Liver Anesthesiology and Critical Care Medicine, 1st Edition

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To Laurie, Ben, and Anna, who allow me to
enjoy life and work, and to my parents,
who contributed so much to what I am.
Foreword

Liver transplantation has made remarkable progress in the 48 years since the
first human liver transplant, and especially in the last 30 years since the intro-
duction of cyclosporine made long-term survival after liver transplantation
feasible.
A procedure that was initially untested and experimental became routine
and is now the accepted treatment for end-stage liver disease in many parts of
the world. About 6,000 liver transplants are done in the USA every year, and
graft and patient survival is excellent. We are able to administer transplants to
children, do living related and split liver transplants, and only the shortage of
organs limits the expansion of our field.
This progress is not only due to advances in immunosuppression, surgical
techniques or organ preservation, but also to improvements in anesthetic
techniques. Anesthesia care initially provided by few experts in a small num-
ber of centers proliferated and is now often standardized and protocolized.
Advances in anesthesiology enabled the development of surgical techniques
such as caval cross-clamp or partial liver transplantation. There are few pro-
cedures in which the close cooperation of surgeon and anesthesiologist is as
essential for the success of the surgery and liver (transplant) surgery would
have never flourished as it did without the teamwork and partnership between
anesthesiologists and surgeons.
Within the last 20 years there has been tremendous progress in clinical
research of liver transplant anesthesia that aims to reduce blood transfusions,
augment organ preservation, and improve overall outcome. Anesthesia for
liver surgery has made a similar astounding progress and now extensive
resections are conceivable that would have been impossible before.
Postoperative critical care medicine as a continuation of the intraoperative
care is now frequently in the hands of anesthesiologists and intensivists spe-
cialized in hepatic intensive care, reflecting the increasing knowledge in this
field.
This book aims to summarize the progress in liver anesthesiology and
critical care medicine of the last 20 years and serves as a guide to those who
care for patients undergoing liver transplantation and liver resections. The
authors are the leaders in the field of liver anesthesiology and critical care in
Europe, Asia, and the United States. The foundation of this book is the

vii
viii Foreword

increasing fund of knowledge gained through clinical research as well as

through the extensive clinical experience of the authors that they share with
the readers.
This textbook provides the necessary background to understand the com-
plexity of the liver and its pathophysiology. It summarizes the elaborate logis-
tics involved in donor and recipient matching in Europe and the United States
and then describes the routine intraoperative management of liver transplant
recipients and patients undergoing hepatic resections. It addresses common
comorbidities and complications and how they may affect the preoperative
work-up and intraoperative management. The postoperative critical care sec-
tion describes the routine care after liver transplantation and resection as well
as diagnosis and management of possible complications including pain
management.
This book aims to summarize our current knowledge of liver anesthesiol-
ogy and critical care. It will serve as a reference for those who routinely care
for patients with liver disease. Those new to our exciting field will gain
sufficient knowledge to successfully address many of the complex issues that
may arise during liver anesthesiology and critical care medicine. To those
who have extensive experience in the care of patients undergoing liver (trans-
plant) surgery this book will serve as an authoritative reference and enable an
in-depth immersion into the exciting field of hepatic anesthesiology and criti-
cal care medicine.

Pittsburgh, PA, USA Thomas E. Starz M.D., PH.D.

