Post Operative ICU Management of Orthotopic Liver Transplant Patients

3/3/20083/3/2008 11

Post Operative ICU Post Operative ICU Management of Orthotopic Liver Management of Orthotopic Liver

Transplant Patients Transplant Patients S/P Chronic Hepatic FailureS/P Chronic Hepatic Failure

Dr. Ahmad KharroubyDr. Ahmad KharroubyPGY2, SurgeryPGY2, Surgery

Surgical Intensive Care Unit

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IntroductionIntroduction

The immediate postoperative care for liver The immediate postoperative care for liver recipients involves: recipients involves: – (1) stabilizing the major organ systems (e.g., (1) stabilizing the major organ systems (e.g.,

cardiovascular, pulmonary, and renal); cardiovascular, pulmonary, and renal); – (2) evaluating graft function and achieving (2) evaluating graft function and achieving

adequate immunosuppressionadequate immunosuppression– (3) monitoring and treating complications (3) monitoring and treating complications

directly and indirectly related to the transplantdirectly and indirectly related to the transplant

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This initial care should generally be This initial care should generally be performed in an intensive care unit (ICU) performed in an intensive care unit (ICU) setting because recipients usually require setting because recipients usually require mechanical ventilatory support for the first mechanical ventilatory support for the first 12 to 24 hours12 to 24 hoursThe goal is to maintain: The goal is to maintain: – adequate oxygen saturationadequate oxygen saturation– acid-base equilibriumacid-base equilibrium– stable hemodynamicsstable hemodynamics

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Continuous hemodynamic monitoring is Continuous hemodynamic monitoring is important to ensure adequate perfusion of important to ensure adequate perfusion of the graft and vital organsthe graft and vital organsHemodynamic instability occurring early Hemodynamic instability occurring early posttransplant is usually due to fluid posttransplant is usually due to fluid imbalance, but the presence of ongoing imbalance, but the presence of ongoing bleeding must first be excludedbleeding must first be excluded

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Hemodynamic instability also may be Hemodynamic instability also may be secondary to the myocardial dysfunction secondary to the myocardial dysfunction that is often seen early in the reperfusion that is often seen early in the reperfusion phase, but which may persist into the early phase, but which may persist into the early postoperative periodpostoperative periodThe usual treatment is to optimize preload The usual treatment is to optimize preload and afterload, and to use inotropic agents and afterload, and to use inotropic agents such as dopamine or dobutamine if such as dopamine or dobutamine if necessarynecessary

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Fluid management, electrolyte status, and Fluid management, electrolyte status, and kidney function require frequent evaluationkidney function require frequent evaluationSerum transaminase levels will usually Serum transaminase levels will usually – Rise during the first 48 to 72 hours post-Rise during the first 48 to 72 hours post-

transplant secondary to preservation injurytransplant secondary to preservation injury– Then should fall rapidly over the next 24 to 48 Then should fall rapidly over the next 24 to 48

hourshours– Normalize in 1 weekNormalize in 1 week

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Platelet counts usually decrease in the first Platelet counts usually decrease in the first week after LT and recover during the week after LT and recover during the second weeksecond weekThis may be caused by platelet This may be caused by platelet sequestration in the liver and spleen due sequestration in the liver and spleen due to preservation injury &/or hypersplenismto preservation injury &/or hypersplenismOnce the liver has recovered, as Once the liver has recovered, as manifested by the return of bilirubin to manifested by the return of bilirubin to normal levels, the platelet count increases normal levels, the platelet count increases

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OutlineOutlineA.A. HemodynamicHemodynamicB.B. PulmonaryPulmonaryC.C. Hepatic allograft functionHepatic allograft function

1.1. Primary nonfunction and initial poor functionPrimary nonfunction and initial poor function2.2. RejectionRejection3.3. Technical ComplicationsTechnical Complications

i.i. Hepatic artery thrombosisHepatic artery thrombosisii.ii. Portal vein thrombosisPortal vein thrombosisiii.iii. Bile duct obstructionBile duct obstruction

4.4. Recurrent infection and neoplasmRecurrent infection and neoplasmD.D. Electrolytes, glucose, and lactateElectrolytes, glucose, and lactateE.E. GI TractGI TractF.F. NutritionNutritionG.G. Infection SurveillanceInfection SurveillanceH.H. Post transplantation Immunossuppression Post transplantation Immunossuppression I.I. Kidney dysfunctionKidney dysfunctionJ.J. Abdominal compartment syndromeAbdominal compartment syndrome

