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Indications & Listing Criteria

Setting	Recommended listing trigger (2024 EASL & AASLD guidance)
Chronic liver disease	• MELD-Na ≥ 15 (or rapid rise ≥ 5 points / 3 months) • Child–Pugh B/C with ≥ 1 de-compensating event (refractory ascites, GI bleed, hepatorenal syndrome, encephalopathy) • Hepatocellular carcinoma within Milan criteria or down-staged into them
Acute liver failure (ALF)	King’s College criteria (updated 2023): –Paracetamol: arterial pH < 7.30 or INR > 6.5 + creatinine > 300 µmol L⁻¹ + grade III–IV encephalopathy. –Non-paracetamol: INR > 6.5 or any 3 of: age < 18 or > 40, jaundice-to-encephalopathy > 7 d, INR > 3.5, bilirubin > 300 µmol L⁻¹, aetiology = indeterminate / HBV / idiosyncratic DILI.

Contra-indications to Elective Liver Transplant

Absolute	Relative (require MDT discussion)
Uncontrolled sepsis, irreversible multi-organ failure, untreated malignancy with vascular/extra-hepatic spread, severe pulmonary HTN (mPAP > 45 mmHg), MELD-Na < 12, active substance abuse, non-adherence.	Age > 70 y, BMI > 40 kg m⁻², portal-vein thrombosis, significant CAD, high frailty index, active extra-hepatic infection, HIV with unsuppressed viral load.

Conduct of Anaesthesia (recipient)

Considerations

Surgical Phase	Surgical Considerations	Anesthetic Considerations
Preoperative	Transplantation evaluation (psychological evaluation, MELD score, UNOS listing)	Preoperative evaluation, vascular access, blood product availability
Dissection	Surgical incision, mobilization of liver and vascular structures, isolation of bile duct	Hemodynamic compromise from loss of ascites, hemorrhage during dissection, decreased venous return
Anhepatic	Clamping of hepatic artery and portal vein, removal of diseased liver, anastomosis of IVC and portal vein of donor liver	Hemodynamic compromise from clamping IVC, metabolic (lactic) acidosis, hypocalcemia from citrate intoxication, hyperkalemia, hypothermia, hypoglycemia
Reperfusion	Anastomosis of hepatic artery and biliary system, reperfusion of transplanted liver	Hemodynamic instability, dysrhythmias, hyperkalemia, acidosis, cardiac arrest
Posttransplantation	Hemostasis, evaluation of graft function, ultrasound for vascular patency	ICU admission, early or late extubation, hemodynamic management

View or edit this diagram in Whimsical.

Surgical Considerations

Surgical Phases of Liver Transplant Procedure and Common Anaesthetic Problems

Phase	Surgical Details	Common Anaesthetic Problems
Pre-anhepatic	Inverse T or extended/bilateral subcostal incision Mobilization of the structures around the liver and porta hepatis Hepatic artery and bile duct divided	Hemorrhage from dissection, varices, and adhesions Cardiovascular instability from ascitic decompression Low SVR state causes hypotension, exacerbated by vasodilatation of blood away from central compartment towards splanchnic circulation
Anhepatic	Portal vein and hepatic veins divided Explantation of native liver IVC preparation for implantation New liver inserted Caval and portal anastomoses fashioned	No production of clotting factors, fibrinogen deficiency, and worsening coagulopathy Progressive hypocalcemia Absent citrate/lactate metabolism, reduced gluconeogenesis, increasing serum lactate Worsening metabolic acidosis
Neo-hepatic	Graft reperfusion Hepatic artery anastomosis Biliary reconstruction	Hypotension and further decrease in SVR Sudden preload increase at reperfusion Worsening metabolic acidosis

View or edit this diagram in Whimsical.

Preparation

• Two large-bore IVs, rapid infuser, arterial line before induction, quad-lumen CVC (internal jugular) + introducer sheath for rapid blood/fluid.
• Cell-salvage and point-of-care visco-elastic testing (TEG 6s® / ROTEM sigma®).
• Baseline ABG, ionised Ca²⁺, lactate, glucose, temperature.
• Blood products: ≥ 10 units PRBC, 10 FFP, fibrinogen concentrate, PCC, platelets.

