TRASPLANTE HEPTICO

TCNICA QUIRRGICA

Etapa I: Preanhepatica

Etapa II: Anheptica

Etapa III: Reperfusin

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 PREANHEPTICA

Inicia al momento de la transfusin

Diseccin de Hgado e Hilio
Sangrado (Re-operados)
Hipertensin Portal
Circulacin colateral mesentrica

FLUJOS
Arterial
Portal

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 PREANHEPTICA

Diseccin VCI Hepatectoma

Escisin completa Cava

Retroheptica junto con el Hgado

- Accesos IV VCS

- Prueba Hemodinmica de Clipaje

- Rpido
- Requiere anastomosis Cava Inferior antes de Reperfusin alargando
Isquemia Caliente

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 PIGGY-BACK

Se pinzan y Se expone
seccionan VCI
ramas V. Porta infraheptica
para hacer y se pinza
mas grande la lateralmente
boca en su cara
anastomotica inferior

Anastomosis Porto-Cava Termino lateral

Objetivo: Asegurar drenaje Esplcnico

Tiempo >
No hay inestabilidad hemodinmica
Vasos colaterales Sistma Acigos

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 ANHEPTICA

Reanudacin del flujo del injerto

Reperfusin
Hiperpotasemia
Acidosis
Labilidad hemodinmica

Inmunosupresores / Corticoides

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 REPERFUSIN

Hemostasia - Anastomosis Cavales y Portales

Presin Perfusin

Ultrasonido Doppler Intraoperatorio

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 VA BILIAR

Anastomosis biliar Entrica

Hgado denervado
100% (Flujo Biliar)

Cierre abdominal
(Sx Compartamental)
Edema visceral

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 BYPASS VENO-VENOSO

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 ANESTESIOLOGA

Semiurgente
Premedicacin VO i IN
Monitoreo estandar
Preoxigenacion

Induccin de secuencia rpida

Atropina 10-20 mcg/kg
Tiopental 3-5 mg/kg
Propofol 2-5 mg/kg
Etomidato 200-300 mcg/kg
Ketamina 1-2 mg/kg
Rocuronio 1mg/kg
Succinilcolina 1-2mg/kg ** D- Pseudocolinesterasas
A+ 0.5-0.7 mmol/L K
Cisatracurio / Vecuronio

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 POSICIN

Brazos guardados
Codos flexionados
Clido
Seco
Zonas de presin sea

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 MONITOREO

PAM extremidades superiores

PVC
Sonda urinaria
2 accesos vasculares grueso calibre

PAP **

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 VENTILATORIO

ETCO2 35-40mmHg
PEEP 5cmH2o
FiO2
NO

IOT Sonda armada

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 EVITAR HIPOTENSIN

En el hgado denervado la presin depende de

Flujo sanguneo

Halogenados (Isoflourano Sub-MAC- Fentanilo)

Alfa 1 agonistas
Hipovolemia
Acidosis
Hipercapnia

Efecto clnico deseado

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 CAMBIOS CARDIOVASCULARES

Etapa I: Hipotensin por Sangrado (Plaquetopenia,

Bridolisis), Compresin VCI, Drenaje de ascitis.
Arritmias ; Pinzamiento Supraheptica
Etapa II: D- GC, RVP y PAP con A+ compensatorio FC y
RVS
Coliodes/ Cristaloides/ Vasopresores (Dopa/ NE/ Adrena/ Fenilefrina
Hgado donante se purga contracorriente
A+ PAP al despinzar
Isquemia caliente < 60 minutos
Etapa III: Hipotensin severa por Reperfusin, Bradicardia,
Arritmia, Paro 0.5%

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 SNDROME POSTREPERFUSIN

Solucin fra, Acidotica e Hipercaliemica

Disminucin PAM y FC > 30%
1-5 minutos de la Reperfusin

ECO: D- Volumen Telediastolico VI

Hipertensin
Congestin
Hemorragia
Edema agudo pulmonar

Furosemide/ Nitroglicerina/ Morfina/ Oxido nitrico/ Prostaglandinas E1

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 HEMOSTASIA, COAGULACIN Y
PERDIDAS SANGUNEAS
Variable

Predictores independientes
Child-Pugh
TP
Previa Ciruga abdominal
Hematocrito
Factor V
Tamao Porta
Tiempo quirrgico

Monitoreo Horario de Tp, TTPa, Plaquetas, Dmero D, TEG

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 FIBRINOLISIS

80%
Aprotinina
Acido aminocaproico
Acido Tranexamico

Heparina Endogena del hgado y de la solucin de

preservacin

Calcio
Magnesio

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 TRASFUSIN?

Trombosis de la arteria heptica

Hipercoagulabilidad
Hct 20-30% (Viscosidad )

Dimetro dependiente

Prot C y Antitromibina III reducen 50% por 10 das

Heparina IV
Dextran 40
Aspirina
Antitrombina III

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 RN
Deficiencia de factores Vit K
dependientes (II, VII, IX y X)
Protena C hasta 6 meses
(Inhibe VIII y V)
Protena S hasta 3 meses

Mezcla
Plasmalyte
1 UI CE
1 UI PFC

Ahorradores celulares

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 ALTERACIONES DE LA GLUCOSA

CE: 84mg/dL al da 35 de almacenamiento

Liberacin de glucosa por los hepatocitos isqumicos

Resistencia a la insulina inducida por esteroides

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 HIPOCALCEMIA

Ionizada Citrato
Significativa > 0.56 mmol/L

Hipomagnesemia D- Contractilidad

HCO3 Dficit de base < 5 meq/L

Calcio anticipadamente

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 POTASEMIA

Insuficiencia heptica crnica

Diurticos/ Aldosterona

No se reemplaza

Hiper Tto agresivo

Transfusin masiva (76mEq/L/35 das almacenamiento fro)

Diurticos
Insulina + Glucosa
Postreperfusion 7-12 mEq/L transitoria con redistribucin a los 2 min

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 REGULACIN DE LA TEMPERATURA

Exposicin
Lquidos IV

Evaporacin /Radiacin

Preservacin rgano 4C

NORMOTERMIA 35

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 FUNCIN PULMONAR

Capacidad pulmonar y de difusin deteriorada

Lesin pulmonar aguda por Transfusin

Edema agudo pulmonar por Terapia IV

Parlisis Diafragmtica 55%

Extubacion?

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 FUNCIN RENAL

Congestin renal en la fase anhepatica secundario

al pinzamiento vena infrahepatica D- diuresis

Manitol
Furosemide
Dopamina 1.5 mcg/kg/min

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
 TRASPLANTE DIVIDIDO

Bismuth y Houssin

Mayor tiempo de isquemia fra

Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama
Smiths Anesthesia for Infants and Children, 8th Edition, edited by Drs. Peter J. Davis, Franklyn P. Cladis, and Etsuro K. Motoyama