Outline the specific management issues to address in a patient during the first 24 hours following liver transplantation.

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College answer

Initial detailed assessment and resuscitation as indicated 
Particular care regarding volume status and identification of bleeding and early graft function Adequate analgesia and sedation 
Protocolised care; close liaison between ICU and other teams involved e.g. surgeons and transplant physicians 
Enteral nutrition 
DVT prophylaxis; usually mechanical Early mobilisation 
Lines and access management: need to rationalise multiple access when stability achieved and coagulation profile acceptable 
Assess suitability for stepdown if no complications 
 
Cardiovascular 
Vasodilated state often requiring pressor support for adequate MAP 
Careful management of volume status and early recognition of bleeding important; large fluid shifts; drain losses may be large and require ongoing volume administration. Avoid elevated CVP 
 
Graft 
Assessment of function via monitoring of coagulation profile, lactate, acid base and transaminases. 
(frequent blood tests/QID) 
Ultrasound assessment of graft particularly hepatic artery / vein / portal vein patency and flow characteristics 
Primary graft nonfunction may be indicated by conventional signs of liver failure i.e. worsening coagulopathy, acidosis, encephalopathy, AKI, hypoglycaemia 
 
Respiratory 
Early extubation when stability ensured 
Patients with hepatopulmonary syndrome or portopulmonary hypertension may need prolongation of ventilation.  pHT may require perioperative management with chronic therapies as well as acute therapies to reduce congestion of graft 
 
Coagulation / Transfusion 
Coagulopathy monitored and indicator of graft function, viscoelastic tests 
Not corrected unless bleeding or severe coagulopathy due to risks vascular thrombosis Hb target above 70 but consideration venesection if Hb > 100g/l 
 
Immunosuppression 
Should be protocoled e.g.  Methylprednisolone / Azathioprine OR MMF / Tacrolimus OR Cyclosporin Variations may be institution based or patient factors e.g. Basiliximab may be given if renal dysfunction preoperatively in lieu of Calcineurin inhibitor 
 
Infection 
Routine postoperative antibiotics not necessary but will depend upon institutional protocols / intraoperative events and preoperative patient status 
Postoperative IV antifungals often given in high risk cases (higher CP or MELD status) 
CMV prophylaxis if CMV pos graft in CMV neg recipient 
Hep B Ig and ongoing antivirals if Hep B patients 
Cytotoxic precautions
 

Renal 
Oliguria likely indicator of hypovolaemia; assess for bleeding 
Consider intraabdominal hypertension 
 
Examiner Comments: 
 
Generally, well answered. Candidates that did poorly made generic comments about post-operative care without specific issues related to liver transplantation or lacked detail in their answers. 

 

Discussion

This is another permutation of the liver transplant SAQ, which in its other incarnations has also included some questions about why the post-transplant patient might be still unconscious after 12 hours. This time,  the college asked about "specific management issues", which is ironically much less specific than the previous questions on this topic. The discussion section for the old SAQs (Question 9 from the second paper of 2015 and Question 11 from the second paper of 2012) was sufficiently detailed that it can also cover this question, and is therefore reproduced here with minimal modification. Furthermore it is worth pointing out that the college model answer to this SAQ is far better than the previous model answers.

The following management steps may be followed in the first 24 hour period:

