Anaesthetic Management

in
Anesthesia Mx of LDLT Donor

Dr. Gaurav Goyal

Professor Anesthesiology
MGMCH, Jaipur
INTRODUCTION
• The disparity between organ demand and the cadaveric
supply for liver transplant initiated other feasible methods of
donor liver procourement techniques.

• LDLT emerged as the only innovation to significantly expand

the scarce donor pool.
We are going to discuss about :
 LDLT Advantages:
(1) Tx performed on an elective basis before serious decompensation.

(2) Grafts are in excellent condition.

(3) Complications due to preservation injury are absent.

(4) Recipients who might otherwise not be eligible for DDLT, chance still
exists.

• Drawback : Potential risk of mortality or serious complications to the

donor.
Live Donor for Liver Lobectomy
• Endorse the ‘living organ donation’ philosophy.

• Apprehension, anxiety and fear of painful surgical experience could

limit a patient’s willingness to proceed with such a life-altering
decision.

• Therefore, providing more optimal and uninterrupted multimodal

perioperative pain management remains important when considering
LDLT surgery.
 Live Donor Liver Lobectomy
• Challenging surgical procedure.
• Significantly different than liver resections.

• To avoid congestion, Intrahepatic bridging veins

draining segments 5 and 8 MHV have to be preserved.
• Ensure optimal perfusion of both lobes at all times.
• A well thought out collaborative surgical approach.

Intraoperative blood cell salvage, prevention of injury,

hypothermia coagulopathy and metabolic derangements are core issues.
LDLT Anesthesia Mx.Goals
• Short duration anesthesia. • Avoid exposure to allogeneic
blood products.
• Early post operative recovery.
• Short LOS in hospital.
• Good perioperative analgesia.
• Post surgery Quality of Life.
• Avoid Post operative complications. (Alopecia , Ala pressure)

• Maintaning Normothermia.
Pre anesthesia check up
• Rapport building meeting
• To gain confidence/ Anxiety

 Education/ASSURANCE
 Ensure pain free pleasant experience
 Video of other donors

 ASA Gr. 1 Donor Young , Female(Wife/Sister)

 No comorbidity
 Good metabolic equivalants
5 STEP LDLT Donor Evaluation and Matching Grid
Step1 Clinical evaluation:history and physical examination

Lab tests:CBC, LFT, RFT, PTTK,PT/INR,

Blood group cross match
Serology: hepatitis A, B, C; HIV, CMV, HSV, EBV

First informed consent

Step 2 Imaging studies: ‘all-in-one’ CT scan

Calculation GRWR
First psychological evaluation
optimization if required.
Step 3 Special studies: ECG, chest X-ray, PFT, echocardiography, stress test (TSH, T3, T4), and
urine r/m

Step 4 Second psychological evaluation (donor and recipient)

Histology: liver biopsy
Board Meeting to chalk out plan of Sx,
Step 5 Anesthesiological consultation

Ethics board evaluation

Final informed consent
 Donor Vol. Matching Evaluation

• This not only guarantee enough graft volume to the recipient but mainly to
assure enough residual liver volume to the donor.

•  Graft volume body weight ratio (GVBWR) of 0.8% BW or 40% of the recipient's
standard liver volume.

• Kyoto group correlation: GVBWR of <0.8%: Complication & graft loss.

• Residual liver volume and the donor's weight ratio = 0.8% (40% total liver
vol.)
Calculation of Liver Volume : Lee’s formula:
• Consisted of standard liver volume (SLV) and portal vein diameters.
• SLV calculation (Urata’s formula) to determine the whole liver weight.
• Rt. Hemiliver volume (RHLV) = SLV × [R2/(R2 + L2)]
• Left Hemiliver volume (LHLV) = SLV × [L2/(R2+ L2)]
• where(R) is maximal right portal vein diameter and (L) is maximal left portal
vein diameter.

