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

Feedback welcome at ketaminenightmares@gmail.com