A 24-year-old man presented as a living donor for LT. Preoperative evaluation revealed a 2.5-pack-year smoking history without any other past medical history or abnormal laboratory/imaging findings.

Spinal and general anesthesia was planned, and 2 mg of midazolam was administered intravenously as a sedative. Spinal anesthesia was performed using 27 G Whitacre needle with a midline approach at L4-5. Morphine sulfate (400 ㎍) was injected intrathecally without any acute complications. Intravenous thiopental (350 mg) was administered as an induction agent and vecuronium (8 mg) was used as a neuromuscular blocking agent. Continuous remifentanil infusion beginning at 0.2 ㎍/kg/min was administered to control pain, as well as to manage discomfort caused by intubation. After mask ventilation with 100% oxygen and isoflurane for 3 min, intubation was performed with ease. The arterial catheter was placed in the right radial artery for monitoring.

Anesthesia was maintained with isoflurane and continuous infusions of both vecuronium and remifentanil. Plasma solution A^® was used for hydration at a rate of 200 ml/h. The Pringle maneuver was applied for 17 min 40 s without significant hemodynamic instability. Four hours after induction, 5,000 units of heparin were administered intravenously and the graft was harvested. Hydroxyethyl starch solution (500 ml) was infused following the harvest, and isoflurane was changed to desflurane. Pyridostigmine (15 mg) paired with glycopyrrolate (0.4 mg) was given as a reversal agent, and 25 mg of pethidine was given as well. Total urine output was 130 ml and the estimated blood loss (expressed as lost red blood cell [RBC] mass was) 463 ml [7]. The donor was transferred to the post-anesthesia care unit after surgery and was discharged on the 10th postoperative day (POD) without any complications; no transfusions were required.

A 59-year-old woman presented for living donor LT and as a liver donor for domino LT. She presented with symptoms of edema and paresthesia of both lower extremities 7 years ago and was found to have cardiomegaly on chest radiography. She was diagnosed with amyloidosis 1 year previously while undergoing a pericardial window operation for pericardial effusion.

Airway examination showed macroglossia. Laboratory findings showed a decrease in hemoglobin concentration (10.1 g/dl); prolongation of prothrombin time (PT) expressed as an international normalized ratio (INR) of 1.13; and elevated cardiac markers (troponin I 0.131 ng/ml [reference range: < 0.04 ng/ml], NT-proBNT 2,739 pg/ml [reference range: < 222 pg/ml]). Chest radiography was consistent with previous findings of cardiomegaly without active lung lesions. Sinus rhythm with atrial premature complexes and left ventricular hypertrophy were found in electrocardiogram. An echocardiogram showed increased left ventricle (LV) wall thickness, diastolic dysfunction (grade 2) with increased LV filling pressure, both atrial enlargement, and a moderate amount of pericardial effusion. The LV ejection fraction was 60.5% without regional wall motion abnormality. The right ventricle cavity size and systolic function were normal. These findings were an improvement compared to echocardiogram findings from 4 months previously. During consultations, cardiologists agreed that the patient’s cardiac condition had improved and that she would be able to undergo the operation. Nerve conduction study results were suggestive of amyloidosis-associated polyneuropathy with abnormal electrophysiology. Autonomic nerve function tests showed severe sudomotor, adrenergic, cardiovagal autonomic dysfunction. After consulting with cardiologists, we decided to proceed without inserting a temporary pacemaker. Instead, an external patch and defibrillator were prepared in the operating room for possible intraoperative cardiac complications such as severe atrioventricular block. Prior to induction, trans-esophageal echocardiography (TEE) was set up in the operating room to ensure that it was ready to use if needed; however, it was not inserted to prevent complications such as varix bleeding.

The arterial line was acquired with administration of local anesthesia before induction in order to monitor arterial blood pressure during induction. Induction was successfully done with 16 mg of etomidate, 8 mg of vecuronium, and isoflurane. Intubation was easily performed with a Macintosh blade #3. Macroglossia with nodules due to amyloidosis was noted, but the vocal cord was spared for infiltration. An additional arterial line at the right femoral artery was acquired. The central venous line was also placed in the right femoral and right internal jugular veins. A multifunction pulmonary artery catheter was inserted to monitor cardiac output, pulmonary arterial pressure, pulmonary artery occlusion pressure, and mixed venous oxygen saturation. During these procedures, the patient’s heart rate did not change in response to the stimuli, such as intubation or line insertion. Instead, the heart rate slowly but continuously decreased to 48 beats/min. Isoproterenol (1 ㎍/min) was administered and the heart rate increased to 80 beats/min. Isoproterenol was tapered to 0.5 ㎍/min and the infusion rate was maintained. Remifentanil and norepinephrine were used appropriately to control blood pressure, and vecuronium was infused continuously to ensure adequate neuromuscular blockade.

