Transplante Heptico Peditrico

Trasplante Heptico PeditricoDra. Rebeca Del Riego Ruiz R5APUMAE. HP. CMNO. IMSS22.04.14Antecedentes histricosIH: Insuficiencia hepticaEHT: Enfermedad heptica terminalTH: Trasplante hepaticoGeneralidadesEl THP es uno de los trasplantes de rgano slido ms exitosos.

Segn OPTN/SRTR: supervivencia al ao 83-91%, dependiendo de la edad en el momento del trasplante.

600/ao en la ultima dcada (10% TH realizados en EU), la mayora en nios menores de 12 aos.

TH en menores de 3 meses con supervivencia del injerto y del paciente similar a los pacientes de mayor edad.

OPTN: Organ Procurement and Transplantation NetworkSRTR: Scientific Registry of Transplant RecipientsIndicaciones Complicaciones con amenaza para la vida secundarias a IH o EHT.

EH primaria progresiva refractaria a mximo manejo medico, antes de que aparezcan complicaciones que amenacen la vida.

Enfermedad metablica (13%).

Tumores primarios irresecables (hepatoblastoma).

Falla heptica fulminante (11%).(hepatoblastoma: Reseccin + QxTx si es iresecable, pero hubo respuesta al tratamiento medico puede realizarse TH.Complicaciones de FHF de rapido desarrollo pueden hacer que el diagnostico no sea factible.4Indicaciones

Fisiopatologa Fisiopatologa similar, independiente de la causa.

Las manifestaciones surgen a partir de la prdida de hepatocitos y de la fibrosis resultante.Fisiopatologia

Fisiopatologia

Fisiopatologa Fisiopatologa Fisiopatologa

Fisiopatologa sensibilidad a catecolaminas y vasoconstrictores Saturacin venosa mixta de O2 Diferencia AV de O2Hipotensin grave con los anestsicos!Respiratorio: HipoxemiaFisiopatologa +Dilatacin vascular intrapulmonarSndrome hepatopulmonarSndrome hepatopulmonarHipoxia x cortocircuitos AV + dilatacin vascular intrapulmonares. Fisiopatologa Hipertensin portopulmonarFisiopatologa Revisin retrospectiva de PMAP como factor predictivo.50 mmHg mortalidad del 100%Encefalopata hepticaComplicacin significativa de EH, aguda (IHF) o crnica.Fisiopatologa Caracterstico de Encefalopatia HepaticaOtros factores:BZDNaCitoquinas inflamatoriasEncefalopata hepticaFisiopatologa Si catabolismo, amonioLos niveles de sricos de amonio se alcanzan a partir del catabolismo endgeno de protenas y de la absorcin intestinal.InfeccinAbsorcion intestinal de dietas hiperproteicasSTDInsuficiencia renalAmonio arterial > 200mcg/dL se correlaciona con herniacin cerebral y muerteTratamiento: Reducir la produccin y absorcin de amonioLactulosa / antibioticosLa bacterias intstinales descomponen productos nitrogenados, que luego son absorbdos a la circulacin portalLactulosa: diuresis osmtica, acidifica luz intestinal para atrapar el amonio y minimizar su absorcinNo mejora supervivencia.Antibioticos: neomicina/metronidazol, eliminar basterias GI que intervienen en el metabolismo de los productos nitrogenados. 17Encefalopata hepticaSe debe asegurar va area de acuerdo al grado de encefalopata.