Induction & Maintenance

Phase	Haemodynamic priorities	Common interventions
Dissection (pre-anhepatic)	Low SVR, haemorrhage from varices/adhesions	Norepinephrine 0.05-0.15 µg kg⁻¹ min⁻¹, permissive low CVP (< 8 mmHg), balanced transfusion guided by VET.
Anhepatic	Loss of venous return after IVC/portal clamping, citrate load	Calcium chloride 5–10 mmol q30 min, NaHCO₃ if pH < 7.20, keep temp > 36 °C.
Reperfusion	Post-reperfusion syndrome (PRS)–MAP ↓ > 30 % for ≥ 1 min ± arrhythmia	100 mg CaCl₂ + 0.5 mg phenylephrine bolus at unclamp, epinephrine 0.05-0.1 µg kg⁻¹ min⁻¹ if PRS, insulin + glucose for K⁺ > 5.5 mmol L⁻¹.

• Volatile (desflurane/isoflurane) or propofol-TIVA (does not worsen PRS).
• Sugammadex 4 mg kg⁻¹ enables immediate reversal if extubation planned.

Coagulation Strategy (TEG-guided)

TEG/ROTEM abnormality	First-line treatment
Prolonged R / CT (> 1.5 × baseline)	15 mL kg⁻¹ FFP or PCC 25 IU kg⁻¹
α-angle < 45° or FIBTEM A5 < 8 mm	Fibrinogen concentrate 3–4 g
MA / MCF < 45 mm (thrombocytopenia)	Platelets 1 pool (≈ 4–6 units)
LI30 > 8 % (hyperfibrinolysis)	TXA 15 mg kg⁻¹ (avoid after reperfusion if thrombotic risk high)

Special Peri-operative Issues

Complication	Prevention / Management
Hypocalcaemia (citrate)	Ionised Ca²⁺ every 15 min; CaCl₂ 5 mmol per 4 units PRBC/FFP.
Hyperkalaemia at reperfusion	Flush liver with 1 L cold albumin-Ringer’s; Ca²⁺, insulin-dextrose, gentle ventilation.
Hepato-renal syndrome	Pre-op vasoconstrictor + albumin protocol (telipressin or norepi) improves outcome
Severe post-reperfusion hypoxaemia	100 % FiO₂ > 5 min + head-down; inhaled prostacyclin 30–50 ng kg⁻¹ min⁻¹ → iNO 20 ppm → methylene blue 1.5 mg kg⁻¹; escalate to VV-ECMO algorithm.

Post-operative Care

Time-frame	Key issues & surveillance
First 24 h	PRS-related vasoplegia, bleeding, early allograft dysfunction (AST/ALT > 2000 IU L⁻¹ + INR > 1.6 + bilirubin > 100 µmol L⁻¹/Day 3), hypocalcaemia, AKI (KDIGO).
Days 2-7	Biliaryor vascular-compromise Doppler, infection screen, rejection (↑ LFT), careful diuresis for ascites.
Late	Immunosuppression toxicity (calcineurin-induced HTN/AKI, PTDM), metabolic syndrome, recurrent disease.

• Early extubation (within 6 h) is feasible in haemodynamically stable, normothermic recipients with PaO₂/FiO₂ > 200 mmHg and minimal vasopressor need.

Donor Considerations

1. Patient Selection:
   • Donors should be fit and healthy (ASA I – II). Confirm fitness pre-operatively.
2. Monitoring:
   • Use an arterial line (A-line).
   • Central venous pressure (CVP) monitoring.
   • Large bore peripheral line.
3. Anaesthetic Technique:
   • Standard general anaesthesia (GA).
   • Cisatracurium is not mandatory; rocuronium with or without sugammadex can be used.
4. Analgesia:
   • Epidural analgesia and/or rectus sheath catheter for midline incisions.
5. Fluid Management:
   • Restrict fluids until after the hepatectomy to reduce bleeding (maintain CVP at 4-5 mmHg).

