If you are nervous about going under anesthesia, you might feel better to know that anesthesiologists are focused on making sure surgery patients are as safe and comfortable as possible. If you or a loved one is undergoing an organ transplant, that work starts long before the day of surgery.

"Our role does not really start and end in the operating room,” says Ranjit Deshpande, MD, Yale Medicine's director of transplant anesthesiology. Anesthesiologists are deeply involved in the entire transplant process, even working with the transplant team to make sure each new patients is an appropriate candidate for transplant, then following patients through surgery and recovery.

Two types of patients are involved in the transplant process: organ donors—who may be living or deceased—and organ recipients. 

“When involved in living donor transplants, we make sure that each patient (both the donor and the recipient) is under the care of a separate anesthesiologist,” says Dr. Deshpande. “This enables us to ensure that each patient receives the most personalized attention possible throughout the transplant process.”

Because living donors are typically healthy, there tend to be few, if any, complications related to their surgeries. After surgery, donors are transferred to an intensive care unit (ICU), where they stay for a day or two, depending on the specifics of the procedure and their overall physical and functional status.

Organ recipients often have complex cases with interrelated conditions. “We are used to taking care of the sickest of the sick patients here,” says Dr. Deshpande, adding that many organ recipients often have more than one chronic disease—and any, chronic disease can impact choices in anesthesia.

Transplant anesthesiologists are involved from the very beginning of the transplant process, starting with the decision to put a patient on an organ waiting list. They work with the transplant team to assess the patient’s overall health and level of illness, as well as their body’s ability to withstand the stress involved in removing a diseased organ and replacing it with a new one.

This assessment involves a range of tests, including a cardiac evaluation that checks for coronary vascular disease and obstructions, lung function and lung vascular pressure testing, and blood work. The transplant team also assesses the patient's level of risk in recovery process—how he or she is expected to fare with the new organ.

In transplant surgery, the anesthesiologist plays the role of a “tactical support system,” Dr. Deshpande says. “If you can imagine the surgeon as a soldier who’s trying to put the liver in, we, as anesthesiologists, manage all the critical medical issues that arise in the operating room.”

The anesthesiologist sees the patient before the operation, during surgery, and after surgery when they are recovering from the effects of general anesthesia and getting used to the new organ.

Anesthesiologists remain involved after surgery when they review how the patient is functioning and help with pain management in the ICU. “A job of an anesthesiologist is not just in the operating room, but it basically encompasses the whole perioperative period,” Dr. Deshpande says.

Organ transplants are highly complex procedures. The degree of complexity depends on the  type of transplant and the circumstances of the patient. Donors tend to be healthy, so their risk is low, while recipients tend to be very sick and at higher risk for complications involving other organs.

“For example, when your liver shuts down, the effects are felt by your heart, your lungs, your kidneys and pretty much everything,” Dr. Deshpande says. “Anesthesiologists consider liver transplant as one of the most complex procedures that there can be.”

Most of the risks of transplant surgery are similar to those in general anesthesia—chipped teeth or a sore throat related to having a breathing tube, allergic reactions to the anesthesia medications, risk of infection from the intravenous line, possible lung collapse related to the use of mechanical ventilation and, in very rare cases, death.

Risks in liver transplant anesthesia are mostly related to the new liver and how the body responds. One might expect blood clots or bleeding, heart failure and kidney injury. “We try our best in the perioperative phase to minimize these risks,” says Dr. Deshpande.

The evolution of surgical monitoring technology allows transplant anesthesiologists to track a host of essential bodily functions and systems in the operating room. The amount of blood in a patient’s system, heart rate, blood pressure, how much blood the heart is pumping through the body, potassium levels and blood coagulation performance can now be monitored during surgery. Doctors have a much clearer understanding of the patient’s overall status during surgery at all times.

“We've come a long way from times when we did not know what your volume status was, what your cardiac output was, which medication we should be giving,” Dr. Deshpande says. 

“We are also using point-of-care coagulation monitoring to assess bleeding in patients, which is, again, an advancement from the time where you would just have to rely on naked eyes. We also utilize advanced monitoring devices like intraoperative echocardiography to guide our fluid therapy.”

Yale Medicine’s team offers skills and resources in all types of organ donation and transplantation, including living donation. “We have an excellent team of professionals who cater to the population in need of organs,” Dr. Deshpande says. “And we are lucky to have a health care system that is making resources available for this patient population.”

Our doctors work with the Yale New Haven Hospital Transplantation Center to educate people interested in donating a portion of their liver or one of their kidneys to people who need them.

While studies show that people who receive organs from living donors do better, living donor procedures are not commonplace in the United States. The Center for Living Donors at Yale New Haven is the first in the country to create supportive communities of living donors and provide them with free, lifelong local medical monitoring for any health issues that may arise related to their organ donation.