III-IV requieren IOT

PIC: medidas teraputicas sencillasElevacin de la cabeza 30Minimizar estimulacin (tiopental/propofol)ManitolHipotermia leveFisiopatologa La bacterias intstinales descomponen productos nitrogenados, que luego son absorbdos a la circulacin portalLactulosa: diuresis osmtica, acidifica luz intestinal para atrapar el amonio y minimizar su absorcinNo mejora supervivencia.Antibioticos: neomicina/metronidazol, eliminar basterias GI que intervienen en el metabolismo de los productos nitrogenados. 18Aparato digestivoFuncin secretora, metablica y excretora anormales

Hipertensin portalFisiopatologa Insuficiencia renalComplica EH aguda y crnica en adultos, menor incidencia en nios. Fisiopatologa Fisiopatologa 12DopaminaDiurticosOctretideRemover exceso de volumen y optimizar la perfusin renalTratamiento definitivo: THO (La falla revierte si el hgado se reemplaza)Trasplante heptico y renal: Opcin para los nios con ambas enfermedades. Anormalidades hematolgicasFisiopatologa ANTIFIBRINOLTICOS

AprotininaAcido E-aminocaproico

Disminuyen prdidas hemticas.

Otras alteracionesElectrolitos / acido base: alterados por disfuncin renal y/o uso de diurticos, cambios en la ventilacin.

Volumen intravascular: Difcil evaluar ascitis, edema perifrico y anasarca. Fisiopatologa Manejo anestsico: PreoperatorioEnfoque multidisciplinario

Laboratorio: Hemotipo, QS, PFH, PFR, PC, serologas

ECG, ECOTT, Rx Trax

Examen neurolgico

Evaluacin anatmica del hgado nativo: USG abdominal, Tac, RMN

Biopsias: Evaluar gravedad y confirmar dx

Evaluacin psicosocial y financiera de la familia.PreoperatorioManejo anestsico PerioperatorioAviso al paciente 8-12 hrs previo al transplante.

Ingreso: HC, EF y labs para actualizar evaluacin previa

Organo: inspeccin final, biopsia para determinar aptitud

Manejo anestsico La comprensin de la fisiopatologa y los cambios que se producen en cada etapa de la ciruga nos permite anticipar y apropiadamente diagnosticar, prevenir y tratar las alteraciones cardiovasculares, hematolgicas y metablicas que se presenten durante la misma.

Scott VL, Wahl KM, Soltys K, Belani KG, Beebe DS, Davis PJ Anesthesia for organ transplantation. En Davias PJ, Cladis FP, Motoyama EK. Smiths Anesthesia for infants and children. 8 ed. Elsevier 2011.Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia. March 2006Manejo anestsico PerioperatorioPremedicacin: Mdz IV/VOEvitar en encefalopata heptica por la depresin del SNC y aumento de PIC

Monitoreo I preinduccin

ISR/ induccin inhalatoria en nios electivosPreoxigenacin adecuada por disminucin en CRF

VM: FiO2 alta + PEEP

Accesos vasculares grandes (2), colocacin de lneas de monitoreoArteria radial/CVC multilumenManejo anestsico PerioperatorioECOTE para monitorear funcin cardiovascular y llenado durante el trasplante

Control trmico, evitar hipotermia

Proteccin de extremidades ante la posibilidad de lesin por la duracin del procedimiento y el potencial de hipoperfusin de la piel.Manejo anestsico Tcnica anestsicaNingn rgimen anestsico ha demostrado ser superior en el trasplante de hgado.Anestesico inhalado+opioide en bolo o infusin = curso intraoperatorio relativamente estable.

El objetivo es mantener la estabilidad hemodinmica y el FSH.Se evitan altas concentraciones de inhaladosManejo anestsico PerioperatorioEs probable que la enfermedad heptica terminal afecte la distribucin y aclaramiento plasmtico de los opioides, el injerto mejorar esta funcin.

Opioides: Biotransformacin heptica (oxidasas fentanil, glucoroniltransferasa morfina).

La extraccin de fentanil y morfina es alta, el aclaramiento plasmtico se ve menos afectada por alteraciones en la funcin heptica que por alteraciones en el FSH. Manejo anestsico PerioperatorioMorfina, fentanil, sufentanil parecen conservar su aclaramiento y volumen de distribucin, lo que refleja la capacidad de los grandes volmenes de distribucin para amortiguar cualquier disminucin en el metabolismo de las drogas. Manejo anestsico PerioperatorioLa EH afecta la duracin de accin de los BNMND, pero depende del grado de afectacin y de la dosis.Vecuronio: 0.1 mg/kg no diferencias farmacolgicas 0.2 mg/kg mayor duracin en EH avanzada.

