Unfortunately, the coagulation changes during liver transplantation are incompletely understood: although activation of the fibrinolytic system has been well documented, especially during the anhepatic state and immediately following graft reperfusion, it is possible that there is also activation of the coagulation system in some patients, possibly leading to intravascular coagulation. Pulmonary thromboembolism has been reported in some patients.

Metabolic Management

Ionized hypocalcemia is a recognized complication of blood transfusion in patients with liver failure because of their decreased ability to metabolize citrate. Patients undergoing liver transplantation may develop hypocalcemia when transfused during the preanhepatic and anhepatic stage, requiring calcium chloride administration. Hyperkalemia may develop in patients undergoing massive transfusion or having renal failure. This is best treated with glucose and insulin, which forces potassium into the cells, or washing of the red blood cells to reduce the potassium load. Metabolic acidosis is more common in patients with liver disease, especially when there is tissue hypoperfusion or massive transfusion. Sodium bicarbonate may increase sodium levels too quickly, possibly resulting in central pontine myelinolysis. However, tromethamine (THAM) also corrects metabolic acidosis but does not contain sodium, and therefore the use of tromethamine (THAM) contributes to the correction of metabolic acidosis but at the same time can ameliorate the hypernatremic effects of sodium bicarbonate. Ionized hypo-magnesemia has been documented, but its clinical consequences are unknown. Therefore, the administration of magnesium sulfate is still controversial.

Selected Readings

1. Marquez J, Martin D, Virji MA et al. Cardiovascular depression secondary to ionic hypocalcemia during hepatic transplantation in humans. Anesthesiology 1986; 65:457-461.

2. Kang YG, Lewis JH, Navalgund A et al. Epsilon-aminocaproic acid for treatment of fibrinolysis during liver transplantation. Anesthesiology 1987; 66:766-773.

3. Krowka MJ, Cortese DA. Hepatopulmonary syndrome: an evolving perspective in the era of liver transplantation (editorial). Hepatology 1990; 11:138-142.

4. De Wolf AM, Begliomini B, Gasior T et al. Right ventricular function during liver transplantation. Anesth Analg 1993; 76:562-568.

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