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Liver Transplant Anesthesia with Courtney Jones · Style Points

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Hello anesthesia enthusiasts and welcome to Style Points. I'm your host John Crowe. I'm
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an assistant professor of anesthesiology at the University of Cincinnati. Today we will be talking
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about liver transplant anesthesia. The University of Cincinnati is one of the top liver transplant
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centers in the country ranked 17th in the United States by volume in 2022. Our residents do an
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average of 15 to 20 liver transplant anesthetics per resident per year starting as early as their
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third month of CA1 year. Today we have the good fortune of speaking with Dr. Courtney Jones,
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associate professor of anesthesiology and critical care and the director of transplant anesthesia
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here at the University of Cincinnati. Courtney thanks for joining us today. Thanks for having me.
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What I like to do is start off with a question that's more of a get to know you question. So
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if you could have dinner with anyone in the world it could be even somebody from the past
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or even from fiction. Who would you have dinner with and why? There are so many great possibilities.
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I think it would be really fascinating to have dinner with Martin Luther going way back to the
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1500s. But he is someone who had the intelligence and creativity to think outside of what was being
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taught at the time as accepted doctrine from the Catholic Church and but then had the conviction
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of his of his beliefs and it led to the Protestant Reformation and changed history from there on. So
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someone with the intelligence and then also the guts so to speak to kind of stand for their
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convictions. So I think you'd be a fascinating person to speak with. I agree that'd be really
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interesting. I would also like to have that dinner. I wonder what we'd have for dinner.
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I'm not sure what German food in the 1500s consisted of. Can you start out by telling us
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a little bit about your background and experience in the field of anesthesia particularly with
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liver transplant? Sure. So as a resident I always really enjoyed being in liver transplants and at
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the time they were very different case by and large than they are now. The blood loss was much
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higher. The cases were longer and the rooms were very very hot. But despite that I still enjoyed
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the challenge of the case and the resuscitation and the satisfaction of taking care of a critically
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ill patient and that feedback of how well you did taking care of the patient in their post-operative
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course. And from there as I became an attending and was involved in the liver team and critical
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care I enjoyed it even more and then attended a critical care conference that had a side meeting
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on liver pathology and liver diseases and then also went to a coagulation conference on coagulopathy
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and liver disease and also hypercoagulability. So those two things really sparked my intellectual
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interest as well to highlight even more the complexities of the pathophysiology of cirrhosis
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and the differences between cirrhosis and acute liver failure and ultimately continued on the
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liver team and whenever the previous director was ready to step down I took over as the director
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of transplant anesthesia and have loved it ever since. When I was a resident I remember the first
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time that I went to do a kidney transplant and I got very excited and it was very stressful time
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for me but then the kidney transplant sort of went okay and it ended up being just a pretty
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standard abdominal case. Could you tell me a little bit about the difference between a standard kidney
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transplant versus what a liver transplant involves? Sure first I think they're both very satisfying
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cases and one of my most favorite cases to do is a living donor kidney transplant and one of the
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reasons that I love that case is the kidney starts working right away and you can see the kidney
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making urine while you're still in the operating room which is to me just kind of mind-blowing and
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incredibly rewarding that you can take an organ out of one person and put it into another and that
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person's life will be forever changed from a morbidity and a mortality standpoint. For a kidney
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transplant it's not as huge of a physiologic insult as it is for a liver transplant. You have
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a smaller incision you're not immediately sub diaphragmatic which has a higher respiratory
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complication right. There tends to be less blood loss but the patients are often sicker in the
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terms of more comorbidities are often diabetic hypertensive have been on dialysis for a long
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time which leads to rapidly progressive coronary artery disease they often have diastolic heart
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failure and post capillary pulmonary hypertension. So the comorbidities that you deal with with kidney
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transplant are often more challenging and can contribute to the patient's long-term morbidity
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and mortality but from an anesthetic standpoint the surgical risk that you're undertaking is much
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less than a liver transplant. You do not have as many fluid shifts you do not have the blood loss
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the operative time is shorter. For a liver transplant I always anticipate a lot of blood
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loss you're planning for at least four to eight hours in the operating room it's usually closer
