Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ ICU MANAGEMENT ++ Early postoperative recovery after liver transplantation occurs in the intensive care unit (ICU). A fast-tracking option is available in certain institutions and includes coordinated operating room, postoperative recovery unit, and specialized ward management with a high-level nursing staffing ratio (e.g., 1:1 during the early postoperative recovery period).1 The early postoperative period is driven by emergence from general anesthesia, recovering multiorgan dysfunction, and establishing liver graft function. +++ NEUROLOGIC SYSTEM ++ Pain2,3 Results in elevated catecholamines with resultant delirium, myocardial ischemia, and hypercoagulable state Commonly used behavioral pain scales include the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) Opioids are the mainstay analgesics: short-acting fentanyl and remifentanil, as well as longer-acting hydromorphone and morphine Sedation2,3 Consists of anxiolysis, hypnosis, and amnesia Indicated for patient comfort and to facilitate mechanical ventilation Daily interruption of sedation or light sedation reduces duration of mechanical ventilation and ICU length of stay Commonly used scales to assess level of sedation are the Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS). RASS can be used across the entire spectrum of sedation and agitation. Provided by benzodiazepines, propofol, and dexmedetomidine Benzodiazepines (midazolam and lorazepam) Associated with development of delirium Accumulate in fat stores with delayed awakening Patients with history of alcohol abuse may require higher doses Propofol Causes hypotension, decrease in intracranial pressure, decrease in cerebral perfusion pressure Side effects include infection, hypertriglyceridemia, and pancreatitis Propofol infusion syndrome is a rare life-threatening complication resulting from block in fat oxidation with resultant lactic acidosis. More common when high dose (>50 mcg/kg/min) infusion for prolonged period in setting of critical illness, shock, and steroid use Dexmedetomidine Hepatically eliminated Does not cause amnesia Allows for serial neurologic evaluation Adverse reactions include bradycardia and hypotension Delirium2,3 Associated with increased mortality, prolonged length of stay in the hospital and ICU, and post-ICU cognitive impairment Involves (1) acute change or fluctuation in mental status and (2) inattention with either (3) altered level of consciousness or (4) disorganized thinking Practical diagnostic approach involves using the Confusion Assessment Method for the ICU (CAM-ICU) in conjunction with the RASS (Fig. 91-1) Prevention involves avoidance of deep sedation, early mobilization, and promoting a structured sleep–wake cycle Atypical antipsychotics (quetiapine, olanzapine) may reduce the duration of delirium. When used, the QTc interval should be monitored to avoid torsades de pointes. Dexmedetomidine is the preferred agent for sedation in patients with delirium Hepatic encephalopathy Characteristic of acute liver disease Ammonia metabolism is implicated in the pathophysiology Postoperatively, the presence or absence of hepatic encephalopathy reflects liver graft function Cerebral edema Severe manifestation of hepatic encephalopathy in acute liver failure Results in intracranial hypertension Management includes avoiding hypoxemia, hypotension, and hypothermia; sedation to reduce cerebral metabolic rate; hyperosmolar therapy (mannitol, hypertonic saline); hyperventilation (PACO2 = 30 to 35 mm Hg); and decompressive craniotomy ++ FIGURE 91-1 Richmond Sedation-Agitation Scale (RASS). ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free a profile for additional features.