Living Donor Liver
- Airway
- Oral ETT. NGT.
- Induction
- Standard
- Maintenance
- Gas/paralytic
- Emergence
- Extubate
- Antibiotics
- Ampicillin/sulbactam 20 mL x1
- Position
- 0. Arms out. Underbody Allon water warmer +/- upper body air warmer. Low CVP during transection to minimize blood loss, avoid excessive preload, replace blood loss judiciously. If need be, raise/lower transducer for a certain surgeon (O.) who wants CVP < 5. Try to keep euvolemic to dryer side.
- Access
- PIV x2-3 large (14 or 16), Triple Set \[Art Line, Triple lumen RIJ\], No TEE probe.
- Pressors
- Vasopressin 20 mL x1, dilute epinephrine x3, code epinephrine x3, calcium chloride x3, nicardipine x1
- Sugars
- Dextrose 50 mL x1
- Misc
- Glycopyrrolate, succinylcholine, albumin 5% x4-8.
- Alaris
- 0/0/phenylephrine/0 || 0/0/0/runner
- Fluids
- Warm line x2 (RBC, FFP).
- Blood
- 4RBC (check to see if the patient donated an autologous unit of RBC) / 4FFP
After resection: re-expand volume to prevent renal or liver hypoperfusion.
Pain plan (see screenshots Penn Pathway)
Pre-op: acetaminophen PO 975 mg + gabapentin 300 mg, ordered by transplant service.
Prior to induction: single shot intrathecal morphine 200 mcg (careful to not use hydromorphone intra-op or post-op, due to concern for respiratory depression with intrathecal morphine having delayed 2nd peak). The morphine is the 10 mg/10 mL vial (draw up 1 mL, and then use a 1 mL syringe to draw up 0.2 mL). Once CSF is obtained, draw back CSF to mix in the morphine successfully. Also, have monitors (BP, SpO2) on + IV running + midazolam during spinal.
Intra-op:
Ketamine 0.35 mg/kg induction, then 0.15 mg/kg/hr (up to 150 mg total for case).
Magnesium 2 g on surgical incision.
Magnesium 2 g one hour prior to case end.
Acetaminophen 500 mg at case end (if > 6 hr from initial admin).
Ketorolac 15 mg at case end.
Fentanyl PRN.
Emergence: TAP block with 0.2% ropivacaine.