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to six to eight. You have a significant amount of fluid shifts that are happening if the patient
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has ascites the portal hypertension, cirrhosis affects every organ system in the body so you
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have to account for the management of all of those pathophysiologic implications in your
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anesthetic plan which is something that makes it a fun challenge in my opinion and I think there's
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so much to learn from taking care of patients with liver disease because you really have to
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understand the implications throughout the body and help your patient have a good outcome by
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attributing for those things. So let's take a look at a liver transplant patient from start to
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finish starting with preoperatively. What do we do here at the University of Cincinnati for liver
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transplant patients in the preoperative phase? Can you talk a little bit about that? Yeah sure
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so a couple of years ago we started a transplant CPC specifically. What's a CPC? Great question
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CPC stands for Center for Perioperative Care which is the name that we use here for our
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preoperative clinic and we still have some transplant patients that come through the
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preoperative clinic but we have embedded an anesthesiologist in the liver clinic on the day
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that they are being seen immediately before listing and that has a lot of advantages. One
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of the largest is that you are in the same space as the hepatologist, the transplant surgeon,
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the social worker, the coordinators. They're being seen by transplant ID that day and then
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also the transplant dietitian. So you have this multidisciplinary clinic which is a fantastic way
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to have good communication, tie up any loose ends, or to discuss any discrepancies in the previous
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workup that's been done up to that point. As far as testing for our patients before liver transplant,
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everyone gets an echo with a bubble and that is looking for systolic function, diastolic function,
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and very importantly RV function. The right ventricle is incredibly important to a successful
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liver transplant both intraoperatively and then also postoperatively. We pay a lot of attention
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to the PA pressures as well and then we're using the bubble to look at interpulmonary shunts
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because hepatopulmonary syndrome is very common in liver transplant patients. Most of the time it is
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not clinically significant but some of our patients will have very low PO2s and qualify for what's
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called meld exception points and that's when the severity of their disease is not accurately
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represented by their meld score and they can get bonus points so to speak on their meld score to
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improve their chances of receiving a liver transplant because something like hepatopulmonary
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syndrome can be improved with liver transplant. We also do a stress test of some variety on almost
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all of our patients that are going for liver transplant. Sometimes it's a stress echo,
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sometimes it's a nuclear med stress test, and then we have a fairly low threshold for doing a
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left heart cath for our patients and that depends on the etiology of the liver disease,
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the comorbidities that the patient has, and then the reliability of the stress test. So the
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guidelines have recently changed from the American Heart Association for the workup of liver transplant
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patients and NASH which is now called MASH, metabolic associated steatohepatitis, is an
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independent risk factor that automatically puts people in the high-risk category for having coronary
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artery disease. So those patients get screened with a coronary CT and if that can't be interpreted
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or if they can't undergo the test or their coronary calcium score is high, then those patients,
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it's recommended that they automatically get a left heart cath because their pre-test probability
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of having coronary artery disease is so high. So we spend a lot of time looking at the heart and
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trying to anticipate the patient's reserve for tolerating the stress of not just the immediate
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operative course which can be significant but also post-operatively because patients after liver
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transplant have a high incidence of arrhythmias, namely aphib, and then also heart failure.
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Cystolic and diastolic heart failure can be a significant complicating factor post-operatively.
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So we spend a lot of time looking at that and then everything else is dictated by the patient's
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comorbidities. If they have a long-term smoking history, asthma, COPD, then those patients are
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going to be getting PFTs, maybe a CT, a high-res CT if there's concern for interstitial lung disease,
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but they get a chest CT looking for any malignancy. They have abdominal CTs to help with operative
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planning. Patients undergo colonoscopy, EGD, among others, and then everything else is dictated by
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comorbidities. It sounds like there's a much bigger workup than even I was aware of for these
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liver transplant patients and that's pretty intense. With this multidisciplinary clinic,
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what have you noticed has changed in what you're doing for these patients beforehand? What do you
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think is the thing that has caught the most that you feel like the patients are benefiting from the
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most? I think one of the things that helps them the most is just having continuity of communication.
