Liver resection

 

Intra-op issues:

Bleeding

Risk factors:

     Liver disease

     Anticoagulants

     ↑CVP (heart failure, TR)

Mitigation:

     Usual: access, warming, products

     Haemostatics: TXA

     CVP <5cmH2O (head up, ↓PEEP, ↓fluid, GTN)

     Clamping

Air embolism

Risk factors:

     ↓CVP

     Open veins

Mitigation:

     Head down 15 degrees

Clamping

During clamp:

     Cardiovascular:

o   Segmental occlusion -> minor insult

o   Inflow occlusion (portal triad) -> ↓CO 10%, ↑afterload 25%

o   Total occlusion (IVC + liver pedicle) -> ↓CO 60%, ↓↓mAP

     Metabolic:

o   Hypoglycaemia

o   Acidosis

After clamp: reperfusion

     Cardiovascular:

o   Vasodilation

o   Myocardial depression

     Metabolic:

o   Hyperkalaemia

-> Fluid, pressor, calcium

 

Post-op issues:

Liver failure

Risk factors:

     Patient: old age, diseased liver (especially Child-Pugh B or C)

     Surgery: resection >50%, ischaemic time >60 mins

Mitigation:

     Ischaemic pre-conditioning

     Intermittent clamping (10-15 mins on, 5 mins off)

     NAC infusion

     NJT feeding and lactulose; NGT drainage

Consequences:

     Liver: coagulopathy, encephalopathy, ↓BSL, ↓Na+

     Other organ failure: lung, kidney, heart

     Death

Pain relief

     Systemic: beware accumulation and encephalopathy

     Regional: beware coagulopathy (TEA vs ITM vs TAP catheters)

Other

     Hypophosphataemia

     Feeding to maintain gut function and immunocompetence

 

 

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