Rocuronio: Se prolonga la duracin de accin despus de dosis repetidas. Manejo anestsico PerioperatorioLa redistribucin de la droga es importante para la terminacin de los efectos del frmaco en pacientes con EH, pero cuando se administran dosis mayores de la droga, la depuracin heptica es mas evidente.

Los estudios sugieren que el injerto reanuda rpidamente su papel para metabolizar los frmacos.

El retraso en la recuperacin anestsica o en el BNM rara vez representa un problemaManejo anestsico ExtubacinDepende del centro.

Inmediata es cada vez mas aceptada

La decisin se basa en ausencia o presencia de comorbilidades.Manejo anestsico El mantenimiento de la anestesia puede llevarse a cabo con diferentes tcnicas y ninguna es mejor que otra.

Lo mas importante es cumplir el objetivo de mantener la estabilidad hemodinmica, reposicin de lquidos, mantenimiento de la temperatura y correccin de las anormalldades metablicas y de la coagulacin.

Manejo anestsico 36MaintenanceMaintenance of anesthesia can be accomplishedin a variety of ways, with no one techniqueshown to be better than another. More importantthan the actual anesthetic technique used isto achieve the goals of maintaining hemodynamic stability, fluid resuscitation, temperature maintenance,and correction of metabolic and coagulation abnormalities. In our institution,this is achieved by a balanced technique ofoxygen/air mixture, isoflurane, fentanyl andvecuronium. Typically, the latter two medicationsare given by continuous infusion throughoutthe procedure.OBJETIVO: Mantener la estabilidad hemodinmica y el flujo sanguneo heptico durante todo el procedimiento.

La etiologa de la inestabilidad depender de la etapa del procedimiento.

HipovolemiaCada de resistencia vascular sistmicaPrdidas sanguneas y de fluidosReduccin del retorno venoso durante el pinzamiento de la vena cava inferior durante la fase anhepticaSndrome de reperfusin.

Manejo anestsico Anestesia general balanceada con desflurano 4.0-6.5%, con la ventaja de un tiempo de recuperacin rpido y metabolismo heptico bajo.

La TIVA con propofol ha sido utilizada con xito, pero puede estar asociada con depresin cardaca despus de la reperfusin.

Una infusin de remifentanilo (0,05-0,3 mg kg 1 min-1) proporciona analgesia intraoperatoria, con la ventaja de una vida media muy corta.

Manejo anestsico 38After intubation, IPPV is established with a suitable volatile agent, for example desflurane 4.06.5% end-tidal concentration in oxygen-enriched air. Desflurane has the advantage of a quick recovery time and low hepatic metabolism. Many centres use either isoflurane or sevoflurane. Nitrous oxide is avoided toreduce cardiovascular depression, gut distension and bubble formation if on veno-venous bypass (VVB). Total i.v. anaesthesia with propofol has been used successfully, but may be associated with cardiac depression after reperfusion. A remifentanil infusion (0.050.3 mg kg1 min1) provides intraoperative analgesia with the advantage of a very short context-sensitive half-life. Alternatives include alfentanil infusion or boluses of morphine. Muscle relaxation with atracurium (at 30 mg h1) provides adequate relaxation and reliable reversal after prolonged use. Most relaxants are safe provided neuromuscular block is monitored to prevent delayed recovery.

