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[ Home ](https://mdster.com) 2. [ Blog ](https://mdster.com/blog) 3. [ Case Discussion ](https://mdster.com/blog?category=case-discussion) 4. Liver Transplant Anesthesia: Reperfusion Collapse Case [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Liver Transplant Anesthesia: Reperfusion Collapse Case ======================================================== A high-yield case discussion on postreperfusion syndrome, hyperkalemia, TEG-guided bleeding management, and early graft function. [ MDster Editorial Team ](https://mdster.com/about) · May 25, 2026 · 6 min read · 335 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Board Review ](https://mdster.com/blog?tag=board-review) [ Anesthesiology ](https://mdster.com/blog?tag=anesthesiology) [ Coagulation ](https://mdster.com/blog?tag=coagulation) [ Liver Transplantation ](https://mdster.com/blog?tag=liver-transplantation) [ Postreperfusion Syndrome ](https://mdster.com/blog?tag=postreperfusion-syndrome) ![Liver Transplant Anesthesia: Reperfusion Collapse Case](https://mdster.com/storage/blog/images/liver-transplant-anesthesia-reperfusion-collapse-case.jpg) Share this article Share this post On this page 1. [ The Case: MELD 28 Meets Portal Unclamping ](#the-case-meld-28-meets-portal-unclamping) 2. [ Liver Transplant Phases: What the Examiner Wants ](#liver-transplant-phases-what-the-examiner-wants) 3. [ Reperfusion Collapse: Differential Diagnosis at the Bedside ](#reperfusion-collapse-differential-diagnosis-at-the-bedside) 4. [ Immediate Management: Treat the Rhythm and the Graft ](#immediate-management-treat-the-rhythm-and-the-graft) 5. [ Diffuse Oozing After Reperfusion: Reading the TEG ](#diffuse-oozing-after-reperfusion-reading-the-teg) 6. [ Citrate, Cell Salvage, and the Gray Zones ](#citrate-cell-salvage-and-the-gray-zones) 7. [ Leaving the OR: Is the New Liver Working? ](#leaving-the-or-is-the-new-liver-working) 8. [ Key Points for Board Exams ](#key-points-for-board-exams) 9. [ Conclusion ](#conclusion) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) On this page 1. [ The Case: MELD 28 Meets Portal Unclamping ](#the-case-meld-28-meets-portal-unclamping) 2. [ Liver Transplant Phases: What the Examiner Wants ](#liver-transplant-phases-what-the-examiner-wants) 3. [ Reperfusion Collapse: Differential Diagnosis at the Bedside ](#reperfusion-collapse-differential-diagnosis-at-the-bedside) 4. [ Immediate Management: Treat the Rhythm and the Graft ](#immediate-management-treat-the-rhythm-and-the-graft) 5. [ Diffuse Oozing After Reperfusion: Reading the TEG ](#diffuse-oozing-after-reperfusion-reading-the-teg) 6. [ Citrate, Cell Salvage, and the Gray Zones ](#citrate-cell-salvage-and-the-gray-zones) 7. [ Leaving the OR: Is the New Liver Working? ](#leaving-the-or-is-the-new-liver-working) 8. [ Key Points for Board Exams ](#key-points-for-board-exams) 9. [ Conclusion ](#conclusion) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) A cirrhotic patient who has tolerated hours of dissection can arrest within seconds of portal unclamping. In this case, the ECG tells the story before the arterial line does: bradycardia, widening QRS complexes, and profound hypotension immediately after graft reperfusion. Treat this as postreperfusion syndrome with acute hyperkalemia until proven otherwise. The Case: MELD 28 Meets Portal Unclamping ----------------------------------------- A 54-year-old, 78-kg man with alcoholic cirrhosis presents for orthotopic liver transplantation. He has refractory ascites, grade II encephalopathy, varices, hemoglobin 8.2 g/dL, platelets 45,000/µL, INR 1.9, and sodium 131 mmol/L. After RSI, arterial access, central access, rapid infusion capability, and TEE are established. Large ascites drainage during hepatectomy requires albumin and blood products. The anhepatic phase is stable, but the team watches lactate, potassium, ionized calcium, temperature, pH, and viscoelastic tracings. Then the portal vein is unclamped. BP falls to 55/30 mmHg, HR to 32 bpm, and the QRS widens. Liver Transplant Phases: What the Examiner Wants ------------------------------------------------ PhaseBoundaryDominant anesthetic concernPreanhepaticInduction