• Lee’s formula can also be used in two adult split liver transplants to
determine the weight of each graft and subsequently the graft-to-recipient
weight ratio (GRWR)
• SLV= -706.2 x BSA (m2)+ 2.4 (Urata et al Hepatology 1995: 21: 1317-21)
Anaesthetic management for liver transplant
include
• Standard monitoring (ASA) protocols: Five lead ECG.
• Pulse oximetry, Non-invasive Blood Pressure and Temperature.
• Large-bore peripheral cannula (used for blood transfusion if required).
• Placement of TEA catheter.
• Induction of anesthesia with intubation.
• Central venous access : (CVP) monitoring and vasopressor infusion.
• Invasive arterial blood pressure measurement & PPV.
• RT / Ur. Cath. / VTE Prophylaxis/ Pressure point care.
Analgesia Mx.
• Thoracic Epidural at T9 • Induction: Propofol/ fentanyl/
• Tip to be placed near T6-T7 Midazolam/ Atracurium.
• Ropivacaine 2% with 2mcg/ ml • Cuffed Oral ETT
Fentanyl 6 ml/hr after test dose • RT Avoid pressure necrosis
• MMA : • Atracurium infusion
• PCM 1g+ MgSo4 2g + Dexona • O2 : Air : Isoflurane
8mg • FGF :1.5-1.8L/min
• IV analgesics 4-6 hrly • TV/RR/ MV to maintain EtCo2
35 ±5 mmhg
Intra Operative Management
• Gastric Aspiration • Vasopressor: Phenylephrine
• Normothermia • Vasodilator : NTG
• DVT Prophylaxis • Mephentermine
• Pressure point Mx • Radial Ar.: PPV
• Covering • Blood Salvage
• EYE CARE • Anti oxidants NAC/ Mannitol
• Change Head position • ABG x 3 : Baseline , Post
every 90 min dissection and Pre extubation
INCISION
Surgical steps : four main steps:
Right Pedicle dissection and (Chg 1 for confirming duct anatomy)

Parenchymal transaction including bile rt.duct isolation (Chg 2 for

deciding duct isolation point)

Refilling, heparinization : clamping and graft extraction.

Secure cut end of heaptic vein to IVC, portal vein hepatic artery and
hepatic duct followed by Chg 3 and then wound closure.
surgical steps
Surical Steps:
• The right hepatic artery is identified in course behind the CBD.
(It was approached from right to minimize devascularization of duct)

• Rt. hepatic artery was carried till the branch to segment IV.
• Rt. hepatic artery was planned to divide distal to it.

• Primary source of portal flow to segment IV originated on the right,

dissection was carried only to this branch.

• Portal vein was exposed by transaction of the parenchyma and the hilar
plate (unroofing of the portal vein)
Anaesthesia Plan According to stage of Sx:
Phase 1 Phase 2
• Pedical Dissection Phase • Parenchymal Dissection Phase
• Avoid giving intravenous volume. • N acetyl cystine
• Keep CVP less then 2 mmHg. • Vasopressor
• Maintain perfusion pressure. • W/F CVP and MAP
• Avoid hepatic ischemia. • Compression over IVC
• W/F Urine Output • Pressure over Axilla
• ABG at the end of dissection
phase.
 Phase 3 Phase 4
• Refilling and Graft Removal • Hemostasis and Closure
• Crystalloid Solution • Convert Atracurium infusion to
• Non lactate balanced salt solution. bolous doses .
• Fluid deficit / Loss • Repair of cut end of hepatic
• CVP/ SVV artery, portal vein and duct.
• Lactate • Chg 3 to confirm no leak/
stricture and obstruction to Lf.
• Turgidity of liver margin H.duct.
• Urine output • Convert to TIVA
• 2000ml
• Prepare for extubation
Controversies of Donor hepatectomy Mx
FLUID MANAGEMENT ERAS PROTOCOL

TO CHASE CVP / SVV USE OF NAC/ MANITOL/

ALBUMIN
USE OF EPIDURAL
USE OF MAGNESIUM
Correction of Lactic acidosis in LDLT DMx

Manipulation → ↓ hepatic blood flow → ↑ lactate levels

• Negative effects of NaHC03 :
• Worsening of intracellular acidosis
• Excessive sodium loading
• Acute shifts in oxygen delivery due to influence of OHD curve.
• Acidosis-induced “hibernation” state at the cellular level.