Preface

Liver transplantation and liver surgery have made enormous strides in the last
20 years. It has been transformed from an often heroic operation requiring
massive amounts of blood transfusions to almost routine surgery with little
blood loss in spite of increasing recipient morbidity. This advancement is
reflected in improved long-term mortality rates in the face of preferentially
allocating more marginal organs to sicker recipients.
Many little steps and advances are responsible for this achievement, not
least improvements of anesthetic techniques and postoperative care. These
little steps may not be immediately obvious but were necessary to accomplish
such a progress. Clinical and preclinical research in liver anesthesiology and
critical care medicine in the last 10 years has thrived, and a new generation of
anesthesiologists and intensive care physicians are willing to scrutinize their
clinical practice using clinical research tools instead of relying only on expe-
rience. This has created a fascinating and productive interaction within the
small group of anesthesiologists and intensivists who care for these severely
sick patients.
This book summarizes their current knowledge by bringing together the
leading experts of our sub-specialty. It not only condenses a large amount of
clinical research but also includes opinions and experiences when evidence is
insufficient.
It is an in-depth review of the field and presents the current best knowl-
edge. It aims to be the definitive resource of liver anesthesiology and critical
care medicine. Experienced and busy practitioners will find essential infor-
mation to manage complex conditions of liver disease. The novice anesthesi-
ologist or resident will be able to use this book as a thorough and comprehensive
introduction to our field and rapidly gain extensive knowledge as well as
obtain practical advice for those complex and scary situations that can occur
so frequently during liver transplantation.
This book provides a comprehensive review of the pathophysiology of liver
disease, pharmacology, immunology, and its implications for the anesthesiol-
ogist and intensivist. Anesthesiologic and postoperative care of liver trans-
plant recipients requires a thorough appreciation of the intricacies of liver
disease and its complications. Extra-hepatic manifestations of liver disease
are addressed in chapters separated by organ systems. Routine management as

ix
x Preface

well as common intra- and postoperative complications are described in detail

to provide the knowledge required to care for these patients.
Liver transplantation is expanding internationally and a large body of work
and experience originates from centers in Europe and Asia. Experts from the
United States, Europe, and Asia have contributed to this book to give a global
perspective of liver transplant anesthesiology.
A separate section reviews the anesthetic and postoperative management
of patients undergoing liver resection. New surgical approaches have
allowed us to perform more extensive and intricate resections that pose new
challenges to the anesthesiologist and intensivists. Surgical techniques and
their physiologic repercussions are described in detail and management
strategies for routine as well as complex cases and their possible complica-
tions are offered.
We hope this book will alleviate the apprehension often associated with
caring for these sick patients and encourage many readers to engage in liver
anesthesiology and critical care medicine.

New York, NY, USA Gebhard Wagener, M.D.

Acknowledgements

I sincerely thank the authors of this book for their excellent contributions.
They have spent many hours of diligent and hard work creating delightful,
intelligent, and insightful chapters that were a pleasure to read and edit.
I would also like thank their families for the time the authors missed with
them while writing these chapters.
This book would not have been possible without the encouragement,
support, and advice of my chair, Dr. Margaret Wood, and all my colleagues
and friends at Columbia University Medical Center. I am immensely grateful
for this.
I would further like to thank my initial editor, Brian Belval, who helped
me start this project, Shelley Reinhardt, my editor from Springer
Science+Business Media, and Daniel Dominguez, the developmental editor,
who have been indefatigable and immensely patient with me. Thank you.
I further thank Moury Minhaz, my research assistant, who has helped me
with the secretarial and editorial work. A special thank you to Serena and
Sharon Mathew, who have done a wonderful job creating some of the illustra-
tions in this book.
I am sincerely grateful to my colleagues, residents, and nurses that I have
had the pleasure to work with for many years now and to my patients, who
taught me so much about disease, life, and death.

xi
Contents

Part I Physiology, Pathophysiology and Pharmacology

of Liver Disease

1 Physiology and Anatomy of the Liver . . . . . . . . . . . . . . . . . . . . . . 3

Teresa A. Mulaikal and Jean C. Emond
2 Acute Hepatic Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Andrew Slack, Navjoyt Ladher, and Julia Wendon
3 Drug Metabolism in Liver Failure . . . . . . . . . . . . . . . . . . . . . . . . 43
Simon W. Lam
4 Evaluation of Liver Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
D. Robert Dufour and Nazia Qazi

Part II Anesthesiology for Liver Transplantation

5 History of Liver Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . 61

J.R. Klinck
6 Recipient and Donor Selection and Transplant
Logistics—The European Perspective . . . . . . . . . . . . . . . . . . . . . 67
Gabriela A. Berlakovich and Gerd R. Silberhumer
7 Recipient and Donor Selection and Transplant Logistics:
The US Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Ingo Klein and Claus U. Niemann
8 Surgical Techniques in Liver Transplantation . . . . . . . . . . . . . . 83
Abdulelah M. Alhawsawi and Juan del Rio Martin
9 Intraoperative Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Claus-Georg Krenn
10 Practice Patterns of Liver Transplant Anesthesiology . . . . . . . 111
Ann Walia and Roman Schumann

