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Subspecialty

Transplant Anesthesia

Complex physiology, complex coordination.

Solid-organ transplant anesthesia (liver, kidney, lung, heart) is a niche of high acuity and prolonged cases. Liver transplant in particular tests every domain — massive transfusion, coagulopathy, hemodynamic upheaval during reperfusion.

Key concepts

Liver transplant — phases

Pre-anhepatic (dissection — coagulopathy emerges), anhepatic (clamp IVC — cardiac filling drops), reperfusion (hyperkalemia, acidosis, hypotension — 'post-reperfusion syndrome').

Reperfusion management

Pre-treat with calcium, bicarbonate (selectively), be ready with epinephrine, vasopressin. Continuously assess with TEE and POCUS.

Kidney transplant

Avoid nephrotoxic agents; mannitol + furosemide at unclamping; maintain CVP / generous volume to support graft.

Lung transplant

One-lung ventilation, often on ECMO/CPB. Right ventricle is the limiting organ — protective ventilation, pulmonary vasodilators.

Monitoring

  • Arterial line
  • Multiple large-bore access
  • PA catheter or TEE
  • Rapid transfusion device
  • TEG/ROTEM

Common drugs

FentanylCisatracuriumAlbuminCalcium chlorideSodium bicarbonateVasopressinNorepinephrineMethylprednisolone (induction immunosuppression)

Clinical pearls

1TEG/ROTEM trumps the conventional coag panel for guiding component therapy in liver transplant.
2Brief communication with surgeon at every clamp/unclamp prevents the worst surprises.

References & Further Reading

  1. 1
    Textbook

    Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

  2. 2
    Textbook

    Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, Sharar SR, Holt NF. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.

  3. 3
    Textbook

    Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist's Manual of Surgical Procedures. 5th ed. Philadelphia: Wolters Kluwer; 2014.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.