Procedimiento quirrgico para anestesilogosFase preanhepticaFase anhepticaFase neohepticaPre-anhepatic phaseAn upper abdominal transverse incision is made, with a midline extension up to the xiphisternum. No irreversible surgery is performed until the new liver is in theatre, and compatability checked and documented. The time until the diseased liver is removed depends on the extent of previous surgery and the development of adhesions. Bleeding at this time may be significant. The use of a harmonic scalpel (ultracision) significantly decreases the amount of bleeding. Children with chronic liver disease usually tolerate clamping of the inferior vena cava well, but those patients with no collaterals may have a significant drop in blood pressure at this time. Trial clamping of the inferior vena cava (IVC) for 30 seconds is advised. Veno-venous bypass is used less frequently today, and is even more uncommon in children under 10kgs, but may be useful if it is necessary to decompress the lower half of the body. This is usually done from the femoral to axillary vein.

Anhepatic phaseThis starts with the interruption of hepatic flow and ends with the revascularization of the new liver. The order of interruption of blood flow is: 1. IVC clamp: the suprahepatic then the infrahepatic IVC 2. Portal vein 3. Hepatic artery The iseased liver is removed and the new liver fitted into the abdomen. The childs body temperature will fall and progressive acidaemia will follow. Vascular anastomoses occur in the following order: 1. Suprahepatic IVC 2. Infrahepatic VC (partial) 3. Portal vein. Once this vein is anastamosed, the portal vein clamp is temporarily released to allow the blood to fill the new liver from retrograde flow from the portal vein. This blood flushes to the infrahepatic IVC and into he surgical field. 4. Infrahepatic IVC (completed)3 In many cases, the liver will be piggy-backed onto the IVC with a single anastomosis rather than separate suprahepatic and then infrahepatic connections (i.e. steps 1 and 2). This vercomes the differences in size with cut-down livers, and avoids venous outflow obstruction.2 Vascular clamps are removed in this order: Portal vein, suprahepatic IVC, then infrahepatic IVC. Perfusion of the new liver is from the IVC nd portal veins, and enous return to the heart is re-established.3 Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

39Fase preanhepticaIncision abdominal en abdomen superior con extension a la lnea media hacia el apndice xifoides.

El tiempo de remocin del hgado depende de las cirugas previas y del desarrollo de adherencias.

El sangrado en este momento puede ser significativo. El uso de un armonico disminue la cantidad de sangrado. Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia March 2006Ciruga para anestesilogos Pre-anhepatic phaseAn upper abdominal transverse incision is made, with a midline extension up to the xiphisternum. No irreversible surgery is performed until the new liver is in theatre, and compatability checked and documented. The time until the diseased liver is removed depends on the extent of previous surgery and the development of adhesions. Bleeding at this time may be significant. The use of a harmonic scalpel (ultracision) significantly decreases the amount of bleeding. Children with chronic liver disease usually tolerate clamping of the inferior vena cava well, but those patients with no collaterals may have a significant drop in blood pressure at this time. Trial clamping of the inferior vena cava (IVC) for 30 seconds is advised. Veno-venous bypass is used less frequently today, and is even more uncommon in children under 10kgs, but may be useful if it is necessary to decompress the lower half of the body. This is usually done from the femoral to axillary vein.

Anhepatic phaseThis starts with the interruption of hepatic flow and ends with the revascularization of the new liver. The order of interruption of blood flow is: 1. IVC clamp: the suprahepatic then the infrahepatic IVC 2. Portal vein 3. Hepatic artery The iseased liver is removed and the new liver fitted into the abdomen. The childs body temperature will fall and progressive acidaemia will follow. Vascular anastomoses occur in the following order: 1. Suprahepatic IVC 2. Infrahepatic VC (partial) 3. Portal vein. Once this vein is anastamosed, the portal vein clamp is temporarily released to allow the blood to fill the new liver from retrograde flow from the portal vein. This blood flushes to the infrahepatic IVC and into he surgical field. 4. Infrahepatic IVC (completed)3 In many cases, the liver will be piggy-backed onto the IVC with a single anastomosis rather than separate suprahepatic and then infrahepatic connections (i.e. steps 1 and 2). This vercomes the differences in size with cut-down livers, and avoids venous outflow obstruction.2 Vascular clamps are removed in this order: Portal vein, suprahepatic IVC, then infrahepatic IVC. Perfusion of the new liver is from the IVC nd portal veins, and enous return to the heart is re-established.3 Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