xiii
xiv Contents

11 Caval Cross-Clamping, Piggyback,

and Veno-Venous Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Ruairi Moulding and Paul Picton
12 Liver Transplantation: Hemodynamic Changes,
Cardiac Output Monitoring and Inotropic Support . . . . . . . . 139
Anand D. Padmakumar and Mark C. Bellamy
13 Coagulopathy: Pathophysiology, Evaluation,
and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Matthew R. Kappus and Arun J. Sanyal
14 Physiology, Prevention, and Treatment
of Blood Loss During Liver Transplantation . . . . . . . . . . . . . . 169
Freeha Arshad, Ton Lisman, and Robert J. Porte
15 The Marginal Liver Donor and Organ
Preservation Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Coney Bae, Scot D. Henry, Giridhar Vedula,
and James V. Guarrera
16 Pediatric Liver Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . 195
Philipp J. Houck
17 Combined Solid Organ Transplantation
Involving the Liver. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Geraldine Diaz
18 Liver Transplantation for the Patient
with High MELD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Cynthia Wang and Randolph Steadman
19 Perioperative Considerations for Transplantation
in Acute Liver Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Christopher P. Snowden and David M. Cressey
20 Renal Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Lloyd Meeks and Joseph Meltzer
21 The Patient with Severe Comorbidities:
Cardiac Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Shahriar Shayan and Andre M. De Wolf
22 Pulmonary Complications of Liver Disease. . . . . . . . . . . . . . . . 255
Mercedes Susan Mandell and Masahiko Taniguchi
23 Liver Transplantation: The Patient with Severe
Co-morbidities, CNS Disease and Increased
Intracranial Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Chris Willars and Georg Auzinger
Contents xv

Part III Anesthesiology for Liver Surgery

24 Hepatobiliary Surgery: Indications, Evaluation,

and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Milan Kinkhabwala and Marcelo Vivanco
25 Liver Resection Surgery: Anesthetic Management,
Monitoring, Fluids, and Electrolytes . . . . . . . . . . . . . . . . . . . . . 299
Jean Mantz and Catherine Paugam-Burtz
26 Anesthetic Aspects of Living Donor Hepatectomy . . . . . . . . . . 313
Navraj Kahlon and Tricia Brentjens
27 Complications of Liver Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 323
Oliver Panzer and Jennifer Sandadi
28 The Patient with Liver Disease for
Non-hepatic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Katherine Palmieri and Robert N. Sladen

Part IV Critical Care Medicine for Liver Transplantation

29 Routine Postoperative Care After Liver

Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Jonathan Hastie and Vivek K. Moitra
30 Immunosuppression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Amit Gera and Kosh Agarwal
31 Acute Kidney Injury After Liver Transplantation . . . . . . . . . . 383
Raymond M. Planinsic, Tetsuro Sakai,
and Ibtesam A. Hilmi
32 Early Graft Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Srinath Chinnakotla and James F. Trotter
33 Sepsis and Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Fuat Hakan Saner
34 Respiratory Failure and ARDS . . . . . . . . . . . . . . . . . . . . . . . . . 405
James Y. Findlay and Mark T. Keegan
35 Pain Management in Liver Transplantation . . . . . . . . . . . . . . . 417
Paul Weyker, Christopher Webb, and Leena Mathew

Part V Critical Care Medicine for Liver Surgery

36 Postoperative Care of Living Donor

for Liver Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Subramanian Sathishkumar and Tadahiro Uemura
xvi Contents

37 Liver Surgery: Early Complications—Liver Failure,

Bile Leak, and Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Albert C.Y. Chan and Sheung Tat Fan