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So instead of getting one message from whoever is seeing them in the pre-op clinic from anesthesia
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as happened before, and then they go to the liver clinic and see a hepatologist and then maybe the
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surgeon and everyone has a slightly different message that can be confusing for the patient,
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we are able to present a unified plan for the patient, which one is better for their understanding,
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it's better for their buy-in and trust. So I think that has been a huge advantage for the patients.
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The other nice thing just physically for the patients is they don't have to traipse across
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campus to come to the pre-op clinic and these are patients who often have a lot of muscle wasting,
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need canes or walkers for stability, maybe even a wheelchair for longer distance, have protuberant
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abdomens full of ascites that make them short of breath. So just from a patient experience
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standpoint, I think it has also been much better for them as well. So let's move from the pre-op
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area into the operating room. We all know that liver transplants are a big surgery, they require
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a lot of lines, but what's different in a liver transplant surgery that you might not see in a
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normal open abdominal procedure from the anesthetic management standpoint? Sure. I think from an
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anesthetic standpoint, one of the largest things that we are preparing for is blood loss and if
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we don't experience the blood loss, that's fantastic for the patient, but blood loss that
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you are prepared for is incredibly different than blood loss that you are not prepared for. And with
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the number of varices in a cirrhotic patient with the blood supply to the liver itself, if they've
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had previous abdominal surgery, there can be significant adhesions that complicate the
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hepatectomy. You have to be prepared for blood loss. So we put in a mat catheter for all of our
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patients, which is a large bore central line that allows rapid transfusion and we have a rapid
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infuser called a Belmont that's hooked up to that line that allows us to transfuse up to a liter a
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minute if we need to. We also place a swan or a pulmonary artery catheter to monitor the PA
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pressures. The CVP, we can shoot cardiac outputs from that, calculate the PVR. Not every center
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places a swan for liver transplant. Some do it on an as-needed basis, others do it routinely,
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and then others do TEE only for their liver transplants. And some places will do a combination
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of the two. We do swans for all of our livers with TEE on a more as-needed or indicated basis. In
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addition to the MAC, we're also looking to place large bore peripheral IVs. If we cannot place
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those, then we will place a second MAC to make sure that we have sufficient access for the case.
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And then we are also putting in an arterial line to monitor the hemodynamics closely and be able
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to sample blood gases throughout the case. Some centers will put in two central lines, one to
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monitor the hemodynamics and the other for lab sampling. We do not do that. We just put in one
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and have not felt that it's been a hindrance to our ability to continually monitor the patient.
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But that is a difference that you'll see between some programs is that they'll put into arterial
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lines for every liver transplant. And then sometimes our patients need CRRT in the operating room. We
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will do continuous dialysis in the operating room in certain circumstances. I think the patients
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that are hardest to manage without CRRT are the ones that are hyperkalemic, acidotic, and
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hyponatremic. That combination of electrolyte abnormalities can be challenging to treat in a
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liver transplant while dealing with the fluid shifts, blood loss, hemodynamics that are happening
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during the transplant. Well, there are definitely a lot of different aspects of liver transplant.
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I'm going to try to zoom out for a second. Could you describe some of the different phases of a
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liver transplant and what you'd look out for in those phases in general? So the liver transplant
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is starting with the hepatotomy and that's when the surgeons are dissecting down and freeing up
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the liver to remove it. When they first open the abdomen, if the patient has ascites, you are doing
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a paracentesis. So if the patient has a large amount of ascites, then you need to be prepared
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to treat it like a large volume paracentesis and have albumin replacement for the ascites loss
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that's going to happen because that can make the patient hypotensive from the very beginning.
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During the hepatotomy, there can be a fair amount of blood loss depending on many different factors.
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So that's something that we're watching for and prepared to treat as well. And in that phase,
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we're trying to have an adequate depth of anesthetic. Patients often do not need nearly
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as much anesthesia with liver disease, especially if they have hepatic encephalopathy. You can
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usually get by with much less anesthetic. And some of our patients need pressors even this
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early on because of their low tone that they have at baseline. It's not uncommon for some
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patients with cirrhosis to have systolic blood pressures in the 80s and 90s at baseline,
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which can make tolerating an anesthetic on top of that a little challenging without adding some
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pressor for tone. So that's something that we always have ready and prepared at the start of
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the case. And then you move on to the anhypatic phase after the liver is out. And sometimes what
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medical students and residents will lose sight of is that when you're anhypatic, you have lost
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all the function that the liver normally does for you in that time period. So you are not making
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your coagulation factors. You're not having gluconeogenesis. You're not clearing lactate.
