Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewSplanchnic and systemic circulation cross talks: Implications for hemodynamic management of liver transplant recipients.
The interaction between splanchnic and systemic circulation has many hemodynamic and renal consequences during liver transplant. In a patient with liver cirrhosis, splanchnic vasodilatation causes arterial steal from the systemic circulation into the splanchnic bed, which decreases the effective blood volume. ⋯ Two approaches of volume therapy have been mentioned to maintain hemodynamic stability during liver transplantation: splanchnic volume reduction by volume restriction with or without phlebotomy to maintain low central venous pressure (CVP), and splanchnic decongestion using splanchnic vasoconstrictors. After reperfusion, an increase in the central blood volume was thought to have a deleterious effect on the new graft function; however, the precise central venous pressure value that causes hepatic congestion after reperfusion is unknown.
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Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewAcute kidney injury: A critical care perspective for orthotopic liver transplantation.
Acute kidney injury (AKI) is associated with high perioperative mortality in patients undergoing liver transplantation (LT). In the era of Model of End-stage Liver Disease score-based allocation, more patients with impaired renal function are receiving LT. The majority of preoperative AKI is secondary to azotemia, including hepatorenal syndrome - a progressive form of renal impairment unique to liver failure. ⋯ Given that, the healthcare providers must develop an expertise in liver failure-related renal complications, specifically their management and perioperative implications. Notably, AKI may complicate intraoperative course, exacerbating hemodynamic instability, metabolic acidosis, and electrolyte and coagulation abnormalities. Adjunctive intraoperative continuous renal replacement therapy has been employed; however, prospective studies remain necessary to validate potential benefits.
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Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewEconomic considerations in abdominal transplantation.
Care for end-stage organ failure through transplant is one of the landmark accomplishments of the modern medicine. At the same time, organ transplant is a resource-intensive service that has been under increasing scrutiny in this era of cost containment. A detailed understanding of the economic implications of organ quality, recipient characteristics, and allocation policy is vital for the transplant professionals. ⋯ Liver transplantation economics are also more challenging because of organ allocation based on the severity of illness. Furthermore, the broader use of marginal organs has been demonstrated to increase costs. Novel strategies are vital to reduce the financial burden faced by the centers that perform transplantations on elevated risk patients and utilize lower quality organs.
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Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewPerioperative management of antithrombotic treatment.
End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. ⋯ Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.
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Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewLiver transplantation for acute-on-chronic liver failure.
Acute-on-chronic liver failure (AoCLF) represents a newly defined entity in patients with liver disease leading to multiple organ failures and increased mortality. To date, no universally accepted definition exists, and different academic societies developed guidelines on the early diagnosis and classification of AoCLF. ⋯ No specific therapies are demonstrated to improve survival, and liver transplantation (LT) remains the only treatment associated with improved outcome. Our review focuses on current evidence for early diagnosis and prognostication of disease in patients with AoCLF, as well of criteria for intensive care unit admission, indication, and futility markers of LT, as well as bridging therapy and optimal timing of surgery.