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Contributors

Kosh Agarwal, BMed Sci, MD, FRCP Institute of Liver Studies, King’s
College Hospital, London, UK
Abdulelah M. Alhawsawi Faculty of Medicine and Allied Sciences, Department
of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Freeha Arshad, MD Department of Hepato-Pancreato-Biliary Surgery and
Liver Transplantation, University Medical Center Groningen, Groningen,
The Netherlands
Georg Auzinger, EDIC Liver Intensive Care Unit, King’s College Hospital,
London, UK
Coney Bae, BS Division of Abdominal Organ Transplantation and Molecular
Therapies and Organ Preservation Research Laboratory, Department of
Surgery, Columbia University Medical Center, New York, NY, USA
Mark C. Bellamy, MA, MB BS, FRCA St. James’s University Hospital,
Leeds Teaching Hospitals NHS Trust, Leeds, UK
Gabriela A. Berlakovich, MD, FEBS Department of Surgery, Division of
Transplantation, Medical University Vienna, Vienna, Austria
Tricia Brentjens, MD Department of Anesthesiology, Columbia University
Medical Center, New York, NY, USA
Albert C. Y. Chan, MBBS Department of Surgery, The University of Hong
Kong, Queen Mary Hospital, Pofulam, Hong Kong, China
Srinath Chinnakotla, MD Department of Surgery, University of Minnesota
Amplatz Children’s Hospital, Minneapolis, MN, USA
David M. Cressey, BSc (Hons), MBBS, FRCA Department of Perioperative
Medicine and Critical Care, Freeman Hospital, Newcastle-upon-Tyne, UK
Geraldine Diaz, DO Department of Anesthesia and Critical Care, University
of Chicago, Chicago, IL, USA
D. Robert Dufour, MD Department of Pathology and Laboratory Medicine
Service, Veterans Affairs Medical Center, Washington, DC, USA

xvii
xviii Contributors

Jean C. Emond, MD Department of Surgery, New York Presbyterian

Hospital, Columbia University Medical Center, New York, NY, USA
Sheung Tat Fan, MS, MD, PhD, DSc, FRCS (Edin & Glasg), FACS
Department of Surgery, The University of Hong Kong, Queen Mary Hospital,
Pofulam, Hong Kong, China
James Y. Findlay, FRCA Department of Anesthesiology, Division of
Critical Care, Mayo Clinic, Rochester, MN, USA
Amit Gera, BSc, MBBS, MRCP Department of Gastroenterology, Queen
Elizabeth Hospital, London, UK
James V. Guarrera, MD, FACS Division of Abdominal Organ
Transplantation and Molecular Therapies and Organ Preservation Research
Laboratory, Department of Surgery, Columbia University Medical Center,
New York, NY, USA
Jonathan Hastie, MD Department of Anesthesiology, College of Physicians
and Surgeons, Columbia University, New York, NY, USA
Scot D. Henry, PhD Division of Abdominal Organ Transplantation and
Molecular Therapies and Organ Preservation Research Laboratory,
Department of Surgery, Columbia University Medical Center, New York,
NY, USA
Ibtesam A. Hilmi, MB, CHB, FRCA QI/QA Division, UPMC Presbyterian,
Pittsburgh, PA, USA
Philipp J. Houck, MD College of Physicians and Surgeons, Columbia
University, New York, NY, USA
Navraj Kahlon, MBBS Department of Anesthesiology, Columbia
University, New York, NY, USA
Matthew R. Kappus, MD Department of Internal Medicine, Virginia
Commonwealth University, Richmond, VA, USA
Mark T. Keegan, MB, MRCPI Department of Anesthesiology, Division of
Critical Care, Mayo Clinic, Rochester, MN, USA
Milan Kinkhabwala, MD Department of Surgery, Montefiore Medical
Center, Bronx, NY, USA
Ingo Klein, MD Department of Surgery I, University of Wuerzburg,
Wuerzburg, Germany
Department of Surgery, Division of Transplantation, University of California,
San Francisco, San Francisco, CA, USA
J. R. Klinck, MD, FRCPC, FRCA Division of Perioperative Care,
Cambridge University Hospitals, Cambridge, UK
Claus-Georg Krenn, MD, PhD Department of Anaesthesia, General Intensive
Care, and Pain Medicine, Medical University of Vienna, Vienna, Austria
Contributors xix