Blood flow to and from the left lobe was kept intact to minimize the changes in hemodynamics throughout the procedures. Post-reperfusion syndrome was noted with a decrease in mean arterial pressure from 75 to 36 mmHg without a change in heart rate (92 beats/min). Pulmonary arterial pressure decreased from 18 to 13 mmHg. Phenylephrine (50 ㎍) was administered and the continuous infusion rate of norepinephrine was increased; autologous blood from Cell Saver was transfused to normalize the blood pressure. Hemodynamic parameters remained stable after the intervention with a vasopressor; thus, TEE was not used throughout the procedure.

The total urine output was 685 ml, and the estimated lost RBC mass was 641 ml [7]. One unit of pre-leukocyte-reduced RBC (PLRBC) and 471 ml of autologous blood from Cell Saver was transfused and the operation commenced uneventfully. The patient was transferred to the intensive care unit (ICU) while intubated after removal of the pulmonary artery catheter. Continuous isoproterenol infusion was maintained during the transfer to the ICU. During the transfer from the operation table to the hospital bed, the external patch was incidentally removed but was not reattached because the patient’s vital signs were stable.

Postoperative laboratory values were as follows: hemoglobin 9.6 g/dl, platelet counts 114 × 10³ /μl, PT INR 1.62, and fibrinogen 180 mg/dl. Five hours later, continuous infusion of vasopressin (0.03 unit/min) was added to maintain blood pressure, and isoproterenol infusion was stopped due to sinus tachycardia (120 beats/min). On the 1st POD, the patient showed stable vital signs and an alert mental status; thus, the patient was weaned off the ventilator and the endotracheal tube was removed. The patient remained alert and vital signs were stable after extubation. However, after 1 h, the patient suddenly complained of chest discomfort, and her mental status changed to stupor. Vital signs showed a blood pressure of 66/19(30) mmHg, heart rate of 120 beats/min, and SpO₂ of 94%; intubation was performed immediately. One liter of Plasma Solution A^® and 1 unit of PLRBC were administered rapidly, and a continuous infusion of norepinephrine (0.6 ㎍/kg/min) was started. Two hours and eight minutes after intubation, ventricular tachycardia was observed on electrocardiogram. Cardioversion with 200 J was performed twice, and amiodarone (150 mg) was administered intravenously as a loading dose. A blood pressure of 81/51(59) mmHg with a heart rate of 130 beats/min was achieved after the intervention. Three units of fresh frozen plasma and six units of cryoprecipitate were transfused. However, after 1 h and 3 min of cardioversion, pulseless electrical activity (PEA) occurred. Cardiopulmonary resuscitation (CPR) was performed with a total bolus injection of epinephrine (14 mg) and recovery of spontaneous circulation (ROSC) was achieved; a continuous infusion of dobutamine (5 ㎍/kg/min) was added. Eighteen minutes after the first ROSC, PEA was checked again and we performed CPR for a second time. Ten minutes after the second CPR session, ROSC was achieved again. However, 13 min after the second ROSC, PEA occurred again. CPR was started for a third time, but she died 4 h and 37 min after intubation.

A 64-year-old man agreed to undergo domino LT. He was diagnosed with liver cirrhosis due to hepatitis B virus infection and had undergone multiple transarterial chemo-embolization due to hepatocellular carcinoma. Without a living donor and with a low model for end-stage liver disease score of 9, he was not eligible for LDLT or deceased donor LT (DDLT). He agreed to undergo domino LT with a liver graft from an FAP patient.

The patient was on medication for hypertension and diabetes mellitus II. Laboratory findings were consistent with cirrhotic liver and chronic illness showing a hemoglobin of 8.6 g/dl, platelet count of 89 × 10³ /μl, and a prolonged prothrombin time (INR) of 1.34. All other test results were within the normal range. Upper and lower gastrointestinal endoscopy was performed and no active bleeding lesions were found, but esophageal and gastric varices were found.

Induction was performed with thiopental (325 mg), atracurium (40 mg), and sevoflurane. Intubation was performed with ease and without complications. Arterial and central lines were placed with a multifunction pulmonary artery catheter. Anesthesia was maintained with isoflurane and continuous infusion of atracurium. The liver was uneventfully extracted. At the start of the anhepatic phase, Hepabig 10,000 IU mixed with 200 ml of 5% dextrose solution was infused. Dopamine and norepinephrine were given at rates of 3 ㎍/kg/min and 0.05 ㎍/kg/min, respectively, to maintain blood pressure. The total urine output was 1,100 ml, and the estimated lost RBC mass was 874 ml. Three packs of PLRBC and 100 ml of blood from Cell Saver were transfused. The patient was transferred to the ICU while still intubated. He was moved to the general ward on the 6th POD without any complications and was discharged 2 weeks later.