Multisystemic Anesthetic Management and Patient Blood Management in Urgent Liver Transplantation for Acute-on-Chronic...

Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality and frequently requires urgent liver transplantation. Perioperative management is challenging due to severe hemodynamic instability, coagulopathy, systemic inflammation, and multiorgan dysfunction. Optimized anesthetic strategies combined with Patient Blood Management (PBM) principles may improve outcomes and reduce transfusion-related complications.

We report the case of a 42-year-old woman with chronic cholestatic liver disease who developed ACLF with hepatic encephalopathy, systemic infection, and hepatorenal syndrome, requiring urgent liver transplantation with a deceased donor graft. Intermittent hemodialysis was initiated preoperatively due to renal dysfunction. The procedure was performed under total intravenous anesthesia with advanced multimodal monitoring, including invasive hemodynamic assessment and cerebral oximetry. Intraoperatively, the patient developed severe vasoplegia requiring high-dose vasoactive support. Fluid therapy followed a restrictive strategy, and coagulation management was guided by viscoelastic testing. Intraoperative blood conservation strategies, including cell salvage, were applied, and no allogeneic blood components or other blood-derived products were required. Postoperatively, the patient was admitted to the intensive care unit under vasoactive support, with progressive hemodynamic stabilization, recovery of renal function, and resolution of encephalopathy. She was discharged home without major complications.

This case highlights the importance of individualized anesthetic management and strict application of PBM principles in urgent liver transplantation for ACLF. Advanced monitoring, goal-directed therapy, and restrictive transfusion strategies may contribute to improved perioperative stability and favorable postoperative recovery. This case report complies with the Declaration of Helsinki and the Declaration of Istanbul regarding ethical organ donation.