Liver Transplantation
Updated On: July 23, 2026
Anesthetic Approaches
Three phases, three plans - dissection, anhepatic and neohepatic each have their own hemodynamics and their own failure mode. Know which phase you are in, because the same blood pressure means a different thing in each one, and the transitions are surgeon-driven.
Dissection phase bleeding - varices, adhesions and portal hypertension make the hepatectomy the bloodiest part of the case in a patient who is already coagulopathic. Stay ahead of the loss rather than chasing it, and warm everything that goes in.
Anhepatic phase - with the graft out there is no hepatic metabolism, no factor production and no lactate or citrate clearance. Core temperature falls, acidosis worsens and ionized calcium drops. Treat the drift as it happens instead of waiting for the next gas.
Caval clamping and piggyback - a full caval cross-clamp removes most of the venous return and the pressure falls hard. The piggyback preserves flow past a side-biting clamp, and veno-venous bypass returns the diverted blood to the upper body. Ask which is planned.
Reperfusion syndrome - unclamping sends a cold, acidotic, potassium-rich load, and sometimes air, straight to the right heart. Expect hypotension, bradyarrhythmia or arrest. Have calcium, epinephrine and a pacing plan in your hand before the surgeon says the word.
Coagulopathy and fibrinolysis - the failing liver makes no factors, the anhepatic phase makes none either, and reperfusion can trigger frank fibrinolysis. Use viscoelastic testing to show what is actually missing, and let current transfusion guidance set the triggers.
Citrate and calcium - with no liver to clear it, citrate from rapidly transfused blood chelates ionized calcium and the ventricle stops responding to anything you give. Measure ionized calcium repeatedly through heavy transfusion and replace to the measurement.
Access before incision - large-bore venous access, a rapid infuser with a fluid warmer and an arterial line go in before the knife, because loss here is counted in units, not milliliters. Keep the left arm and groin free if veno-venous bypass is planned.
Hyperdynamic circulation - a high output against a low, poorly responsive systemic vascular resistance means a normal-looking pressure can sit over a struggling ventricle. Use echo to decide, and expect vasopressor requirements to be higher than usual.
Hepatopulmonary syndrome - intrapulmonary shunting gives resting hypoxemia that oxygen only partly corrects and that worsens sitting up. Accept a lower baseline saturation rather than chasing it with airway pressures the new graft will not tolerate.
Portopulmonary hypertension - a fixed high pulmonary pressure turns reperfusion into acute right heart failure, and severe disease is a reason to stop before induction. Know the right heart catheter numbers beforehand and have an inhaled pulmonary vasodilator ready.
Full stomach at induction - ascites, delayed gastric transit and encephalopathy leave a stomach that is never reliably empty, and many of these cases are called overnight at short notice. Decompress the gastric tube and induce with a rapid sequence technique.
Renal impairment - hepatorenal syndrome and heavy diuretic use leave no reserve, and clamping and reperfusion both add insult. Hold perfusion pressure with vasopressor rather than volume, and expect hemofiltration to be asked for intraoperatively.
Handover to intensive care - the patient stays intubated and goes to the unit. Hand over ischemic times, products given and the last coagulation picture, the support running, and that the pressure has to stay up to protect the hepatic artery.
Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it's going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient's arms.
High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also, consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.
High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.
Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.
High Blood Loss RISK (general considerations): Though most of these cases don't result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
End-stage liver disease is a whole-body disease. The circulation is hyperdynamic, running a high cardiac output against a low systemic vascular resistance that responds poorly to alpha agonists. Portal hypertension fills the abdomen with ascites and the operative field with thin-walled varices. Synthetic failure means no clotting factors and no albumin, and the kidneys fail behind the liver as hepatorenal syndrome. In the lungs, intrapulmonary shunting causes hypoxemia that oxygen only partly corrects, while a smaller group develop fixed pulmonary hypertension. Encephalopathy ranges from subtle inattention to cerebral edema in fulminant failure. The operation replaces the liver in three stages, and for part of it the patient has no liver at all.
Incision and exploration - a bilateral subcostal incision with a midline extension to the xiphoid, then manual exploration to exclude occult malignancy or sepsis before the transplant is committed.
Hepatectomy - the liver is mobilized and the porta hepatis dissected, ligating the hepatic artery, then the bile duct, then freeing the portal vein. Varices and previous upper abdominal surgery make this slow and bloody.
Vascular control - either the vena cava is cross-clamped above and below the liver, or it is left in situ and clamped at the confluence of the hepatic veins (piggyback). A temporary portocaval shunt or veno-venous bypass may be used to decompress the splanchnic bed.
Anhepatic implantation - the graft suprahepatic vena cava is sewn first, then the infrahepatic cava, then the portal vein. Before the last caval sutures, the graft is flushed through the portal vein to clear preservation solution and air.
Reperfusion - the clamps come off and the graft is revascularized, ending the anhepatic phase. All anastomoses and the cut surface of a segmental graft are inspected for bleeding.
Hepatic artery reconstruction - performed once the patient is stable after reperfusion. Arterial pressure has to be maintained afterwards, because this anastomosis thromboses at low flow.
Biliary reconstruction - duct-to-duct anastomosis where the recipient duct is normal, or a choledochojejunostomy to a Roux limb where it is diseased or size-mismatched.
Closure - the gallbladder is removed, hemostasis secured and drains placed. The abdomen may be left open if the graft is a tight fit.
Reperfusion is the one moment here you cannot improvise through. Ten minutes before the clamps move, say it out loud: potassium and ionized calcium checked and corrected, calcium and epinephrine drawn up and labeled in your hand, vasopressor already running rather than ready, pads on and the pacing plan agreed, and the surgeon asked to warn you. Recovering from a reperfusion arrest is far harder than preventing one.