Liver transplantation in man

Orthotopic liver transplantation poses unique problems, mostly biochemical in nature, for the anaesthetist.Not only is the choice of anaesthetic agents and techniques limited by the diseased state of the existing liver and by the need to provide optimal conditions for the donor organ, which may have suffered ischaemic damage during removal, but the anaesthetic management is further complicated by other factors.First, the operation involves simultaneous clamping of the inferior vena cava and portal vein, severely reducing the venous return to the heart.Secondly, removal of the diseased liver and insertion of the allograft gives rise to changes in acid-base and other metabolic functions of a type not seen in any other operation.Thirdly, the general condition of the patient may be impaired by severe and often longstanding derangement of the many metabolic and anabolic functions of the liver which, unlike the case of patients with renal failure, cannot at present be corrected.Lastly, it is a long operation often accompanied by considerable blood loss.Whilst anaesthetic aspects of liver transplantation in America have been reported,' our experiences differ from theirs because of differences in the technique of obtaining and preserving the donor liver, and because our patients have mostly been adults.Previous reports from our group have described the general organisation, operative technique, changes in liver function in relation to immunosuppression, and the control of clotting factors.4p7Some aspects of the anaesthetic management of our earliest patients have already beenIn this paper, our experiences of the complete series of twenty-seven patients operated on to date are described, with particular reference to pre-operative complications, practical management of anaesthesia and to the physiological and biochemical disturbances encountered.