  • Airway:
    • Historically these patients tend to remain intubated for the first 12-24 hours, although there is good evidence that early extubation (eg. in theatre) has no adverse effects.
  • Breathing:
    • In order for the graft to survive normoxia must be established
    • The general "word of mouth" advice in these situations is to minimise the PEEP. In order for the anastomoses to remain intact, PEEP should be minimised, as it will increase the CVP and thus compromise the venous vascular anastomotic sites. However, some studies have reported no significant change to the hepatic venous flow even with PEEP as high as 15cm H2O.
    • Positive pressure ventilation in general is a bad idea, as organ perfusion is decreased by positive pressure, and perfusion of the donated liver is very important in the early stages.
    • Thus, early weaning from invasive ventilation is one of the major goals
  • Circulation
    • There is likely to be a degree of shock. Given that fluid management must remain relatively conservative, vasopressors and inotropes must be deployed liberally. After all, the graft needs to remain perfused.
    • Hepatic oedema due to over-resuscitation should be avoided.
    • Arbitrarily, the CVP should remain within the range of 6-10.
    • Observe for reactive vasoconstriction
      • These patients, with heir dead livers, have been in a vasodilated state, associated with nitric oxide synthase hyperactivity.
      • Now, with their new livers, normal vascular tone will return.
      • This might mean a sudden massive increase in the afterload.
      • Thus, their left ventricles, which are chronically deconditioned, might decompensate when faced with such demands.
      • Thus, GTN or nitroprusside infusions should be used liberally in these people.
    • The need for RF and LV functional assessment as well as pulmonary arterial pressure measurements and
  • Neurology and sedation
    • No specific recommendations can be made, rather than to say that both hepatic and renal dysfunction in the post-operative period is to be anticipated, and thus drugs which do not rely on organ metabolism should be used. Remifentanyl and propofol spring to mind.
  • Fluids and electrolytes
    • There is some "magical" preload at which the CVP is reasonable, preload adequate, and cardiac output satisfactory. Finding this magic preload is something of an art.
    • Initially, fluid resuscitation should take place, but the fluid of choice should not be Hartmanns because the new liver will probably not be able to metabolise the lactate.
    • After the initial post-operative resuscitation phase is over, a negative fluid balance should be pursued; generating a lower pressure in the right side of the thoracic circulation will serve to draw blood from the graft, and thus theoretically should improve graft perfusion.
    • Renal function needs to be watched closely - renal failure is associated with poor graft survival.
  • Graft function
    • There is a phase of "preservation injury" with very high LFTs but this tends to disappear over the first 3-4 days. Thereafter, synthetic function should be restored.
    • Monitoring of the graft consist of several sequential assessments:
      • Hepatic arterial Doppler
      • BSL
      • Lactate
      • Bilirubin
    • Typically, 1-9% of liver transplants fail within hours of surgery.
  • Surveillance for abdominal compartment syndrome
    • Due to the extensive nature of the procedure and due to the preexisting portal venous pathology, this issue (with pressure over 25mmHg) is fairly common.
    • Abdominal girth values are required as sequential measurements.
  • Nutritional support
    • There is no string reason to recommend TPN here. Like in most other situation, nasogastric enteral feeding is probably best. A degree of ileus is to be expected, and usually resolves
  • Hematological support
    • This consists of the replacement of missing blood products and blood cells.
    • Essentially, there is no specific hemoglobin goal, and what you are trying to do is prevent bleeding from the anastomotic sites.
    • Its probably OK to be slightly coagulopathic, because you don't want to develop a hepatic arterial thrombus.
  • Immune suppression
    • I will not litter this summary with discussion of the relative merits of each class of antirejection drug. Suffice to say, cyclosporin tacrolimus and mycophenolate are gradually giving way to monoclonal antibodies and other immunomodulator drugs which have slightly less devastating organ system effects.
  • Antibiotics and sepsis surveillance
    • Many of these patients die from postoperative infectious complications
    • 48 hrs of IV antibiotics are typically administered
    • The Sanford Guide recommends linezolid, ciprofloxacin and fluconazole.
    • The belowlinked article from 2011 also suggests 14 days of aciclovir, given the propensity for embarrassing HSV reactivation.

References

References

Chapter 101  (pp. 1040)  Liver  transplantation by Anish  Gupta,  Simon  Cottam  and  Julia  Wendon

Roberts, Mark S., et al. "Survival after liver transplantation in the United States: a disease‐specific analysis of the UNOS database." Liver transplantation 10.7 (2004): 886-897.

Onaca, Nicholas N., et al. "A correlation between the pretransplantation MELD score and mortality in the first two years after liver transplantation." Liver transplantation 9.2 (2003): 117-123.

Vaid, Arjun, et al. "Molecular adsorbent recirculating system as artificial support therapy for liver failure: a meta-analysis." ASAIO Journal 58.1 (2012): 51-59.

Bañares, Rafael, et al. "Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute‐on‐chronic liver failure: The RELIEF trial." Hepatology 57.3 (2013): 1153-1162.

Schroeder, Rebecca A., et al. "Intraoperative fluid management during orthotopic liver transplantation." Journal of cardiothoracic and vascular anesthesia 18.4 (2004): 438-441.

Kirby, R. M., et al. "Orthotopic liver transplantation: postoperative complications and their management." British journal of surgery 74.1 (1987): 3-11.

Hannaman, Michael J., and Zoltan G. Hevesi. "Anesthesia care for liver transplantation."  Transplantation Reviews 25.1 (2011): 36-43.

Moreno, Rosalba, and Marina Berenguer. "Post-liver transplantation medical complications."  Ann Hepatol 5.2 (2006): 77-85.

McCaughan, Geoffrey W., and Stephen R. Munn. "Liver transplantation in Australia and New Zealand." Liver Transplantation 22.6 (2016): 830-838.