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, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC