Perioperative Care for Liver Transplantation: A Review

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I am quite honored to be editing the third volume of International Anesthesiology Clinics on the topic of liver transplantation. The first 2 were published in 2006,1 with significant clinical expertise and input from foreign centers. For this volume, I have invited Dr A. Pustavoitau, a faculty intensivist and anesthesiologist at the Johns Hopkins Hospital, to share in the selection and editing process.
After extensive animal research, the first human liver transplant was performed in 1963. At that time, roughly 15,000 people between 5 and 60 years of age were dying of liver-related illness annually in the United States, 90% from cirrhosis.2 It was an experimental surgical procedure through the 1970s: the recipients were profoundly ill—1-year survival did not occur until 1967—and by the mid-1970s, the 1-year survival had improved to only around 25%. Techniques were in development; merely getting out of the operating room was a demanding effort for both surgeons and anesthesiologists, not to mention the significant preoperative and postoperative issues. By 1981, after considerable debate, guidelines were improved for the declaration of death, and thus the potential for organ donation both cardiopulmonary death and brain death.3
Even with revised criteria for the declaration of death and more available organs, immunosuppression was inadequate. With the approval of cyclosporine in 1983, a new era for transplantation began to emerge and major advances in immunosuppression have continued. Recipient selection has continued to improve, intraoperative management of hemodynamics and hypocoagulability/hypercoagulability progressed, and pretransplant and posttransplant ICU care has advanced. Still, today, roughly 20 patients per day in the United States die awaiting a transplant organ.
By 1988, 13.6% (n=713) of transplants in the United States were of the liver; 23.5% (n=7127) in 2015. These numbers reflect the enormous growth in transplantation.4 By 1984, UNOS (United Network for Organ Sharing) was incorporated to support the efforts of transplantation professionals, and the OPTN (Organ Procurement and Transplantation Network) was formed to manage the efficient use of deceased organs with equitable and timely sharing, as well as the collection and analysis of data for patients and programs. These regulatory organizations have continued to evolve with the needs and realities of transplant care.
From January 1, 1988, through August 31, 2016, 129,488 patients have had a liver transplant in the United States. Despite phenomenal advances, most, if not all, early management concerns remain potential problems. Continued improvement in the understanding of hemodynamics, coagulation, multiorgan failure/dysfunction, donor and recipient selection, and immunosuppression remain ongoing issues, as do advances in surgical techniques.
In this monograph, prominent transplant perioperative physicians will review continuing and nagging peritransplantation problems. Although many of these issues and questions in liver transplantation have remained the center of focus, the management and the answers are changing. In this volume, issues of special importance to anesthesiologists and intensivists are addressed.
Drs Della Rocca and Chiarandini thoughtfully review the problems we face in acquiring real-time and accurate hemodynamic data. We need to understand the advantages and disadvantages of our monitoring options. This is an evolving area—there is really not 1 answer, but an integration of options.
There have been changes and improvements over the last decade or so in the way in which donor organs are matched to recipients. This allocation system has protocols that involve geographic considerations, redistricting, and acknowledged exceptions. Candidate selection is also a complex process involving staging of liver dysfunction, psychiatric and behavioral issues, cardiac function, comorbidities, and contraindications. These are reviewed by Drs Cameron and Jackson.
Assessing the complicated coagulation system in cirrhotics is challenging. Pathologic thrombus, excessive bleeding, and hyperfibrinolysis can all be noted in liver disease, and not just during the transplant surgical procedure.
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