Navjoyt Ladher, MD Institute of Liver Studies, King’s College Hospital,

London, UK
Simon W. Lam, PharmD Department of Pharmacy, Cleveland Clinic,
Cleveland, OH, USA
Ton Lisman, PhD Department of Hepato-Pancreato-Biliary Surgery and
Liver Transplantation, University Medical Center Groningen, Groningen,
The Netherlands
Mercedes Susan Mandell, MD, PhD Department of Anesthesiology,
University of Colorado, Aurora, CO, USA
Jean Mantz, MD, PhD Department of Anesthesiology and Critical Care,
Beaujon University Hospital, Paris Diderot University, Paris, France
Juan del Rio Martin, MD Director del Trasplante Hepatico y Cirugia
Hepatobiliar, Hospital Espanol Auxilio Mutuo, San Juan, PR, USA
Leena Mathew, MD Department of Anesthesiology, New York Presbyterian
Hospital, Columbia University, New York, NY, USA
Lloyd Meeks, MD Department of Anesthesiology, Division of Critical Care,
Columbia University College of Physicians and Surgeons, New York,
NY, USA
Joseph Meltzer, MD Division of Critical Care, Department of Anesthesiology,
David Geffen School of Medicine, University of California, Los Angeles,
Los Angeles, CA, USA
Vivek K. Moitra, MD Department of Anesthesiology, College of Physicians
and Surgeons, Columbia University, New York, NY, USA
Ruairi Moulding, BSc, MBBS, FRCA Department of Anesthesiology,
University of Michigan, Ann Arbor, MI, USA
Teresa A. Mulaikal, MD Department of Anesthesiology, Columbia
University Medical Center, New York, NY, USA
Claus U. Niemann, MD Departments of Anesthesia and Perioperative Care
and Surgery, Division of Transplantation, University of California, San
Francisco, San Francisco, CA, USA
Anand D. Padmakumar, MB, BS, FRCA St. James’s University Hospital,
Leeds Teaching Hospitals NHS Trust, Leeds, UK
Katherine Palmieri, MD Department of Anesthesiology, Kansas University
Medical Center, Kansas City, KS, USA
Oliver Panzer, MD Department of Anesthesiology, Columbia University,
New York, NY, USA
Catherine Paugam-Burtz, MD, PhD Department of Anesthesiology and
Critical Care, Beaujon University Hospital, Clichy, France
Paris Diderot University, Paris, France
xx Contributors

Paul Picton, MB, ChB, MRCP, FRCA Department of Anesthesiology,

University of Michigan, Ann Arbor, MI, USA
Raymond M. Planinsic, MD Department of Anesthesiology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA
Robert J. Porte, MD, PhD Department of Hepato-Pancreato-Biliary
Surgery and Liver Transplantation, University Medical Center Groningen,
Groningen, The Netherlands
Nazia Qazi, MD GI/Hepatology Nutrition Section, Veterans Affairs Medical
Center, Washington, DC, USA
Tetsuro Sakai, PhD, MD Department of Anesthesiology, University of
Pittsburgh School of Medicine, Pittsburgh, PA, USA
Jennifer Sandadi, MD Department of Anesthesiology, Columbia
University, New York, NY, USA
Fuat Hakan Saner, MD Department of General-, Visc.- and Trans. Surgery,
University Essen, Essen, Germany
Arun J. Sanyal, MD Department of Gastroenterology and Hepatology,
Virginia Commonwealth University, Richmond, VA, USA
Subramanian Sathishkumar, MBBS Department of Anesthesiology, Penn
State Hershey Medical Center, Hershey, PA, USA
Roman Schumann, MD Department of Anesthesiology, Tufts Medical
Center, Tufts University School of Medicine, Boston, MA, USA
Shahriar Shayan, MD Department of Anesthesiology, Northwestern
University Feinberg School of Medicine, Chicago, IL, USA
Gerd R. Silberhumer, MD Department of Surgery, Division of
Transplantation, Medical University Vienna, Vienna, Austria
Andrew Slack, MBBS, MRCP Institute of Liver Studies, King’s College
Hospital, London, UK
Robert N. Sladen, MBChB, MRCP(UK), FRCP(C), FCCM Division of
Critical Care, Department of Anesthesiology, College of Physicians and
Surgeons of Columbia University, New York, NY, USA
Christopher P. Snowden, B.Med Sci (Hons), FRCA, MD Department of
Perioperative Medicine and Critical Care, Freeman Hospital, Newcastle-
upon-Tyne, UK
Randolph Steadman, MD Department of Anesthesiology, David Geffen
School of Medicine at UCLA, Los Angeles, CA, USA
Masahiko Taniguchi, MD Department of Surgery, Hokkaido University,
Sappora, Japan
James F. Trotter, MD Department of Transplant Hepatology, Baylor
University Medical Center, Dallas, TX, USA