# Successful anesthetic management of >10-liter blood loss in a Budd-Chiari syndrome patient undergoing living donor liver transplantation: A case report and review of literature

## TL;DR

This case report describes the successful management of a rare liver transplant surgery involving extreme blood loss in a patient with a complex liver condition.

## Contribution

The paper presents a novel case of managing >10-liter blood loss during liver transplantation for Budd-Chiari syndrome with a hydatid cyst.

## Key findings

- A multidisciplinary approach with advanced monitoring and transfusion protocols successfully managed severe intraoperative bleeding.
- The patient recovered well with stable graft function after the liver transplant.
- Combining cell salvage and massive transfusion protocols preserved hemodynamic stability.

## Abstract

Budd-Chiari syndrome is an uncommon condition induced by thrombotic or nonthrombotic obstruction of the hepatic venous outflow and is characterized by hepatomegaly, ascites, abdominal pain. The successful anaesthetic and transfusion treatment of a patient with BCS who had a hepatic hydatid cyst following LDLT is described in this report. Venous obstruction and parasitic cysts together pose a significant perioperative risk, especially in cases of severe intraoperative bleeding.

A 30 years old woman was admitted with weight loss, abdominal distension, recurrent haematemesis, and progressive jaundice. She had undergone multiple endoscopic variceal band ligations and treatment for pulmonary tuberculosis. Imaging revealed hepatic vein thrombosis, caudate lobe hypertrophy, and a hydatid cyst in segment VII that measured 5.8 × 4 cm. Anaemia (haemoglobin 7.6 g/dL) with preserved renal and coagulation function was found in the laboratory (MELD 14, Child-Turcotte-Pugh A6). LDLT was scheduled for her following multidisciplinary optimization.

General anesthesia was achieved and then transesophageal echocardiography, arterial, central venous and PiCCO lines, were placed for invasive haemodynamic monitoring. The more than 10 liters of intraoperative blood loss were controlled by an organized massive transfusion protocol that used packed red blood cells, plasma, cryoprecipitate, and 2.9 litres of autologous blood through cell salvage. In order to preserve haemodynamic stability and keep mean arterial pressure above 70 mmHg, norepinephrine and vasopressin infusion were used. The patient showed stable graft function and recovered without any problems.

Even in severe hemorrhagic episodes during LDLT for BCS, successful outcomes can be ensured by multidisciplinary coordination, advanced monitoring, and adherence to transfusion protocols.