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A-HemodynamicA-Hemodynamic

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Intravascular volume resuscitation usually is Intravascular volume resuscitation usually is required in the immediate postoperative period required in the immediate postoperative period secondary to: secondary to:

– Third-space lossesThird-space losses– Increased body temperatureIncreased body temperature– VasodilatationVasodilatationAdequate perfusion is assessed by: Adequate perfusion is assessed by:

– Left and right heart filling pressuresLeft and right heart filling pressures– Cardiac outputCardiac output– Urine outputUrine output– Absence of metabolic acidosisAbsence of metabolic acidosis– Sequential Hemoglobin levelsSequential Hemoglobin levels

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Avoid Lactated Ringer, & use NSS and Avoid Lactated Ringer, & use NSS and other colloid solutions instead, because other colloid solutions instead, because lactate that is metabolised in the liver will lactate that is metabolised in the liver will be already elevatedbe already elevated

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Hepatic edema might ensue secondary to Hepatic edema might ensue secondary to aggressive resuscitation & increased aggressive resuscitation & increased intravascular volume, so aim to CVP 6-10 intravascular volume, so aim to CVP 6-10 to minimize increased hepatic vein to minimize increased hepatic vein pressures & sinusoidal congestion that pressures & sinusoidal congestion that impair graft perfusion & exacerbate impair graft perfusion & exacerbate reperfusion injuryreperfusion injury

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Hypertension is common and should be Hypertension is common and should be aggressively treated using nitroprussideaggressively treated using nitroprussideDiuretics may be required to remove excess fluid Diuretics may be required to remove excess fluid acquired intraoperatively, but they may result in acquired intraoperatively, but they may result in hypokalemiahypokalemiaSerial hematocrits and transfuse accordingllySerial hematocrits and transfuse accordingllyCorrection of bleeding parameters using FFPs, Correction of bleeding parameters using FFPs, platelet transfusions, and even Desmopressin platelet transfusions, and even Desmopressin and factor 7 infusions to be done accordinglyand factor 7 infusions to be done accordingly

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B-PulmonaryB-Pulmonary

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B-PulmonaryB-Pulmonary

Ventilatory support is required postoperatively Ventilatory support is required postoperatively until the patient until the patient – Is awake and alertIs awake and alert– Is able to follow commands and protect the airwayIs able to follow commands and protect the airway– Is able to maintain adequate oxygenation and Is able to maintain adequate oxygenation and

ventilation ventilation

Infectious and noninfectious pulmonary Infectious and noninfectious pulmonary complications can occur in up to 75% of liver complications can occur in up to 75% of liver recipients recipients TRALI is common in these patientsTRALI is common in these patients

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C-Hepatic allograft functionC-Hepatic allograft function

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Monitoring of hepatic allograft function Monitoring of hepatic allograft function begins intraoperatively after begins intraoperatively after revascularizationrevascularization

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Reassessinent of hepatic allograft function Reassessinent of hepatic allograft function continues postoperativelycontinues postoperativelyinitially occurring every 6 hoursinitially occurring every 6 hours

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Satisfactory hepatic allograft function is Satisfactory hepatic allograft function is indicated by an:indicated by an:– Improving coagulation profileImproving coagulation profile– Decreasing transaminase levelsDecreasing transaminase levels– Normal blood glucoseNormal blood glucose– Hemodynamic stabilityHemodynamic stability– Adequate urine outputAdequate urine output– Bile productionBile production– Clearance of anesthesiaClearance of anesthesia

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Early elevations of bilirubin and Early elevations of bilirubin and transaminase levels may be indicators of transaminase levels may be indicators of preservation injurypreservation injuryThe peak levels of SGOT and SGPT The peak levels of SGOT and SGPT usually are less than 2,000 units/L and usually are less than 2,000 units/L and should decrease rapidly over the first 24 should decrease rapidly over the first 24 to 48 hours postop.to 48 hours postop.

