Fast-track anesthesia in a pregnant female patient undergoing liver transplantation: a case report

Liver transplantation (LT) is a critical life-saving intervention that can improve outcomes in patients with acute liver failure (ALF). However, consensus regarding LT management during the second trimester of pregnancy is lacking. For pre-delivery LT, anesthesia and perioperative management are crucial factors influencing fetal survival. Recently, fast-track anesthesia (FTA) has been applied in adult LT, with favorable outcomes. A 41-year-old female patient at 22-weeks of gestation was diagnosed with ALF and hepatic encephalopathy. The patient’s condition did not improve after 3 weeks of treatment. The model for end-stage liver disease (MELD) score was 39. LT was performed using the piggyback technique with caval sparing. We implemented an FTA protocol with total intravenous anesthesia. Dobutamine and phenylephrine were titrated to maintain hemodynamics, and a detector was attached to the abdominal wall to monitor fetal heart rate. The surgery proceeded without complications. Toward the end of the operation, propofol was discontinued, and remifentanil infusion was reduced and continued until completion. After surgery, muscle relaxation was reversed with sugammadex. Five minutes later, the patient regained clear consciousness and was able to follow instructions. On-table extubation was successfully performed. Subsequently, the patient was transferred to the intensive care unit. On postoperative day 8, the patient developed threatened labor due to vaginal bleeding, which necessitated an emergency cesarean section, and a male infant was delivered. The patient returned to the surgical ward after a 14-day intensive care unit stay and was discharged 46 days after the LT. The infant was discharged 4 months after birth. At the 9-month follow-up, neither mother nor infant had any LT-related complications. FTA with on-table extubation was successfully implemented in a second-trimester pregnant female patient undergoing LT. Evolving evidence demonstrates the safety and efficacy of FTA in different patient populations; however, multidisciplinary collaboration and implementation of LT in pregnant patients remains challenging.