Post hemihepatectomy care
OVERVIEW
- major surgery
- perioperative mortality = 3%
- usual indication = metastatic colorectal adenocarcinoma or cholangiocarcinoma
- complications common post operatively
INTRAOPERATIVE
- be prepared for catastrophic blood loss (10U crossmatch)
- use shorting acting drugs that are ideally minimally metabolised by liver
- invasive monitoring
- massive access (12Fr CVL or 7.5Fr Swan-Ganz introducer)
- thoracic epidural effective
- preserve hepatic blood flow (use isoflurane or desflurane)
- keep CVP 0-2mmHg and SBP 70-80mmHg (decreases bleeding and congestion)
- actively warm
- subarachnoid morphine
- remifentanil
- clonidine 1-2mcg\kg IM
Stages
- perihepatic dissection
- identification of vascular anatomy
- may use intraoperative U/S to pinpoint lesions
- resection
Resection causes bleeding that may need to be controlled using Pringle Manoeuvre (intermittent cross clamping of vascular inflow) -> may cause ischaemic injury
POSTOPERATIVE
General Problems
- bleeding/coagulopathy -> day 3: INR 1.2-1.8 + on LMWH! -> just when you want to pull epidural!
- hypothermia
- anaesthesia: partially reversed, N+V, pain, excessive analgesia
- cardiovascular: hypotension (mult-factorial), acute coronary syndrome, CVA, arrhythmias
- respiratory: atelectasis, pleural effusions, early infection, TRALI
- renal: oliguria, ATN -> ARF
- gastric stasis
- VTE risk
- sepsis
Specific Problems
- pre-morbid conditions: ulcerative colitis -> primary sclerosing cholangitis, metastatic disease, steroids, immune state, nutrition
- coagulopathy -> bleeding: multifactorial
- pathophysiological cardiovascular changes: increased splanchnic blood flow, increased Q
- liver dysfunction: early sign = low urea day 1
- liver failure: within 72 hrs (jaundice, encephalopathy, coagulopathy, transaminitis)
- cholangitis
- respiratory: right pneumo/haemothorax, right diaphragmatic dysfunction
- gastrointestinal: ileus, ascites, haemorrhage, anastomotic leak
- renal: hepatorenal syndrome
- metabolic: hyperlactataemia, hypernatraemia, hypokalaemia
References
- Allman KG, Wilson IH. Oxford Handbook of Anaesthesia
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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