Objectives: We aimed to document the anesthetic management and metabolic, hemodynamic, and clinical outcomes of liver-graft recipients who subsequently undergo nontransplant surgical procedures.
Materials and Methods: We retrospectively analyzed the data of 96 liver-graft recipients who underwent 144 nontransplant surgeries between October 1998 and April 2016 at Baþkent University Hospital.
Results: The median patient age at the time of nontransplant surgery was 32 years, and 35% were female (n = 33). The median time between transplant and nontransplant surgery was 1231 days. The most frequent types of nontransplant surgery were abdominal (22%), orthopedic (16%), and urologic (13%). Seventy patients had an American Society of Anesthesiologists status of 2 (49%); the status was 3 in 71 patients (49%) and 4 in 3 patients (2%). Of the 144 procedures, 23 were emergent (16%) and 48% were abdominal. General anesthesia was used in 69%, regional anesthesia in 19%, and sedoanalgesia in 11%. Twenty-five patients required intraoperative blood-product transfusion (17%). Intraoperative hemodynamic instability developed in 17% of patients, and hypoxemia developed in 2%. Eleven patients remained intubated at the end of surgery (8%). Of the 144 procedures, 19 (13%) required transfer to the intensive care unit, 108 (75%) transferred to the ward, and the remaining 17 (12%) were discharged on the same day. Eight patients developed respiratory failure (6%), 7 had renal dysfunction (5%), 4 had coagulation abnormalities (3%), and 10 had infectious complications (7%) in the early postoperative period. The median hospital stay was 4 days, and 5 patients (4%) developed rejection during hospitalization. Five patients died of respiratory or infectious complications (4%).
Conclusions: Most liver-graft recipients who undergo nontransplant surgery are given general anesthesia, transferred to the ward after the procedure, and discharged without major complications. We suggest that orthotopic liver transplant recipients may undergo nontransplant surgery without any postoperative graft dysfunction.
Key words : Anesthetic management, Liver graft recipients, Metabolic hemodynamic and clinical outcomes, Undergo nontransplant surgery, Postoperative complications
Improved survival techniques and effective immunosuppressive and supportive therapy in patients undergoing liver transplant have resulted in an increase in the number of patients who present for subsequent elective or emergency surgery unrelated to their transplant.1 Graft recipients have the physiologic and pharmacologic problems of graft denervation, risk of infection, adverse events of immunosuppressive therapy, and the potential for rejection; infection and rejection are the main causes of mortality.2 Graft rejection may have minimal symptoms, or patients may have nonspecific systemic symptoms such as poor appetite, irritability, or fatigue. Patients who undergo nontransplant surgery during graft rejection may have a higher risk of mortality.2 Appropriate anesthetic and intensive care management of these nontransplant procedures is therefore important.3
This study documents the anesthetic management and metabolic, hemodynamic, and clinical outcomes of 96 liver-graft recipients who underwent 144 nontransplant surgical procedures.
Materials and Methods
A total of 545 liver transplants were performed at Baþkent University Hospital in Ankara, Turkey, between October 1998 and April 2016. We retrospectively analyzed the data of 96 liver-graft recipients who underwent a total of 144 subsequent nontransplant surgeries during this period. The analyzed data included patient demographics, reason for transplant, type of nontransplant surgery, intraoperative anesthetic management (including cardiopulmonary complications), postoperative follow-up findings, and mortality. We recorded the results of perioperative liver- and renal function tests, including levels of serum alanine transaminase, aspartate transaminase, total bilirubin, blood urea nitrogen, prothrombin time, activated partial thromboplastin time, and the international normalized ratio; and the results of blood gas analysis.
