The Weight of Balance: Anesthetic Management in Liver Transplantation for Critically Ill Patients. A Case Report

Liver transplantation in critically ill patients with multiple organ dysfunction poses a unique anesthetic challenge due to profound coagulopathy, hemodynamic instability, and metabolic derangements.

We describe a 50-year-old male with alcoholic cirrhosis (MELD-Na 27) who underwent 2 consecutive liver transplants within 72 hours. The initial surgery involved aspiration of 15 L of purulent ascites and 8000 mL of blood loss. Advanced hemodynamic monitoring, balanced fluid therapy with albumin, vasopressor support (norepinephrine and vasopressin), goal-directed coagulation management (ROTEM), and strict metabolic control were implemented. Post-reperfusion hypotension and bradycardia were managed with adrenaline and atropine. Twelve hours later, he was reoperated for hemoperitoneum and subsequently underwent urgent retransplantation for hepatic artery thrombosis. Hemodynamic stability was achieved during the second procedure. Despite successful graft perfusion, the patient developed pneumonia and renal failure requiring replacement therapy, leading to a fatal outcome.

Physiology-guided anesthesia can sustain intraoperative stability in extreme scenarios, but outcome depends on preoperative physiological reserve and timing of intervention.