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So all of those things are contributing to some of the physiologic effects that you see during
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that phase. And then you're moving from the anhypatic phase, you are preparing for reperfusion,
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which is the most hemodynamically rocky time of the transplant. While the patient is anhypatic,
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the surgeons are working on sewing in the new liver. And this is called the warm ischemia time
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for the new liver. They try to keep that as short as possible. It's usually in the neighborhood of
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20 to 30 minutes, sometimes slightly longer. But the more warm ischemia time on the organ,
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the worse it is for the new organ. So they try to minimize that. That's not a great time to
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interrupt the surgeons with lots of random questions and distractions. They're working
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pretty fast during that time period and sewing tiny blood vessels and putting things together.
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And while they are sewing in the liver, you're preparing for reperfusion. So you're getting your
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pressors ready. We usually load the Belmont with blood or fluid, depending on what the patient's
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hemoglobin is and fluid status. But you will have a huge physiologic insult with reperfusion. So at
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this time, there are clamps on the IVC in the portal vein, you have acid building up, potassium
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building up in the body. And you're putting a cold liver that just came out of ice into the abdomen.
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So when they reperfuse, you are getting cold blood washed back to the heart, you're getting
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acid coming back to the heart, you're getting potassium coming back to the heart. And that is
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why the right heart function is so important, because all of those things make it difficult
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for the right heart to work at its normal capacity. In addition to that, the right heart doesn't
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tolerate sudden volume changes very well. And when you take the clamp off the IVC in the portal vein,
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you have a large increase in preload back to the heart. So if you're RV struggling, and you hit it
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with acid and potassium and cold, and a huge volume bolus, then you can get into trouble really
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quickly. So while the surgeons are working to sew in the liver, we are preparing for reperfusion.
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And then you move into reperfusion and all those things that I was just talking about
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can manifest as hypotension, you can have arrhythmias of any variety, you can have
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asystole, you can have bradycardia, you can have BFIV, you can have Btac, you can have pauses,
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you can see peak T waves, you can see a widening QRS. So you really have to be paying attention
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to what's going on and what you're seeing on your monitors at this time. We try to manage the volume
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very carefully. Our surgeons will do a blood flush, so the patient will lose 200 to 300 ml of blood
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very, very quickly at the start of reperfusion. And you have to account for that, but then you're
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going to have all of the preload coming back from the clamps coming off to the heart. And you do not
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want to engorge the new liver with a high venous pressure. So you need adequate volume, but you
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don't want to overdo it. And then pressures are usually needed during this time to varying
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degrees. And then after the liver is reperfused, you're in the neo-hepatic phase. And then you're
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the surgeons are sewing in the hepatic artery. They are cleaning up any blood loss that is
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visible after the clamps come off. You can always see tiny holes whenever you have clamps on.
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So they're repairing that. And the liver starts to work. It's really amazing, even though this
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liver has been out of a body in ice with preservative fluid in it, it'll start to make bile.
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Your coagulopathy will start to get better. Your acidosis will start to get better. The lactate
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will start to clear, which is amazing to see. And then the surgeons will also work on the bile duct
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after they get the hepatic artery sewn together. And one of the things that you really have to
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watch out for in this time period is intracardiac thrombus. So that can occur at any point during a
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liver transplant, but the highest risk time is about 10 to 15 minutes after reperfusion,
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after the clamps have come off. And that happens in about one to 6% of liver transplants. And the
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mortality is really high if that happens. So that's something that we're watching for and prepared
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to treat if it does occur. And then the rest of the neo-hepatic phase is management of an open abdomen,
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repairing any abnormalities in the coagulation cascade that occur. Transfusion is needed for
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blood loss. Usually during this period, your pressure requirement will come down as the liver
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starts to work and the acidosis is improving. Replacing any electrolytes that are needed,
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managing the glucose are all important parts of this phase of care for the anesthetic. We've
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talked a lot about turning the pressors on and off and when they might be needed. Which ones are
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you reaching for and why? We typically will spike epinephrine, levathed, and vasopressin
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in our liver transplants as far as having those on the pump. If someone has
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some RV dysfunction, a lot of times we'll use dibutamine instead of epinephrine.