The anesthetic management for the nontransplant surgery was planned by the transplant anesthesia team, and the methods used included general anesthesia and regional blocks. General anesthesia was achieved using induction with intravenous midazolam 0.05 to 0.1 mg/kg, lidocaine, fentanyl 1 μ/kg, and vecuronium 0.5 mg/kg, and maintained using inhaled 6% desflurane, 2% sevoflurane, or 1% isoflurane. Nitrous oxide or remifentanil were given as needed throughout the procedure, and neuromuscular blockade was achieved with vecuronium. Regional nerve blocks were performed using 0.5% ropivacaine. Sedoanalgesia achieved by given separately Midazolam (0.05 mg/kg IV), fentanyl (1-2 mcg/kg IV), ketamine (1–1.5 mg/kg or an IM dose of 2–4 mg/kg) and propofol (50 to 200 μg/kg/minute IV) . Intraoperative monitoring included the measurement of blood pressure, heart rate, electrocardiography, pulse oximetry and capnography, rhinopharynx temperature, and urinary output. Invasive measurements of blood pressure, central venous pressure, blood gases, electrolytes, and blood glucose were conducted as needed. The vasodilator dose was titrated to the desired clinical effect.
The most common immunosuppressive drugs used were cyclosporine, azathioprine, tacrolimus (FK506), mycophenolate mofetil, and corticosteroids.2 Because blood levels of cyclosporine or tacrolimus may decrease during surgery due to hemodilution or bleeding, their levels were carefully monitored. Oral cyclosporine or tacrolimus was administered 4 to 7 hours before surgery to maintain therapeutic blood levels.2 Oral doses of prednisolone were considered equal to intravenous methylprednisolone doses, and we gave supplemental “stress-coverage” steroids.
Statistical analyses were performed using software (SPSS version 20.0, SPSS Inc., Armonk, NY, USA). Values are given as the mean ± standard deviation or as the median and range. For statistical comparison, we used the chi-squared test for categorical data and paired t tests for independent analysis. P values of less than .05 were regarded as statistically significant.
This study was approved by the Institutional Review Board of Baþkent University (Project no: KA 14/313) and supported by the Baþkent University Research Foundation.
The mean patient age at the time of nontransplant surgery was 32 years (range, 0-75 years), and 35% of patients were female (n = 33). The mean time between transplant and nontransplant surgery was 1231 days (Table 1). The most frequent types of nontransplant operations were abdominal, orthopedic, and urologic. Thoracic, neurosurgical, cardiac, gynecologic, thyroid, vascular, and urologic operations were also performed, in descending order of frequency (Figure 1). Seventy patients had an American Society of Anesthesiologists status of 2 (49%), 71 patients had a status of 3 (49%), and 3 patients had a status of 4 (2%) (Figure 2). Of the 144 procedures, 23 were emergent (16%), and 48% were abdominal (Figure 3). General anesthesia was used in 69%, regional anesthesia in 19%, and sedoanalgesia in 11% (Figure 4).
A total of 25 patients required intraoperative blood product transfusion (17%). Intraoperative hemodynamic instability developed in 17% of patients, and hypoxemia developed in 2%. Eleven patients remained intubated at the end of surgery (8%) (Table 2). General anesthesia was administered most frequently, most recipients were transferred to the ward after surgery, and most were discharged without a major complication (Table 3).
Several anesthetic techniques have been used successfully in patients with a history of transplant who are undergoing nontransplant surgery. The preferred anesthesia modality is determined by the type of surgery and the requirements of the patient. In our study, general anesthesia was given to 70% of patients, regional anesthesia was given to 19%, and sedoanalgesia was used in 11%. There were no perioperative complications related to anesthesia or to the metabolic, hemodynamic, and clinical outcomes (Table 4).