to vascular isolation of native liverHemorrhage, ascites drainage, venous return swingsAnhepaticHepatic inflow/outflow clamped to graft reperfusionNo hepatic clearance of lactate, citrate, tPANeohepaticReperfusion through closurePRS, hyperkalemia, coagulopathy, graft assessment The phase matters because the physiology changes faster than the lab turnaround. During the anhepatic period, citrate and lactate accumulate, ionized calcium falls, and fibrinolytic tone may increase. Consequently, the patient arrives at reperfusion metabolically fragile even if the monitors appear acceptable. Reperfusion Collapse: Differential Diagnosis at the Bedside ----------------------------------------------------------- Postreperfusion syndrome is commonly recognized as a major MAP fall shortly after graft reperfusion, often within the first 5 minutes. In an oral board scenario, severe bradycardia with QRS widening should move hyperkalemia to the top of the list. Consider these simultaneously: - **Acute hyperkalemia** from cold preservation solution, graft washout, transfusion load, acidosis, and renal dysfunction. - Ionized hypocalcemia from citrate binding and absent hepatic metabolism. - Acidosis-related myocardial depression. - Air or thromboembolism, especially with abrupt RV failure on TEE. - Massive hemorrhage or impaired venous return. - Vasoplegia from ischemia-reperfusion mediators. TEE helps separate electrical collapse from mechanical catastrophe. A hyperdynamic empty LV suggests vasodilation or bleeding; acute RV dilation suggests embolic or pulmonary vascular pathology; globally poor contractility points toward acidosis, hyperkalemia, hypocalcemia, or ischemia. > **Clinical Pearl:** At reperfusion, do not wait for the potassium result if the ECG shows widening QRS complexes. Calcium is the temporizing drug that buys myocardial time. Immediate Management: Treat the Rhythm and the Graft ---------------------------------------------------- Management should be rehearsed before unclamping. Clinical judgment dictates exact dosing, but the priorities are consistent. 1. Announce severe PRS and request temporary surgical control if feasible. 2. Give calcium chloride through central access to antagonize hyperkalemic membrane toxicity and correct ionized hypocalcemia. 3. Use epinephrine boluses for bradycardia, vasodilation, and impaired contractility; escalate norepinephrine or vasopressin if vasoplegia persists. 4. Hyperventilate briefly and correct severe metabolic acidosis, often with sodium bicarbonate when pH and potassium physiology support it. 5. Treat hyperkalemia with insulin/glucose and adjuncts while preparing for renal replacement therapy if refractory. 6. Confirm volume status and ventricular function with TEE rather than reflexively flooding the patient. Insider tip: the best treatment begins before reperfusion. Many teams aim to enter unclamping warm, not acidotic, with acceptable ionized calcium, controlled potassium, and vasopressors already running at a modest dose rather than starting from zero during collapse. Diffuse Oozing After Reperfusion: Reading the TEG ------------------------------------------------- Thirty minutes later, the field shows microvascular bleeding. A TEG tracing with clot formation followed by rapid return toward baseline is hyperfibrinolysis until proven otherwise. A narrow MA also suggests inadequate clot strength from low platelets and/or fibrinogen. Management is not simply more FFP: - Give an antifibrinolytic, commonly tranexamic acid or aminocaproic acid, when VET supports clinically significant fibrinolysis and surgical thrombosis concerns are acceptable. - Replace fibrinogen with cryoprecipitate or fibrinogen concentrate if the functional fibrinogen component is poor. - Give platelets when MA remains low in the setting of thrombocytopenia and bleeding. - Correct ionized calcium, temperature, and pH because VET-guided transfusion fails if the enzymatic environment is hostile. As of May 2026, viscoelastic testing is widely used in liver transplantation, but device-specific thresholds vary. The defensible oral-board answer is pattern recognition plus targeted therapy, not memorizing a universal TEG