Outline the specific management issues to address in a patient during the first 24 hours following liver transplantation.
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
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
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
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
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
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
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
Oliguria likely indicator of hypovolaemia; assess for bleeding
Consider intraabdominal hypertension
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.
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:
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.
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