No individual general anesthetic agents are contraindicated when hepatic and renal function is normal.3 A well-functioning liver graft responds normally to the agents commonly used in anesthesia.2 Appropriate perioperative antibiotic prophylaxis should be used, just as in nontransplant patients.4 Nonsteroidal anti-inflammatory drugs should be avoided because of the potential adverse effects of gastrointestinal hemorrhage, nephrotoxicity, and hepatic dysfunction.4 If an epidural or spinal anesthetic is planned, clotting studies and platelet counts should be normal.4
General anesthesia is used more frequently in our liver-graft recipients undergoing nontransplant surgery. Similarly, Feng and associates reported the use of general anesthesia over regional anesthesia in transplant patients undergoing subsequent surgery.3 Medications for anesthesia induction include propofol, fentanyl, and rocuronium. Anesthesia can be maintained with a combination of oxygen and nitrous oxide, or oxygen and air, with desflurane, sevoflurane, or isoflurane. Muscle relaxation is maintained with rocuronium or atracurium. Although stress-coverage steroid doses are not necessarily advised in graft recipients who no longer use steroid therapy, we administered 1 mg/kg methylprednisolone to all of our surgical patients who previously underwent transplant surgery.4
The preoperative assessment of graft recipients undergoing nontransplant surgery should focus on graft function and rejection, the presence of infection, and the function of other organs. Rejection should always be ruled out preoperatively.4 There is some evidence that patients who undergo surgery during a period of rejection have higher morbidity.4 In our group of patients, 4% had a diagnosis of rejection before nontransplant surgery; this was not associated with increased morbidity.
The long-term substantial adverse events of immunosuppressive drugs include anemia, thrombocytopenia, leukopenia, neurotoxicity, central nervous system toxicity, nephrotoxicity with hyperkalemic renal tubular acidosis, hypertension, and diabetes.2 Recipients are generally immunocompromised, as they are taking immunosuppressive therapy, and they are at high risk for postoperative infection. Infection is a major cause of morbidity and the most common cause of death in liver-graft recipients.3,5 Postoperative infection was observed in 7% of our recipients.
The normal physiologic mechanisms that protect liver blood flow are blunted after liver transplant. The liver is normally an important source of blood volume when shock results in a vasoconstrictive response, and this mechanism may be impaired after liver transplant.4 Our liver-graft recipients were generally stable, and the function of their liver and other organs did not change perioperatively. However, during the intraoperative period, 17% of the recipients experienced hemodynamic instability, and 17% of these underwent blood transfusion. Feng and associates3 reported that the incidence of hypotension and the number of patients in the intensive care unit after surgery is significantly higher in the perioperative stage (< 30 days after transplant) for adult liver-graft recipients undergoing nontransplant surgery. Our recipients underwent nontransplant surgery about 3 years after liver transplant, and we observed less need for intensive-care admission (13%). We observed an incidence of postoperative acute respiratory failure of 6%, acute kidney dysfunction of 5%, and coagulopathy of 3%. Feng and associates3 reported no mortality over the long term (> 90 days) in recipients; however, our observed mortality was 4%.
There is no scientific proposal for the perioperative management of graft recipients. A registry for the perioperative problems seen in previously transplanted patients is needed to formulate appropriate management and to create relevant guidelines.2
In conclusion, most liver graft recipients who undergo nontransplant surgery do so under general anesthesia, most transfer to the ward, and some are discharged on the same day. Most of our patients are discharged without major complications. We suggest that orthotopic liver transplant recipients can undergo nontransplant surgery, assuming proper anesthetic and intensive care management from a dedicated transplant anesthesia team, without any postoperative graft dysfunction.
Volume : 15
Issue : 1
Pages : 42 - 45
DOI : 10.6002/ect.mesot2016.O24
From the 1Department of Anesthesiology and the 2Department of General Surgery,
Baþkent University Hospital, Ankara, Turkey
Acknowledgements: The authors declare that they have no conflicts of interest to declare. This study was supported by the Baþkent University Research Foundation.
Corresponding author: Zeynep Ersoy, MD, Department of Anesthesiology, Baþkent University, Fevzi Cakmak Cad. 10. Sok. No.45 Bahcelievler, Ankara, Turkey
Phone: +90 312 203 6868
Table 1. Demographic Features and Surgical Interval
Table 2. Intraoperative Events
Table 3. Postoperative Findings
Table 4. Changes in Pre- and Postoperative Laboratory Values
Figure 1. Type of Surgery
Figure 2. American Society of Anesthesiologists (ASA) Status
Figure 3. Number of Elective and Emergency Surgeries
Figure 4. Anesthetic Techniques