number. Citrate, Cell Salvage, and the Gray Zones ----------------------------------------- Massive transfusion creates two classic citrate problems. First, citrate chelates calcium, causing ionized hypocalcemia, hypotension, reduced contractility, and coagulopathy. This is amplified during the anhepatic phase because citrate metabolism is impaired. Second, after the graft begins functioning, accumulated citrate can be metabolized to bicarbonate, producing delayed metabolic alkalosis. This is why serial ABGs and ionized calcium values matter even after the dramatic reperfusion moment has passed. Cell salvage may reduce allogeneic exposure, but hepatocellular carcinoma introduces concern for reinfusion of malignant cells. Many centers use leukocyte depletion filters or avoid salvage selectively. The key is not to state that cell salvage is categorically safe or prohibited; practice varies by institutional protocol and oncologic context. Leaving the OR: Is the New Liver Working? ----------------------------------------- Before transport, look for early graft function rather than a single reassuring number: - Lactate is falling or at least no longer climbing rapidly. - Glucose is stable, or hyperglycemia appears as hepatic metabolism resumes. - Coagulation improves clinically and on VET. - Bile production is present, when reported by the surgeons. - Hemodynamics are supportable without escalating rescue therapy. For ICU handoff, emphasize ventilation that avoids hepatic congestion. Use lung-protective ventilation, but avoid unnecessarily high PEEP or high mean airway pressure that worsens venous return, RV loading, and hepatic venous outflow. Key Points for Board Exams -------------------------- - Bradycardia plus wide QRS at reperfusion is hyperkalemia until proven otherwise. - PRS management prioritizes calcium, epinephrine/vasopressors, acidosis correction, potassium shifting, and TEE-guided volume decisions. - The anhepatic phase magnifies citrate toxicity and fibrinolysis risk. - A rapid clot lysis TEG pattern supports antifibrinolytic therapy, with platelets and fibrinogen guided by clot strength. - Early graft function is assessed by lactate clearance, glucose behavior, improving coagulopathy, bile production, and hemodynamic stabilization. Conclusion ---------- This case is a classic SOE trap because the correct answer is physiologic prioritization, not transfusion reflexes. At reperfusion, diagnose the lethal electrolyte pattern, stabilize the myocardium, use TEE to avoid blind resuscitation, and then let VET guide hemostasis. Frequently Asked Questions ---------------------------- ### What electrolyte abnormality most strongly fits bradycardia with wide QRS after portal unclamping? Acute hyperkalemia is most likely, especially immediately after graft reperfusion. Give calcium promptly while confirming potassium and acid-base status. ### Does diffuse bleeding after reperfusion always mean the patient needs FFP? No. Use TEG or ROTEM when available. Hyperfibrinolysis, low fibrinogen, thrombocytopenia, hypocalcemia, hypothermia, and acidosis require different treatments. ### Why is citrate toxicity worse during the anhepatic phase? The native liver has been removed and the graft is not yet functioning, so citrate metabolism is impaired. Citrate chelates ionized calcium and can worsen hypotension and coagulopathy. ### What ventilator issue should be highlighted during ICU handoff? Avoid unnecessarily high PEEP or high mean airway pressure because elevated intrathoracic pressure can impair venous return and hepatic venous outflow. References (4) ------------------ 1. 1. [ Practice Guidelines for Perioperative Blood Management: ASA Task Force, Anesthesiology 2015 ](https://doi.org/10.1097/ALN.0000000000000463) 2. 2. [ Brustia et al. Guidelines for Perioperative Care for Liver Transplantation: ERAS Recommendations, Transplantation 2022 ](https://journals.lww.com/transplantjournal/fulltext/2022/03000/guidelines_for_perioperative_care_for_liver.23.aspx) 3. 3. [ Sakai T. Viscoelastic testing in liver transplantation, Transfusion 2020 ](https://pubmed.ncbi.nlm.nih.gov/33089935/) 4. 4. [ Bezinover et al. 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