESLD. Although this patient does not presently have ESLD, she may well do in a few years or even less. Liver transplantation is no longer experimental. With the advance of excellent immunosuppressive drugs, overall graft survival rates now exceed 80%. Life expectancy and quality are greatly improved in recipients of liver transplants.

Numerous anesthetic problems should be anticipated in conjunction with liver transplantation. The spectrum of patients presenting for transplantation is wide, ranging from the seemingly healthy to those with acute fulminant hepatic failure. The myriad and complex medical problems accompanying liver disease, as discussed above, require treatment prior to and during transplantation. However, once a liver becomes available, postponing surgery to correct medical conditions prolongs graft ischemic time and increases the risk of graft failure.

Transfusion requirements of this operation vary widely, and usually require additional personnel for the manage-ment of transfused blood products. The median number of packed red blood cell (PRBC) units transfused varies between 10 and 20 per transplant. The average value is higher because some patients had extremely large transfu-sion requirements (>150 units PRBC). Coagulation abnor-malities seen during this operation are numerous and complex. Preoperatively, patients usually are deficient in both coagulation factors and platelets. Development of intraoperative dilutional coagulopathies exacerbates this problem. During the anhepatic phase, citrate toxicity is commonly seen and must be promptly treated. Additionally, fibrinolysis begins and peaks immediately on reperfusion of the donor graft. Severe hemodynamic changes usually occur on reperfusion and, if prolonged, are called the reperfusion syndrome. With prompt recognition and treatment, hematologic and hemodynamic changes are generally remediable.