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But those are kind of our go-to's here. There are other choices that are acceptable. Occasionally
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we'll use milrinone but not often because of the vasodilatory effect that you can get from
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milrinone. So levathed, epinephrine, and vasopressin are most commonly used agents.
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As far as a push dose, we typically have epiphenolephrine and I personally like having
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push doses of levathed as well. Gotcha. Okay, thanks very much. That was an excellent overview
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and I appreciate you going over that. Moving on to postoperative care of the patient,
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what sort of things are you looking for when the patient hits the ICU and during their stay in the
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ICU? There are a lot of things that are really important in this phase of care and it's a
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continuation of what's happening in the operating room. There's been a big push over the last several
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years in liver transplant to improve the rate of extubation in the operating room for patients.
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There's still kind of this antiquated notion that patients need to rest on the ventilator
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after a big surgery and we know that there's harm from patients being on a ventilator longer than
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necessary and increases the risk of ventilator associated pneumonia. Patients are in bed longer,
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they're on sedation, they have a higher risk of DVT. So that early postoperative phase is trying
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to move patients towards extubation if we were not able to do it in the operating room. It's also
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continuing to correct any abnormalities in the in the TIG, resuscitating the patient if they still
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need it from a volume or blood standpoint, weaning off the pressors and then monitoring for
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the liver function. So you want to see the lactate continuing to come down, you want to see
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the acidosis improving. The LFTs will initially spike after a liver transplant,
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but you want to see those starting to trend down. They get an early postoperative ultrasound to look
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at flow in the vessels in the liver itself and make sure that you have good flow in the hepatic
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arteries and veins. And then just general good ICU care that includes early mobilization, DVT
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prophylaxis, pulmonary toilet, all of those things are important for any patient.
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How long do these patients typically stay in the ICU? Of course, every patient is going to be
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different. Sure. So here are patients on average stay in the ICU about two to three days. And the
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average hospital course for our patient is about seven to eight days after a liver transplant.
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There's obviously a lot of heterogeneity because you can have somebody coming in from home who is
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pretty functional and maybe having a liver transplant for cancer and they're not serotic.
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That's a very different patient than someone who has acute liver failure and is obtunded and on
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the ventilator in the micu before going to the OR. So there's a huge range, but average is two to
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three days in the ICU and about a week in the hospital. Some places that have a little bit
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different structure of their floors and nursing ratios will bypass the ICU for patients who are
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extubated in the operating room. They might have a longer PACU stay or their post-transplant floor
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set up a little bit more like a step-down unit. So there's some difference based on where the
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transplant is being performed. So in recent years, what advancements or innovations within
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anesthesia or within liver transplant surgery have impacted the way that we do liver transplant
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procedures? One of the biggest changes is the machine perfusion that's happening. And it's been
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very common for years to put kidneys on a pump and you can delay the transplant of the kidney and it
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also has a little bit of the ability to improve some of the kidney function for some of the marginal
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graphs. There have been multiple studies, several different types of pumps that are in use. It was
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more common in Europe initially and you're seeing them more in the United States now.
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But the ability to machine perfuse a liver before putting it into a patient expands the ability to
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use DCD graphs, which are graph organs that come from a cardiac death instead of a brain death.
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Those organs are typically not quite as good as a brain death organ. They take a little longer to
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work, but you can see better function from those graphs and the ability to use more marginal graphs
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to improve the donor pool. So that's one of the big changes that's occurring. The machine perfusion
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is still not widespread, not used for every organ. There still tends to be need for IRB approval
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and things like that. But I think that's something that we'll keep in mind. So that's
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something that will continue to change in the years to come.
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So what advice would you give to anesthesia residents or medical students who are new to
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or interested in specializing in liver transplant anesthesia?
