Recovery from Extreme Hemodilution (Hemoglobin Level of 0.6 g/dL) in Cadaveric Liver Transplantation

Abstract

Decompensated hepatic failure occurred in a patient with a rare blood type. The patient had extreme hemodilution due to massive bleeding during liver transplantation. A shortage of matched and universal donor blood prompted us to transfuse albumin and fresh frozen plasma for intravascular volume resuscitation. The lowest hemoglobin was 0.6 g/dL, accompanied by ST depression and a serum lactate of 100 mg/dL. The accuracy of the measured value of 0.6 g/dL was confirmed. However, the patient recovered from this critical situation after transfusion, and he was eventually discharged from the hospital without significant sequelae. Maintaining normovolemia, administering pure oxygen, ensuring appropriate anesthetic depth, and maintaining minimal inotropic support were essential for this patient's survival during massive bleeding.

Figure 1.

Traces from the monitored electrocardiogram of the patient, a 45-year-old Japanese man. Preincisional trace (A) (leads II and V5) showed sinus rhythm without ST-T change. The ST segment was elevated (B) 2 minutes after the portal reperfusion (lead II) and was followed by nonsustained ventricular tachycardia (C) (lead II). ST segment depression (D) occurred during extreme anemia (hemoglobin 0.6 g/dL) (lead V5). ST segment depression was resolved (E) concomitantly with red cell concentrates transfusion (hemoglobin 5.6 g/dL) (leads II and V5).

Figure 2.

Overview of the patient’s anesthetic care. The serial changes in the serum lactate level, hemoglobin concentration, and cumulative amount of transfused red cell concentrates–leukocytes reduced (RCC-LR) are shown, along with the dosages of oxygen, sevoflurane, and inotropic drugs. T is the time when the hemoglobin concentration was the lowest. Fio₂ = fraction of inspired oxygen.