RESUMEN
Orthotopic liver transplantation (OLT) in patients with end-stage liver disease is a procedure associated with high cardiac output, low systemic vascular resistance (SVR), coagulopathy and the potential for significant blood loss. A feature of hypertrophic obstructive cardiomyopathy (HOCM) is left ventricular outflow tract obstruction which may be exacerbated by reduced SVR, reduced filling pressures, tachycardia and positive inotropy. We report two cases of OLT in patients with HOCM. Our anaesthetic technique involved the use of halothane and vecuronium and avoidance of drugs causing tachycardia and positive inotropy. Management was aided by intraoperative transoesophageal echocardiography which showed that filling pressures poorly reflected end-diastolic volumes. Volume administration, vasoconstrictors and avoidance of inotropes and chronotropes reduced the outflow tract obstruction which was particularly severe in the reperfusion period.
Asunto(s)
Anestesia General/métodos , Cardiomiopatía Hipertrófica/complicaciones , Ecocardiografía Transesofágica , Trasplante de Hígado/métodos , Monitoreo Intraoperatorio/métodos , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Cardiomiopatía Hipertrófica/fisiopatología , Hemodinámica , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Using both conventional laboratory clotting profile and thrombelastography, coagulation status was monitored intraoperatively during liver transplantation in the first 75 cases performed at the Austin Hospital between June 1988 and October 1992. Superimposed on a baseline coagulopathy due to liver disease is a specific pattern of coagulation disturbance which occurs during a liver transplant. Fibrinolysis occurs in the anhepatic stage, worsens with early reperfusion and then spontaneously resolves. In addition reperfusion is associated with a transient clotting defect. If blood loss is excessive, coagulopathy due to massive transfusion may compound the situation. Thrombelastography is a measurement technique allowing rapid on-site assessment of functional clotting status. It is particularly useful in liver transplant surgery. In combination with clinical bleeding assessment it facilitates selective use of component therapy (fresh frozen plasma, platelets and cryoprecipitate) and specific drug treatment only when it is appropriate. It also acts as a liver function test, being especially useful in assessing the graft after reperfusion.
Asunto(s)
Trastornos de la Coagulación Sanguínea/etiología , Trasplante de Hígado , Tromboelastografía , Coagulación Sanguínea/fisiología , Trastornos de la Coagulación Sanguínea/tratamiento farmacológico , Trastornos de la Coagulación Sanguínea/fisiopatología , Trastornos de la Coagulación Sanguínea/prevención & control , Transfusión de Componentes Sanguíneos , Pérdida de Sangre Quirúrgica/prevención & control , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Fibrinógeno/análisis , Fibrinólisis/fisiología , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/fisiología , Monitoreo Intraoperatorio , Tiempo de Tromboplastina Parcial , Recuento de Plaquetas , Protrombina/análisis , Reperfusión/efectos adversos , Seroglobulinas/análisis , Reacción a la TransfusiónRESUMEN
The blood loss data and transfusion requirements including blood bank, salvaged washed red cells, fresh frozen plasma and cryoprecipitate were analysed for the first 75 cases of liver transplantation performed at the Austin Hospital between June 1988 and October 1992. The mean blood loss was 8.8 litres (standard deviation 14.1) with a median value of 4.0 litres. Blood product use expressed as mean number of units (SD) was bank red blood cells 7.1 (12.7), washed red blood cells 3.9 (5.9), fresh frozen plasma 7.1 (9.1), platelets 5.1 (7.4), and cryoprecipitate 1.7 (5.1). These results demonstrate that liver transplantation can be performed without imposing excessive demands on blood transfusion services. Management should include surgical techniques to minimize bleeding and use of autologous transfusion. Use of component therapy (FFP, platelets and cryoprecipitate) should not be empirical. It should be selective on the basis of clinical bleeding assessment and guided by results of the laboratory coagulation profile and changes in thrombelastographic (TEG) parameters.