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First of all, I would say that's fantastic and I do not think you'll be disappointed in choosing
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that as a career specialty. For the medical students, I would encourage you to get as much
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exposure to a multidisciplinary approach to transplant patients as you can. For example,
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when you're on your internal medicine rotation trying to rotate with hepatology if possible,
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or on your surgery rotation trying to rotate with transplant surgery, it will give you a more
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complete picture of these patients and what their perioperative course looks like and how you move
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from dying of cirrhosis to living a full life after transplant. For the residents, I would
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encourage you to be involved with as many liver transplants as possible. If your program offers
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an elective in transplant, I would encourage you to do that and customize your experience so that
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you can see more of the behind the scenes work that happens with transplant. You can attend
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selection committee meetings and hear people talk about what makes someone a good candidate or not a
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good candidate and how you're trying to move people through the process. You can learn more about
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appropriately matching organs with the right recipient, which was not something that I
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really appreciated before I started getting deeper into this role. And then it's also,
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I think, really important to know that UNOS requires that every liver transplant program
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have a director of transplant anesthesia. So that is something that every hospital with a
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transplant program must have. And that person is required to either have a critical care fellowship,
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cardiac anesthesia fellowship, or a liver transplant anesthesia fellowship, which is
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not an ACGME fellowship, but something that's offered in a number of programs around the country.
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That's often a part-time attending position and a part-time liver transplant anesthesia fellow
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position. So if that's something that you think you might be interested in long term, then I would
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encourage you to pursue one of those fellowships to have the door open for you. And then attending
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conferences, there's many different transplant societies and conferences. There's SATA, which
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is the Society for the Advancement of Transplant Anesthesia, which is a great resource and
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opportunities for residents and fellows to get involved. And then the International Liver
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Transplant Society is also another great opportunity that has multidisciplinary educational
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topics, conferences, journal articles, moderated journal clubs, where you can learn more about the
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topic as well. Thank you for walking us through liver transplants. That was a fantastic look at
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liver transplants from start to finish. I have one last question for you. Through your career,
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you've undoubtedly developed a unique style and style of practices that define your work.
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Could you share with us some of your personal style plans and strategies for your work?
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Could you share with us some of your personal style points or distinctive methods that you think
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contribute to your effectiveness and success in the operating room? Sure, I'd be happy to. I think
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there are a couple of different things. One, I really try to remember that what is a routine day
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for us is often the worst day in somebody else's life or a very stressful, scary day for them.
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So, giving the patient and their family the grace to be upset or be snippy or be emotional,
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I try to take that in stride and also try to put their mind at ease and develop a rapport as quickly
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as I can with them so that they trust me. So I think that's one thing that I try to do with all
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of my patients. Another thing is that I have high expectations for myself and then for those that
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I'm working with. We have a wonderfully fun, rewarding job, but it's also a serious job
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that we need to do the best that we can for the patient and their family. So I expect people to
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do a good job and I expect that of myself. But I also want opportunities for feedback and improvement,
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not just for the trainee, but also for myself. So if someone catches something which has happened,
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I mean, we're human and can make mistakes too. So I want someone to give me that feedback or be open
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to saying, did you mean to do that? That is an important part of taking good care of patients.
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And then I think another thing is I like efficiency. I don't like redoing work. So if
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there's something that can be done one way, take EKG leads, for example, that you're only positioning
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them one time so that they are in the correct position for the ultimate surgical position,
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then I would rather do that instead of putting them on, taking them off, turning the patient,
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and then putting them on again, because that's wasted steps and time. Those are a couple of things
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that come to mind. I'm sure the residents could probably tell you others, but those are a couple
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that come to mind offhand. Well, thank you for sharing all that with us. I think that wraps up
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all the questions I had for you, but I really appreciate your time today. I hope you enjoyed
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it. I really appreciate your time and thank you for sharing your expertise with us. Thank you for having me.
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And that's it for today's episode of Style Points. Having listened to a lot of podcasts in the past,
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I think I might be legally obligated to ask you to like and or subscribe. I'm still pretty new to this,
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so if you have feedback for me, please feel free to email me at stylepointspodcasts.gmail.com.
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Thanks for listening.