Arrive
in OT with IV running, usually either Dextrose/Saline or FFP. Remember to
turn operating table if you wish use Image Intensifier for central line
position confirmation.
Pre-oxygenate
then induction - usually using
isoflurane 2.5% in oxygen.
Paralyse
with pancuronium 0.2 mg/kg.
Intubate
(nasal or oral - snug fit), secure ETT, reduce isoflurane to 1 - 1.5% in
oxygen.
Stabilise on ventilator and secure monitoring:
|
Pulse
oximetry |
End-tidal CO2 |
ECG |
| NIBP |
Ventilator disconnect |
May
need to increase IV fluids to compensate for vasodilatation from isoflurane.
Use FFP for volume, and 5% dextrose for maintenance.
Insert
intra-arterial line, preferably in the left radial artery.
Insert
right subclavian (or internal jugular) triple-lumen central venous line.
Insert
left subclavian (or internal jugular) single-lumen central venous line with
4 x 3-way taps.
Insert
large peripheral line for Red Blood Cell transfusions.
Position
bed horizontal.
Remove
NIBP and wrap limbs with insulation wool and bubble plastic.
Stabilise
head and anaesthetic circuit. Place "bat's wings"' screen on
table.
Catheterise
bladder and bring urine bag up near anaesthetist.
Zero
all pressure lines.
Set
gases: usually 40-50% O2 in air and isoflurane 1.5% with PEEP of 5 cm.H2O
Send
off blood specimens (FBC, electrolytes, ABG's, coagulation screen) and
repeat hourly.
Give
bolus of fentanyl ( 2-5 µg/kg) and establish fentanyl infusion at about 1-2
µg/(kg.h).
Commence
dopamine infusion as necessary, usually about 5 µg/(kg.h).
Give
antibiotics - usually ceftriaxone 50 mg/kg and gentamicin 3 mg/kg.
Give
immunosuppressants - methyl
prednisolone 20 mg/kg and azathioprine 2 mg/kg
Commence
prostaglandin E1 infusion 50 µg/kg in 50 ml at 2.0 ml/h (about 2.0 µg/(kg.h).
DO NOT MIX WITH 5% DEXTROSE.
Adjust
FFP and RBC infusions to maintain satisfactory BP and CVP (10-20 cm.H2O).
Filter
blood through 40 micron filter and wash banked blood via "cell
saver" if possible.
An
FFP/RBC ratio of about it 2:1 usually maintains haematocrit at about 0.3.
Give
platelets if count < 50. Infuse through left central line.
Give
calcium chloride 10 % boluses (about 20 mg/kg) through a central line as
required.
Treat
any low potassium with K+ infusion via central line at about 0.5 mmol/(kg.h)
& adjust. (Hypokalaemia often occurs after new liver starts to work but
can be due to preoperative diuretics, etc. and often needs treatment
earlier. May be exacerbated by uptake of K+ by washed red cells, and by an
osmotic diuresis from hyperglycaemia.)
Treat
hyperglycaemia with insulin infusion of 50 units regular (soluble) insulin
in 50 ml saline. Only treat if blood glucose greater than 13-15 mmol/l and
rising. Start with 1-2 unit/h. When blood and FFP replacements slow at end,
be prepared to stop insulin.
Before
cold donor liver is put into abdominal cavity, try to get core temperature
to 38 ºC. The cold liver will drop body temperature and it is difficult to
increase temperature without a metabolising liver.
Adjust
gas flows to maintain normal pCO2 and keep pO2 at 200-250 mg.Hg. When
anhepatic, CO2 production will drop and gas flows will need to be reduced.
Before
new liver revascularised;
Give
methyl prednisolone 20 mg/kg and azathioprine 1 mg/kg (dose depends on
WCC)
Raise
CVP to 20 cm.H2O, with isoflurane on 2 %.
Change
to 100 % O2.
Prepare
full packs of FFP and RBC under pressure, ready for rapid infusion.
Give
bolus of CaCl2.
As soon as vascular clamps are released on new liver,
Turn
off isoflurane.
Open
pressure infusions of FFP and RBC. Be prepared to infuse rapidly.
Give
bolus of CaCl2 if indicated.
May
need to increase dopamine to 10-15 µg/(kg.min).
After
5-10 min, circulation should be stabilised, and isoflurane may be restarted
& the infusions reduced.
When
liver perfusion and circulation are satisfactory, return to air/O2 mixture.
Anticipate
rise in blood glucose from new liver glycogen and rapid infusion of FFP.
Potassium
may fall as new liver starts to work.
During
closure of the abdomen, watch CVP and respiratory pressures. Pressures may
rise too high indicating need for abdominal patch and delayed closure.
AT
conclusion, keep anaesthetised but change to 100 % O2 with isoflurane.
Change oral to nasal tube if necessary.
Turn
off isoflurane and watch CVP, as it may steadily rise. May need to venesect
blood from patient to maintain CVP around 15 cm.H2O. Hydralazine, a GTN
patch, or midazolam may be useful.
Remove
K+ infusion. Transport to ICU on IPPV with 100 % O2.
Homepage:- https://gasline.tripod.com/
Posted:- 01 Aug 2002
Source: Datuk Dr. Radhakrishna,
Probably obtained around May 2002.