Uh Oh…Is That Supposed To Be There???

By:  SK Shillcutt, MD, FASE

The use of transesophageal echocardiography (TEE) in liver transplantation is often used to manage hemodynamics, measure pulmonary artery pressures, and guide therapeutic interventions.  After graft implantation, the caval clamps are removed, and is often a time of significant cardiopulmonary changes.  Anesthesiologist can use TEE to watch for right ventricular failure, a common cause of hypotension and arrhythmias after unclampling. TEE can be used to identify proper filling, right ventricular distention, right ventricular function, tricuspid regurgitation and right-sided cardiac outputs.

With improvements in survival of post liver transplantation, older patients have become eligible for transplantation.1  These patients often have higher prevalence of coronary artery disease and other coronary risk factors.  Recent studies show that echocardiography perioperatively reduces incidence of cardiac and pulmonary events.  Cotton, et al uses positive predictive value to show that echocardiography is a useful tool in estimating pulmonary artery systolic pressure in liver transplant patients as part of the preoperative evaluation.2 The use of transesophageal echocardiography (TEE) performed continuously through liver transplantation has shown to provide clarification the mechanism of myocardial dysfunction, visualize and lyse thrombous or embolisms, and asses ventricular function following transplantation.3-12

Common echocardiography findings after unclamping during liver transplantation associated with right ventricular failure are right ventricular dilation, right ventricular dysfunction, intraatrial septal bowing to the left, right to left shunting through a patent foramen ovale, worsening tricuspid regurgitation from baseline, pulmonary hypertension, microemboli consistent with air and/or debris, and acute thromboemboli.

The more recently reported phenomenon of intraoperative cardiopulmonary thromboembolism has been a major contributor to patients mortality and morbidity during and following liver transplantation.6,7  Although this is a rare event, it is often a lethal complication during orthotopic liver transplantation.  Frequent clinical symptoms include systemic hypotenstion and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse.8  Retrospective studies show a relationship between cardiopulmonary-related mortality and initial (untreated) pre-orthotopic liver transplantation pulmonary hemodynamics.13  Additional pulmonary complications that arise from liver transplantation include heptaopulmonary syndromes and portopulmonary hypertension and generally believed to adversely affect outcome after liver transplantation. Echocardiography is able to detect severe pulmonary hypertension syndrome, and information can be used to diagnose, treat and follow critical cardiac events during the intraoperative period.14,15,16

Learning Objectives:

1.  Right heart failure is a complication of unclamping the vena cava during liver transplantation.

2.  Causes of right heart failure during liver transplantation can be microemboli from air and debris, thromboembolus, acute or chronic (or both) pulmonary hypertension, severe tricuspid regurgitation, acute distension from volume overload, acidosis, hyperkalemia or ischemia (multiple factorial).

3.  Transesophageal echocardiography (TEE) can rapidly identify thrombus, emboli, right ventricular function, triscuspid regurgitation, filling pressures, right sided cardiac output, as well as left-sided function and filling.

Figure 1

Figure 2


  1. Tiukinhoy-Liang SD, Rossi JS, Bayram M, De Luca L, Gafoor S, Blei A, Flamm S, Davidson CJ, Gheorghiade M. Cardiac hemodynamic and coronary angiographic characteristics of patients being evaluated for liver transplantation. Am J Cardiol 2006;98:178-81
  2. Mejia A, Mendoza ML, Kieta D, Guiden H, Aramoonie AES, Lee GW, Cheng S. Nonfatal intracardiac thromboembolism during liver transplantation. J Cardiothorac Vasc Anesth 2010;24:109-11
  3. Cotton CL, Gandhi S, Vaitkus PT, Massad MG, Benedetti E, Mrtek RG, Wiley TE. Role of echocardiography in detecting portopulmonary hypertension in liver transplant candidates. Liver Transpl 2002;8:1051-4
  4. Ellis JE, Lichtor JL, Feinstein SB, Chung MR, Polk SL, Broelsch C, Emond J, Thislethwaite JR, Roizen MF. Right heart dysfunction, pulmonary embolism, and paradoxical embolization during liver transplantation. Anesth Analg 1989;68:777-82
  5. Ellenberger C, Mentha G, Giostra E, Licker M. Cardiovascular collapse due to massive pulmonary thromboembolism during orthotopic liver transplantation. J Clin Anesth 2006;18:367-71
  6. Lerner AB, Sundar E, Mahmood R, Sarge T, Hanto DW, Panzica PJ. Four cases of cardiopulmonary thromboembolism during liver transplantation without the use of antifibrinolytic drugs. Anesth Analg 2005;101:1608-12
  7. Xia VW, Ho JK, Nourmand H, Wray C, Busuttil RW, Steadman RH. Incidental intracardiac thromboemboli during liver transplantation: incidence, risk factors, and management. Liver Transpl 2010;16:1421-27
  8. O’Connor CJ, Roozeboom D, Brown R, Tuman KJ. Pulmonary thromboembolism during liver transplantation: possible association and antifibrinolytic drugs and novel treatment options.  Anesth Analg 2000;91:296-9
  9. Warnaar N, Molenaar IQ, Colquhoun SD, Sloof MJH, Sherwani S, De Wolf AM, Porte RJ. Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review. J Thromb Haemost 2008;6:297-302
  10. Gologorsky E, De Wolf AM, Scott V, Aggarwal S, Dishart M, Kang Y. Intracardiac thrombus formation and pulmonary thromboembolism immediately after graft reperfusion in 7 patients undergoing liver transplantation. Liver Transpl 2001;7:783-89
  11. De Wolf AM, Begliomini B, Gasior TA, Kang Y, Pinsky MR. Right ventricular function during orthotopic liver transplantation. Anesth Analg 1993;76:562-8
  12. Krowka MJ, Plevak DJ, Findlay JY, Rosen CB, Wiesner RH, Krom RAF. Pulmonary hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation. Liver Transpl 2000;6:443-50
  13. Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y. Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation.  Liver Transpl Surg 1996;2:426-30
  14. Krowka MJ, Mandell MS, Ramsay AE, Kawut SM, Fallon MB, Manzarbeita C, Pardo Jo M, Marotta P, Uemoto S, Stoffel MP, Benson JT. Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. Liver Transpl 2004;10:174-82
  15. Starkel P, Vera A, Gunson B, Mutimer D. Outcome of liver transplantation for patients with pulmonary hypertension. Liver Transpl 2002;8:382-88
  16. Hofer CK, Zollinger A, Rak M, Matter-Ensner S, Klaghofer R, Pasch T, Zalunardo MP.  Therapeutic impact of intra-operative transesophageal echocardiography during noncardic surgery. Anaesthesia 2004;59:3-9