Proponents of bicarbonate therapy: Positive effects such as

improved diaphragmatic and myocardial function .
• Because of potential worsening of hepatic functions, we corrected
metabolic acidosis in initial stages and propose aggressively
correcting metabolic derangement.
Perioperative Fluid Management in LDLT-D
• Non lactated acetate based crytalloid solution (PLASMALYE, PHYSIOMAX)
• colloid solutions Tetra starch had no definitive advantage

• 0.9% NS : Hyperchloremic metabolic acidosis

• NS compared to RL :↑ metabolic acidosis

• Avoid lactate containing crystalloid solutions to minimize lactate load.

• Albumin has been shown to modulate cellular apoptosis and decrease

neutrophil activation, and complications associated with its use are rare.

• 5% Albumin solution ↑ plasma oncotic pressure

• This large-scale multicenter
retrospective study found that
the intraoperative use of HES did
not increase the overall incidence
of post-OLT AKI in patients when
compared with GEL, and whether
to increase the risk of post-OLT
AKI needs to be further explored.
• Lactate free balanced crystalloid
solutions.
• Albumin 5% when indicated.
• 20% Albumin : fluid retention
• The low CVP technique can still be
effective for reducing blood loss
during hepatectomy.
• However, it may not be advantageous
regarding the safety of healthy donors
undergoing hepatectomy. Therefore,
to reduce blood loss during donor
hepatectomy, we propose an
alternative fluid management
technique using a high stroke volume
variation method.
• For the type of fluid, the use of a non-
lactate-containing crystalloid solution
is advisable during donor
hepatectomy.
• Colloid administration has no
definitive advantage.
• Turk J Anaesthesiol Reanim
2018; 46: 28-37

• Role of Ketamine as compliment

to analgesia management.
• Implementation of multimodal
analgesia to manage
perioperative pain in living liver
donation resulted in a 50%
reduction of postoperative
opioid consumption.

• Clinically satisfactory average

pain scores were maintained for
PODs 0 to 4.
• Myth :Postoperative
coagulopathy is more
prevalent.

• Truth :
hypercoagulability is
more observed in POC
test : TEG
Anesthesia-Related Complications

Intra operative Post operative

• Vasovagal episode during epidural • Metabolic Derangements
• Postoperative hoarseness/ sore Th. • Postoperative mucous plug
• PDPH during epidural placement • Respiratory distress requiring
• Hypertension in PACU reintubation in PACU
• Low back pain/ shoulder blade pain • Transient p/o blurry vision
• Pneumothorax of CVC placement • Postoperative paraesthesia
• Pressure Alopecia • Brachial Plexus injury between
• Altered hepatic & renal dysfunction the first rib and clavicle as the
result of surgical retraction of the
rib cage
Review of Literature:
• Complications, however, do occur and proper monitoring and timely
treatment are mandatory.
• With further experience and prospective studies, it is anticipated that
these patients undergo liver donor lobectomy in a physiologic
condition with minimal complications.
FAST TRACKING
• BIS : Minimal anesthesia drugs to maintain plane of anesthesia
• NM Monitoring : Minimal muscle relaxant required for adequate MR.
• SVV / HPI : Adequate volume replacement.
• Inhalational Agents : Converted to Propofol infusion for last phase.
• No. NITROUS OXIDE
• Adequate Pain relief.

• DEXMED/ PROPOFOL INFUSION

• DRUG METABOLISM CHANGES AFTER LIVER DISSSECTION
• DELAY IN RECOVERY FROM ANESTHESIA
ERAS Protocol in Donor Liver Tx Sx.
• Preop councelling
• Prehabilitation
• Fasting
• Preanesthesia medication
• DVT Prophylaxis
• Skin Prep and A/B
• MMA Analgesia
• Early Ambulation
• Post Sx Physiotherapy
• Early Return to daily routine
RECENT ADVANCES
• Laproscopic Donor Hepatectomy
• Robotic Donor Hepatectomy
• ABO Incompitable Liver Donor
Our Experience @mgmch :45 Live Liver
donor Transplant

• Female :67% : (Wife 43%, followed by son 20% )

• Avg. age of donors : 34.25 yrs.
• Blood loss 496± 106 ml. Blood transfusion: None
• Avg. Remnant Liver Vol : 37.6%
• Duration Of Surgery : Induction to Extubation time : 9hrs 48 min.
• Complication : Minor self resolving :4 Alopecia, Ala necrosia, pain, Ache
• Significant : 1 Each: RUL Paresis, Bl. C/s +
• Ready to discharge avg. Days : 6
Thank you !