Acute Liver Failure Management

1. Cardiovascular System (CVS):
   • Profound vasodilation and circulatory collapse may occur.
   • Volume replacement guided by cardiac output (CO) monitoring and the use of vasopressors as needed.
2. Coagulation:
   • Check prothrombin time (PT) every 12 hours.
   • Do not correct PT routinely; correct only if there is acute hemorrhage or before invasive procedures.
3. Renal Function:
   • Use renal replacement therapy (RRT) for oliguric/anuric renal failure.
   • Continuous venovenous hemodialysis (CVVHD) with lactate-free dialysate is preferred.
4. Infection Control:
   • Routine infection screening.
   • Administer antibiotics only for Grade 3-4 encephalopathy.
5. Glycaemic Control:
   • Patients are prone to hypoglycemia.
   • Monitor blood glucose every 2 hours and correct as needed.
   • Initiate early enteral nutrition.
6. Intracranial Pressure (ICP) Management:
   • Consider ICP monitoring for Grade 3 or 4 encephalopathy.
   • Maintain ICP < 20 mmHg.
7. Specific Therapies:
   • Consider N-acetylcysteine (NAC) for all patients with acute liver failure (ALF).
   • Administer antivirals for acute hepatitis B.
8. Liver Replacement Therapies:
   • Use Molecular Adsorbent Recirculating System (MARS) or Prometheus as a bridge to transplantation.

Anaesthetic Concerns in Recipients of Liver Transplants Presenting for Non-Transplant Surgery

1. Paracetamol:
   • Safe to use.
2. Hepatitis Recurrence:
   • Monitor for recurrence of hepatitis.
3. Reversal of Pre-Transplant Issues:
   • Early Post-Transplant (Days to Weeks):
     • Portal hypertension, ascites, pleural effusions.
   • Intermediate Post-Transplant (Weeks to Months):
     • Encephalopathy, pulmonary hypertension (PHT), hepatopulmonary syndrome, hepatorenal syndrome.
     • Risk of prolonged emergence from anesthesia due to hypoalbuminemia and any residual encephalopathy.
   • Long-Term Considerations:
     • Post-transplant hypertension (due to steroids and cyclosporine), increasing the risk of cardiac events.
     • Hepatopulmonary syndrome may persist; pulmonary hypertension may take months to improve.
     • Cirrhotic cardiomyopathy can cause heart failure post-transplant.
     • Renal failure can be secondary to liver disease or immunosuppression.
     • Metabolic issues such as hyperlipidemia, diabetes mellitus, and non-alcoholic liver disease may arise.

Links

• Brainstem death
• Transplants and organ donation
• Liver resection
• ICU and liver disease
• Liver physiology and pathology

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References:

1. Kashimutt, S. and Kotzé, A. (2017). Anaesthesia for liver transplantation. BJA Education, 17(1), 35-40. https://doi.org/10.1093/bjaed/mkw031
2. Brezeanu LN, Brezeanu RC, Diculescu M, Droc G. Anaesthesia for Liver Transplantation: An Update. J Crit Care Med (Targu Mures). 2020 May 6;6(2):91-100. doi: 10.2478/jccm-2020-0011. PMID: 32426515; PMCID: PMC7216023.
3. Fabbroni, D. and Bellamy, M. C. (2006). Anaesthesia for hepatic transplantation. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 6(5), 171-175. https://doi.org/10.1093/bjaceaccp/mkl040
4. EASL Clinical Practice Guidelines on Liver Transplantation. J Hepatol. 2024. journal-of-hepatology.eu
5. American Association for the Study of Liver Diseases (AASLD). Principles of Patient Selection for Liver Transplantation. 2023. sciencedirect.com
6. Peri-operative coagulopathy management with PCC in LT–randomised trial. Br J Anaesth. 2023. pmc.ncbi.nlm.nih.gov
7. Post-reperfusion syndrome update 2024. World J Hepatol. pmc.ncbi.nlm.nih.gov
8. Goal-directed haemodynamic therapy after LT (COLT trial). Transplant Evidence Watch 2024. transplantevidence.com
9. Telipressin plus albumin for hepatorenal syndrome: meta-analysis. Clin Gastroenterol Hepatol. 2023. easl.eu

Summaries

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Copyright
© 2025 Francois Uys. All Rights Reserved.

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