Chapter 92: Liver Transplantation: Postoperative Guidelines

INTRODUCTION

Immediately postoperatively care of liver transplant recipients can be very tenuous. These patients require close monitoring in the intensive care unit (ICU). Several aspects of care have to be carefully managed to successfully transition the liver transplant patient to long-term care.

VENTILATOR WEANING

Most patients are brought from the operating room intubated, requiring mechanical ventilation. Early extubation has been shown to reduce infection, decrease the stay in the ICU, and may decrease readmission rates to the ICU.¹

Several factors will determine whether a patient can be extubated soon after arrival to the ICU. The length of the case, amount of blood products transfused, Model for End-Stage Liver Disease (MELD) score, ischemia time, graft status, and patient hemodynamics all play a key role in determining how quickly a patient can be weaned from ventilator management. Three components are important in ventilator weaning: oxygenation, ventilation, and neurologic status.²

Appropriate oxygenation is a major goal when weaning from the ventilator. Pulmonary edema, pleural effusions, and hepatopulmonary syndrome all can cause significant problems with adequate oxygenation and ventilation. Fluid management, use of diuretics, hemodialysis, and positive end expiratory pressure (PEEP) are all effective ways to manage oxygenation and keep saturations over 95%.³

Neurologic status and sedation can be major deterrents to early ventilator weaning. It is very important to have a sedation and analgesia plan to safely extubate the patient. Hepatic encephalopathy, high MELD, and intraoperative anesthesia can all adversely affect the patient's mental status and their ability to be alert, responsive, and protect their airway.^1,3,4 The first step is to allow the anesthetics to wear off and choose a sedation scheme to keep the patient comfortable. It is common to use propofol; however, it can cause hypotension, which is an unwanted effect.⁵ Intermittent doses of narcotics can be used to allow for adequate pain control without oversedation during weaning and after liberation from the ventilator.

HEMODYNAMIC MONITORING

Liver transplant recipients require intense monitoring of their hemodynamic status. The cirrhosis physiology before surgery places them in a vasodilatory state.⁶ It is very important to measure blood pressure, heart rate, central venous pressure, and cardiac output to adequately assess the patient's status. Use of pulmonary catheters, arterial lines, and other noninvasive tools are very helpful. Patients with a high MELD score and massive blood product transfusion during the operation are continuously coagulopathic and very often require vasopressor support for blood pressure management and appropriate peripheral perfusion. Maintaining adequate cardiac output with fluid/blood product resuscitation and use of pressors to maximize perfusion are paramount.

FLUID AND ELECTROLYTE MANAGEMENT

Electrolyte disturbances in this patient population occur frequently and can be quite severe. Electrolytes such as magnesium, sodium, potassium, calcium, and phosphate can all be disarranged. Close monitoring is very ...