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After the patient leaves the intensive care unitAfter the patient leaves the intensive care unit– LFTs are obtained dailyLFTs are obtained daily– Bile is inspected dailyBile is inspected daily– A T-tube cholangiogram may be obtained to ensure A T-tube cholangiogram may be obtained to ensure

adequate biliary drainage and to rule out adequate biliary drainage and to rule out extravasationextravasation

It is important to correctly diagnose the cause of It is important to correctly diagnose the cause of liver dysfunction, because each cause has its liver dysfunction, because each cause has its own unique treatment own unique treatment

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C-Hepatic allograft functionC-Hepatic allograft functionCommon Causes:Common Causes:1.1. Primary nonfunction and initial poor functionPrimary nonfunction and initial poor function2.2. RejectionRejection3.3. Technical ComplicationsTechnical Complications

i.i. Hepatic artery thrombosisHepatic artery thrombosisii.ii. Portal vein thrombosisPortal vein thrombosisiii.iii. Bile duct obstructionBile duct obstruction

4.4. Recurrent infection and neoplasmRecurrent infection and neoplasm

The most common causes of early graft loss include The most common causes of early graft loss include primary nonfunction and hepatic artery thrombosis primary nonfunction and hepatic artery thrombosis

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1-Primary nonfunction and initial 1-Primary nonfunction and initial poor functionpoor function

The use of UW solution for organ The use of UW solution for organ preservation has decreased the incidence preservation has decreased the incidence of primary nonfunctionof primary nonfunctionFor poorly understood reasons, however, For poorly understood reasons, however, 1% to 9% of transplanted livers fail 1% to 9% of transplanted livers fail immediately after the surgeryimmediately after the surgery

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1-Primary nonfunction and initial 1-Primary nonfunction and initial poor functionpoor function

Primary nonfunction is characterized by:Primary nonfunction is characterized by:– Hemodynamic instabilityHemodynamic instability– Poor quantity and quality of bilePoor quantity and quality of bile– Renal dysfunctionRenal dysfunction– Failure to regain consciousnessFailure to regain consciousness– Increasing coagulopathyIncreasing coagulopathy– Persistent hypothermiaPersistent hypothermia– Lactic acidosis in the face of patent vascular Lactic acidosis in the face of patent vascular

anastomosis (as demonstrated by Doppler anastomosis (as demonstrated by Doppler ultrasonography)ultrasonography)

Without re-transplantation, death ensue Without re-transplantation, death ensue

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2-Rejection2-Rejection

Acute rejection is relatively common after Acute rejection is relatively common after liver transplantation, with 60% of recipients liver transplantation, with 60% of recipients experiencing at least one cell-mediated or experiencing at least one cell-mediated or acute rejection episodeacute rejection episodeHowever, rejection is an extremely However, rejection is an extremely uncommon cause of graft loss because it uncommon cause of graft loss because it can be treated by increasing can be treated by increasing immunosuppression (increase immunosuppression (increase corticostroids dose)corticostroids dose)

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3-Technical complications3-Technical complications

A variety of technical problems can lead to A variety of technical problems can lead to liver allograft dysfunction, including: liver allograft dysfunction, including: – Hepatic artery stenosis or thrombosisHepatic artery stenosis or thrombosis– Portal vein stenosis or thrombosisPortal vein stenosis or thrombosis– Biliary tract obstructionBiliary tract obstruction– Bile duct leakBile duct leak– Hepatic vein or vena caval thrombosisHepatic vein or vena caval thrombosis

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i.i. Hepatic artery thrombosisHepatic artery thrombosisIncidence of about 3 to 5% in adults and Incidence of about 3 to 5% in adults and about 5 to 10% in children about 5 to 10% in children May occur in the early post transplantation May occur in the early post transplantation period and may lead to: period and may lead to: – FeverFever– Hemodynamic instabilityHemodynamic instability– Rapid deterioration of the patient,Rapid deterioration of the patient,– Marked elevation of the transaminasesMarked elevation of the transaminases– Associated bile leak soon after liver Associated bile leak soon after liver

transplantation due to the loss of the bile transplantation due to the loss of the bile ducts' main vascular supplyducts' main vascular supply

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i.i. Hepatic artery thrombosisHepatic artery thrombosis

Acute hepatic artery thrombosis may be treated Acute hepatic artery thrombosis may be treated by attempted thrombectomyby attempted thrombectomyIf this is unsuccessful, retransplantation is If this is unsuccessful, retransplantation is needed, needed, Hepatic artery thrombosis that occurs long after Hepatic artery thrombosis that occurs long after liver transplantation may produce intra- and liver transplantation may produce intra- and extrahepatic bile duct strictures and may be an extrahepatic bile duct strictures and may be an indication for elective retransplantationindication for elective retransplantationOccasionally, hepatic artery thrombosis is Occasionally, hepatic artery thrombosis is completely asymptomaticcompletely asymptomatic