40Fase preanhepticaLos nios con EH crnica usualmente toleran el pinzamiento de la VCI, pero los pacientes sin colaterales pueden tener una caida sbita de la TA. Con poca frecuencia se utilizan derivaciones veno-venosas, pero pueden ser necesarias para descomprimir la mitad inferior del cuerpo. Usualmente van de la vena femoral a la axilar. Ciruga para anestesilogos Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia March 2006Pre-anhepatic phaseAn upper abdominal transverse incision is made, with a midline extension up to the xiphisternum. No irreversible surgery is performed until the new liver is in theatre, and compatability checked and documented. The time until the diseased liver is removed depends on the extent of previous surgery and the development of adhesions. Bleeding at this time may be significant. The use of a harmonic scalpel (ultracision) significantly decreases the amount of bleeding. Children with chronic liver disease usually tolerate clamping of the inferior vena cava well, but those patients with no collaterals may have a significant drop in blood pressure at this time. Trial clamping of the inferior vena cava (IVC) for 30 seconds is advised. Veno-venous bypass is used less frequently today, and is even more uncommon in children under 10kgs, but may be useful if it is necessary to decompress the lower half of the body. This is usually done from the femoral to axillary vein.

Anhepatic phaseThis starts with the interruption of hepatic flow and ends with the revascularization of the new liver. The order of interruption of blood flow is: 1. IVC clamp: the suprahepatic then the infrahepatic IVC 2. Portal vein 3. Hepatic artery The iseased liver is removed and the new liver fitted into the abdomen. The childs body temperature will fall and progressive acidaemia will follow. Vascular anastomoses occur in the following order: 1. Suprahepatic IVC 2. Infrahepatic VC (partial) 3. Portal vein. Once this vein is anastamosed, the portal vein clamp is temporarily released to allow the blood to fill the new liver from retrograde flow from the portal vein. This blood flushes to the infrahepatic IVC and into he surgical field. 4. Infrahepatic IVC (completed)3 In many cases, the liver will be piggy-backed onto the IVC with a single anastomosis rather than separate suprahepatic and then infrahepatic connections (i.e. steps 1 and 2). This vercomes the differences in size with cut-down livers, and avoids venous outflow obstruction.2 Vascular clamps are removed in this order: Portal vein, suprahepatic IVC, then infrahepatic IVC. Perfusion of the new liver is from the IVC nd portal veins, and enous return to the heart is re-established.3 Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

41Fase anhepticaInicia con la interrupcin del FSH y termina con la revascularizacion del hgado nuevo.

El orden de la interrupcin del FS es: Pinzamiento de VCI: supreahepatica y luego infrahepaticaVena portaArteria heptica

El hgado enfermo es removido y el hgado nuevo se coloca dentro del abdomen. Caida de la temperatura del nio y acidemia progresiva. Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia March 2006Ciruga para anestesilogos Pre-anhepatic phaseAn upper abdominal transverse incision is made, with a midline extension up to the xiphisternum. No irreversible surgery is performed until the new liver is in theatre, and compatability checked and documented. The time until the diseased liver is removed depends on the extent of previous surgery and the development of adhesions. Bleeding at this time may be significant. The use of a harmonic scalpel (ultracision) significantly decreases the amount of bleeding. Children with chronic liver disease usually tolerate clamping of the inferior vena cava well, but those patients with no collaterals may have a significant drop in blood pressure at this time. Trial clamping of the inferior vena cava (IVC) for 30 seconds is advised. Veno-venous bypass is used less frequently today, and is even more uncommon in children under 10kgs, but may be useful if it is necessary to decompress the lower half of the body. This is usually done from the femoral to axillary vein.