UNMC at the ASA

It’s that time of year again. The leaves are turning, the air turns crisp and half the department disappears to some exotic local to come back more intelligent, more connected and perhaps more disheveled. . . .

It’s time for the ASA.

Technically, it was not quite half of the department up in Chicago but we had excellent representation this year at ASA.   Check out the number of posters presented by our department:

Saturday October 15th 

Pulmonary Embolus prior to Anhepatic Phase of Orthotopic Liver Transplant; Nick Markin & Tom Schulte

Right-to-left Shunting through a Patent Foramen Oval (PFO) Leading to Acute Myocardial Ischemia during Total Hip Arthroplasty (THA) Revision: Use of Rescue Transesophageal Echocardiography (TEE); Mark Reisbig & Sasha Shillcutt

A Comparison of Direct versus Indirect Laryngoscopy during Endotracheal Intubation of Lightly Embalmed Cadavers utilizing the Glide Scope®, Storz Medi Pack Mobile Imaging System ™ and the Storz C-MAC™  Videolaryngoscopes;  BenBoedeker & Tom Nicholas
Reexpansion Pulmonary Edema in an Orthotopic Liver Transplant Recipient; Derek Fulcher & Kristina Birch

Fatal Air Embolus during Endoscopic Retrograde Cholangiopancreatography; Nick Markin & Candice Montzingo

Sunday, October 16, 2011

Performance Comparison of Laryngoscopy and Suction Techniques in a Hemorrhagic Airway Manikin Simulator: Direct Laryngoscopy with Yankauer vs Storz C-MAC with Attached Suction Tip; BenBoedeker & Tom Nicholas
Virtual Intubation Training at a Remote Military Site; Ben Boedecker & Nick Markin  

Acute Pulmonary Embolism during Induction of Anesthesia in a 20-year-old with a Left Malleolar Fracture; Elford Stephens & Katie VanDemark

Massive Blood Transfusion in a 25 kilogram 10-year-old for a Liver, Small Bowel, Pancreas and Kidney Transplant; MichaelLankhorst & Katie VanDemark

Monday, October 17, 2011

Ex-Utero Intrapartum Treatment: An Anesthesia Challenge; Dustin Ward & Sheila Ellis        

PE and Antithrombin Three; Michael Lankhorst and Kristina Birch

Noninvasive Hemoglobin Measurement Assistance for a Pediatric Solid Organ Transplant; Jim Sullivan & Ankit Agrawala

Tuesday, October 18, 2011

Seratonin Toxicity after Administration of Methylene Blue for Vasoplegia; Megan Chacon & Jim Chapin    

Advanced Medical Technology Capacity Building: A Unique Application of SOF Counterinsurgency Medical Seminars Medical Programs; Ben Boedeker & Tom Nicholas

Use of Cardiac Algorithm in a Preoperative Evaluation Clinic—A Pilot Study; Ben Boedeker & Tom Nicholas

Video or Direct Laryngoscopy, Does It Really Make a Difference? A Retrospective Comparison of 155 Emergency Cases from 2009-2010; Tom Schulte & Ankit Agrawal

If you are keeping track, that is 16 posters this year!  Not to mention the faculty who headed up the NAPE booth and several faculty and residents representing us on the political front.  

And finally a word of thanks to those who stayed behind and kept the clinical services afloat,  it’s this kind of the teamwork that promotes our academic and clinical missions and makes this department great.



Welcome to the UNMC Anesthesia blog! 

The purpose of this blog is to serve as a venue for news, information and education.  Check in here to not only get information about events happening in the department but also articles about key topics in anesthesia, board question review and editorials. 

“Why a blog?” you ask.

My experience with blogs has largely been in the realm of hobbies and general news.  One day, however, I was visiting Anesthesiology’s website.  I noticed a link to subscribe to Page2.  Page 2 is the blog for the ASA publication and after subscribing I must say it is a great source for news in Anesthesia and recent articles in the Journal.  If you are anything like me, you perhaps don’t get Anesthesiology read cover-to-cover every month.  Page 2 is a great way to get clued in to the articles of interest.  It has also motivated me to pick up my copy of Anesthesiology and check it out.

This is just one example of how blogs create a platform for experts to share information in an entirely new way.   In fact, the use of blogs for medical education and in medicine in general is rapidly rising.   I hope you will check back in with us and see what we have to offer.  I have some great authors and posts lined up.

Here’s to living in the digital age,

Jennifer Adams, MD