Intraoperative hemodynamic monitoring during liver transplantation: goals and devices

With the introduction of orthotopic liver transplantation (OLT) almost 40 years ago, changes in the cardiovascular system that manifest during the different phases of the operation combined, sometimes with massive hemorrhage in likely critically ill patients have been a challenge. Here hemodynamic monitoring of the patients during OLT is addressed with focus on maintaining the patients' central blood volume (CBV) and methods and devices that can serve that purpose are listed. It is considered that a stable CBV maintains cerebral blood flow and oxygenation and thereby the well-being of the patient, while even a small reduction in blood pressure affects cerebral blood flow and oxygenation if it reflects a reduced CBV and thereby cardiac output. In that regard it is accepted that for the patient going through OLT cardiac output (~8 L/min-1) and also venous oxygen saturation (~85%) are larger than for other categories of patients when a flow related parameter (cardiac stroke volume, cardiac output or (mixed) venous oxygen saturation) does not respond to a fluid challenge, i.e. the patient is "normovolaemic". Also the administration strategy for liver transplantation is considered with emphasis on haemostatic control resuscitation, i.e. balanced administration of red blood cells, plasma and platelets to massively bleeding patients.