Anhepatic phaseThis starts with the interruption of hepatic flow and ends with the revascularization of the new liver. The order of interruption of blood flow is: 1. IVC clamp: the suprahepatic then the infrahepatic IVC 2. Portal vein 3. Hepatic artery The iseased liver is removed and the new liver fitted into the abdomen. The childs body temperature will fall and progressive acidaemia will follow. Vascular anastomoses occur in the following order: 1. Suprahepatic IVC 2. Infrahepatic VC (partial) 3. Portal vein. Once this vein is anastamosed, the portal vein clamp is temporarily released to allow the blood to fill the new liver from retrograde flow from the portal vein. This blood flushes to the infrahepatic IVC and into he surgical field. 4. Infrahepatic IVC (completed)3 In many cases, the liver will be piggy-backed onto the IVC with a single anastomosis rather than separate suprahepatic and then infrahepatic connections (i.e. steps 1 and 2). This vercomes the differences in size with cut-down livers, and avoids venous outflow obstruction.2 Vascular clamps are removed in this order: Portal vein, suprahepatic IVC, then infrahepatic IVC. Perfusion of the new liver is from the IVC nd portal veins, and enous return to the heart is re-established.3 Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

42Fase anhepticaLas anastomosis se efectan en el siguiente orden: VCI suprahepatica

VCI infrahepatica parcial

Vena porta Cuando se anastomosa se despinza temporalmente para permitir que la sangre llene el nuevo hgado con flujo retrogrado. Esta sangre fluye de la VCI y al campo quirrgico.

VCI inferior completa. En muchos casos se puede hacer una anastomosis simple en la VCI ca travs de su conexiones suprahepaticas e infrahepaticas

Eso evita la obstruccin al flujo de salida venoso. Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia March 2006Ciruga para anestesilogos Pre-anhepatic phaseAn upper abdominal transverse incision is made, with a midline extension up to the xiphisternum. No irreversible surgery is performed until the new liver is in theatre, and compatability checked and documented. The time until the diseased liver is removed depends on the extent of previous surgery and the development of adhesions. Bleeding at this time may be significant. The use of a harmonic scalpel (ultracision) significantly decreases the amount of bleeding. Children with chronic liver disease usually tolerate clamping of the inferior vena cava well, but those patients with no collaterals may have a significant drop in blood pressure at this time. Trial clamping of the inferior vena cava (IVC) for 30 seconds is advised. Veno-venous bypass is used less frequently today, and is even more uncommon in children under 10kgs, but may be useful if it is necessary to decompress the lower half of the body. This is usually done from the femoral to axillary vein.

Anhepatic phaseThis starts with the interruption of hepatic flow and ends with the revascularization of the new liver. The order of interruption of blood flow is: 1. IVC clamp: the suprahepatic then the infrahepatic IVC 2. Portal vein 3. Hepatic artery The iseased liver is removed and the new liver fitted into the abdomen. The childs body temperature will fall and progressive acidaemia will follow. Vascular anastomoses occur in the following order: 1. Suprahepatic IVC 2. Infrahepatic VC (partial) 3. Portal vein. Once this vein is anastamosed, the portal vein clamp is temporarily released to allow the blood to fill the new liver from retrograde flow from the portal vein. This blood flushes to the infrahepatic IVC and into he surgical field. 4. Infrahepatic IVC (completed)3 In many cases, the liver will be piggy-backed onto the IVC with a single anastomosis rather than separate suprahepatic and then infrahepatic connections (i.e. steps 1 and 2). This vercomes the differences in size with cut-down livers, and avoids venous outflow obstruction.2 Vascular clamps are removed in this order: Portal vein, suprahepatic IVC, then infrahepatic IVC. Perfusion of the new liver is from the IVC nd portal veins, and enous return to the heart is re-established.3 Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

43Fase anhepticaLos pinzamientos vasculares se remueven el siguiente orden: Vena portaVCI suprahepaticaaVCI infrahepatica.

La perfusion de injerto viene de la VCI y de la porta re-estableciendo el retorno venoso al corazn.

Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia March 2006Ciruga para anestesilogos Pre-anhepatic phaseAn upper abdominal transverse incision is made, with a midline extension up to the xiphisternum. No irreversible surgery is performed until the new liver is in theatre, and compatability checked and documented. The time until the diseased liver is removed depends on the extent of previous surgery and the development of adhesions. Bleeding at this time may be significant. The use of a harmonic scalpel (ultracision) significantly decreases the amount of bleeding. Children with chronic liver disease usually tolerate clamping of the inferior vena cava well, but those patients with no collaterals may have a significant drop in blood pressure at this time. Trial clamping of the inferior vena cava (IVC) for 30 seconds is advised. Veno-venous bypass is used less frequently today, and is even more uncommon in children under 10kgs, but may be useful if it is necessary to decompress the lower half of the body. This is usually done from the femoral to axillary vein.

Anhepatic phaseThis starts with the interruption of hepatic flow and ends with the revascularization of the new liver. The order of interruption of blood flow is: 1. IVC clamp: the suprahepatic then the infrahepatic IVC 2. Portal vein 3. Hepatic artery The iseased liver is removed and the new liver fitted into the abdomen. The childs body temperature will fall and progressive acidaemia will follow. Vascular anastomoses occur in the following order: 1. Suprahepatic IVC 2. Infrahepatic VC (partial) 3. Portal vein. Once this vein is anastamosed, the portal vein clamp is temporarily released to allow the blood to fill the new liver from retrograde flow from the portal vein. This blood flushes to the infrahepatic IVC and into he surgical field. 4. Infrahepatic IVC (completed)3 In many cases, the liver will be piggy-backed onto the IVC with a single anastomosis rather than separate suprahepatic and then infrahepatic connections (i.e. steps 1 and 2). This vercomes the differences in size with cut-down livers, and avoids venous outflow obstruction.2 Vascular clamps are removed in this order: Portal vein, suprahepatic IVC, then infrahepatic IVC. Perfusion of the new liver is from the IVC nd portal veins, and enous return to the heart is re-established.3 Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

44Fase neohepticaEs el tiempo de la reperfusion al final de la ciruga. El metodo de reconstruccin de la arteria hepatica depende de la anatomia del receptor y del donador

Lo mas simple es una anastomosis trmino-terminal.

En este momento puede ser necesario pinzar la aorta parcial o totalmente.

Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia March 2006Ciruga para anestesilogos Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

45Fase neohepticaCuando se alcanza una hemostasia adecuada se reconstruye el tracto biliar. Si el paciente tiene atresia de via biliar sin Kasai, se realiza una coledocoyeyunostomia de Roux.Thomas J, McCulloch M, Spearman W, Butt T, Numanoglu A. A practical approach to anaesthesia for paediatric liver transplantation. Southern African Journal of Anaesthesia & Analgesia March 2006Ciruga para anestesilogos Neohepatic phase is the time from reperfusion to the end of surgery. The method of reconstruction of the hepatic artery epends on the recipient and donor anatomy. The simplest method is an end-to-end anastomosis, but there are other options. During this time, it may sometimes be necessary to emporarily clamp the aorta, partially or totally. Once adequate haemostasis is achieved, biliary reconstruction is performed. If it has not already been done as part of the asai operation in patients with biliary atresia, this usually involves the formation of a Roux limb of the jejunum to which the bile duct is attached (choledochojejunostomy).

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Que cuidar durante el transplante?Hemodinmia

Hemostasia

Control metablico

Temperatura HemodinmiaLos periodos de inestabilidad hemodinamica son comunes en muchos momentos:

Que cuidar? 49Fase preanheptica (hepatectoma)Reduccin de la precarga al momento del pinzado de la VCI.

La hipotensin es comn por muchos factores:Cambios en el sistema cardiovascular, hematolgico y metalico.Hipotensin Hipovolemia secundaria a hemorragia y a prdidas al tercer espacio.

Hipocalcemia secundaria a productos sanguneos citratados.

