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Combined lung and liver transplantation (CLLT) is a rare intervention for end-stage lung and liver diseases. It poses a challenge for patients with increased bleeding risk due to Hemophilia A and liver coagulopathy. We present the first documented case of CLLT in an elderly male with Hemophilia A, HCV-associated cirrhosis, and Idiopathic Pulmonary Fibrosis (IPF). Despite the patient exhibiting stable liver function and hemophilia, his lung condition rapidly deteriorated, prompting the listing for transplant. The patient underwent a successful CLLT with perioperative management coordinated by the multidisciplinary team to address the unique challenges of Hemophilia A, resulting in intra-operative correction of coagulopathy. The patient exhibited a favorable recovery, with no requirement for Factor FVIII replacement therapy postoperatively. This case demonstrates that CLLT can address three diseases with distinct pathophysiologies: end-stage lung and liver disease, and correct the hemophilia A phenotype. Our report contributes to the limited literature on the suitability of CLLT in patients with hemophilia A.

Abstract We describe an unusual case of hyperacute hepatic failure following general anesthesia in a patient receiving a simultaneous kidney-pancreas transplant. Despite an aggressive evaluation of structural, immunological, viral, and toxicological causes, a definitive cause could not be elucidated. The patient required a liver transplant and suffered a protracted hospital course. We discuss the potential causes of fulminant hepatic failure and the perioperative anesthesia management of her subsequent liver transplantation.

Historically, patients undergoing liver transplantation were left intubated and extubated in the intensive care unit (ICU) after a period of recovery. Proponents of this practice argued that these patients were critically ill and need time to be properly optimized from a physiological and pain standpoint prior to extubation. Recently, there has been a growing movement toward early extubation in transplant centers worldwide. Initially fueled by research into early extubation following cardiac surgery, extubation in the operating room or soon after arrival to the ICU, has been shown to be safe with proper patient selection. Additionally, as experience at determining appropriate candidates has improved, some institutions have developed systems to allow select patients to bypass the ICU entirely and be admitted to the surgical ward after transplant. We discuss the history of early extubation and the arguments in favor and against fast track anesthesia. We also described our practice of fast track anesthesia at Mayo Clinic Florida, in which, we extubate approximately 60% of our patients in the operating room and send them to the surgical ward after a period of time in the post anesthesia recovery unit.