Compresin de VCI o VD por la manipulacin. Fase preanheptica El sangrado ocurre de los colaterales frgiles, de las adhesiones de cirugas previas y de la coagulopata.

Las anormalidades hematolgicas incluyen anemia, trombocitopenia, deficiencia de factores de la coagulacin.

En esta etapa se puede desarrollar tambin una coagulopata progresiva.

Los daos metablicos incluyen hipercalemia, hipocalcemia, hipomagnesemia y acidosis resultantes de la administracin de productos sanguneos. Fase preanhepticaFase anhepticaCambios cardiovasculares: hipotensin resultante del pinzado de la VCI ( precarga)

Hemodinmicamente: GC, PVC, PAP mientras RVS.

Precarga: puede ser gentilmente aumentada para mantener la PAM con las menores presiones de llenado posibles porque la HIPERVOLEMIA puede causar congestin heptica durante la reperfusin. Se puede requerir e dopamina o epinefrina para mantener la PAM.

Si se hace una derivacin portocaval, se pueden atenuar estos cambios hemodinmicos preservando la precarga desde la vena porta.

Fase anheptica El citrato sin metabolizar causa hipocalcemia e hipomagnesemia porque quela ambos metales.

La acidosis se genera del citrato no metabolizado, del lactato y otros cidos. Se puede administrar bicarbonato si hay una acidosis metablica significativa (dficit de base 30% por muchos factoresDisfuncin miocrdica colapso cardiovascularLiberacin de NO y TNF-aPueden requerir NEArritimasHiperkalemia (cloruro de calcio 10-30 mg/kg, y las medidas que ya mencionamos) Sangrado

Fase neoheptica El alto contenido de k en la solucion de preservacion es la causa mas comun. De hiperkalemia en este momento. Sobretodo con UW (universidad de wiscoinsis) (120 mmmol/L.

HTK: histidinea, triptofano, cetoglutarato tiene menos potasio (10mmol/L). Tiene menor viscosidad y es mas facil introducirla al higado del donador. Un estudio encontro que la sobrevivencia del injerto al mes y al ao es igual con ambas soluiones. 59ReperfusinFibrinolisis: 60% nios y 80% adultosIncremento en la actividad del activador tisular del plasmingeno Disminucin de la sntesis de los inhibidores de la fibrinolisis.

El efecto de la heparina viene de heparinoides endogenos del injerto y de la heparina residual de la solucin de preservacion y estimula al activador tisular del plasmingeno de las celulas endoteliales del injerto revascularizado.Fase neoheptica La aprotinina disminuye esta respuesta inhibiendo la plasmina y la kalicreina

Los beneficios de la aprotinina para reducir las prdidas sanguneas no estn claras, pero se ha demostrado una asociacin entre su uso y los eventos tromboticos intraoperatorios.Fase neoheptica Los nios presentan un estad de hipercoagulabilidad despus del transplante heptico por disminucin de la proteina C y antitrombina III, por lo que son mas propensos a desarrollar trombosis de la arteria hepatica o mbolos.

Por eso no se usa la apotinina en ellos. Fase neoheptica 19156543 reporte telmex62Reconstruccion arterial y biliarEn este momento se presentan la alteraciones hematologicas y metabolicas.

Con el funcionamiento del injerto, se metaboliza el citrato y se desarrolla alcalosis metabolica. Fase neoheptica Reconstruccin arterial y biliarLas metas hemodinamicas incluyen mantener una PVC normalSi es mayor de 8 mmHg el injerto puede congestionarse y no funcionar adecuadamente.

El riesgo de trombosis en la arteria hepatica del 0-25% es alto.

El riesgo aumenta si se corrigen los tiempos de coagulacionFase neoheptica La hiperviscosidad sangunea tambin puede predisponer a una trombosis de la arteria heptica o de la porta. Mantener Hb entre 8 y 9 g/dL es seguro.

Las estrategias de anticoagulacin con heparina, dextran, aspirina pueden reducir el riesgo de trombosis arterial. Fase neoheptica Gracias