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hepatic artery thrombosis, particularly early after transplantationwhen the allograft is devoid of arterial collaterals, results in selectivenecrosis of the Biliary tree and surrounding connective tissue

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Typical appearance of a liver allograft that failedbecause of hepatic artery thrombosis

leakage of bile

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ii.ii. Portal vein stenosis or Portal vein stenosis or thrombosisthrombosis

Portal vein stenosis or thrombosis is rarePortal vein stenosis or thrombosis is rareWhen it occurs, the patient's condition may deteriorate When it occurs, the patient's condition may deteriorate rapidly, with:rapidly, with:– Profound hepatic dysfunctionProfound hepatic dysfunction– Massive ascitesMassive ascites– Renal failureRenal failure– Hemodynamic instabilityHemodynamic instability

Although surgical thrombectomy may be successful, Although surgical thrombectomy may be successful, urgent re-transplantation is often necessaryurgent re-transplantation is often necessaryLate portal vein thrombosis may allow normal liver Late portal vein thrombosis may allow normal liver function but usually results in variceal bleeding and function but usually results in variceal bleeding and ascites ascites

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iii.iii. Bile duct obstructionBile duct obstructionBile duct obstruction is diagnosed by Bile duct obstruction is diagnosed by cholangiographycholangiographyA single short bile duct stricture may be treated A single short bile duct stricture may be treated by either percutaneous or retrograde balloon by either percutaneous or retrograde balloon dilationdilationA long stricture, ampullary dysfunction, or failed A long stricture, ampullary dysfunction, or failed dilation necessitates revision of the biliary tract dilation necessitates revision of the biliary tract anastomosisanastomosisFever and abdominal pain in the early post Fever and abdominal pain in the early post transplantation period should raise the possibility transplantation period should raise the possibility of biliary anastomotic disruption, which requires of biliary anastomotic disruption, which requires urgent surgical revisionurgent surgical revision

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4-Recurrent Infection and 4-Recurrent Infection and neoplasmneoplasm

CMV can cause hepatic allograft CMV can cause hepatic allograft dysfunction and usually occurs within 8 dysfunction and usually occurs within 8 weeks of transplantationweeks of transplantation

– Diagnosis is made by liver biopsy, with CMV Diagnosis is made by liver biopsy, with CMV inclusion bodies being found with light inclusion bodies being found with light microscopy or by PCR in peripheral bloodmicroscopy or by PCR in peripheral blood

– Treatment consists of decreasing baseline Treatment consists of decreasing baseline immunosuppression and administering immunosuppression and administering ganciclovir (5 ganciclovir (5 mg/kg mg/kg every 12 hours via every 12 hours via central venous access for 3 weeks)central venous access for 3 weeks)

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4-Recurrent Infection and 4-Recurrent Infection and neoplasmneoplasm

Viral hepatitis and malignancy (e.g" hepatoma, Viral hepatitis and malignancy (e.g" hepatoma, cholangiocarcinoma, neuroendoc:rine tumors) cholangiocarcinoma, neuroendoc:rine tumors) can recur in the hepatic allograft but are can recur in the hepatic allograft but are uncommon in the early post-transplantation uncommon in the early post-transplantation periodperiod– The clinical presentation includes elevations on liver The clinical presentation includes elevations on liver

function testsfunction tests– The diagnosis is made by liver biopsyThe diagnosis is made by liver biopsy– Imaging studies (e.g., CT scan, liver ultrasonography) Imaging studies (e.g., CT scan, liver ultrasonography)

are important for following patients transplanted for are important for following patients transplanted for neoplasmsneoplasms

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D-Electrolytes, glucose, and D-Electrolytes, glucose, and lactatelactate

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D-Electrolytes, glucose, and lactateD-Electrolytes, glucose, and lactate

The use of diuretics may result in hypokalemiaThe use of diuretics may result in hypokalemiaWhereas cyclosporine or tacrolimus toxicity may Whereas cyclosporine or tacrolimus toxicity may cause hyperkalemiacause hyperkalemiaTransfusion of citrate rich blood products results Transfusion of citrate rich blood products results in decreased serum magnesium & calciumin decreased serum magnesium & calciumMagnesium levels are maintained above 2 Magnesium levels are maintained above 2 mg/dL (0,82 mmol/L) because the seizure mg/dL (0,82 mmol/L) because the seizure threshold is lowered bv the combination of threshold is lowered bv the combination of hypomagnesemia and cyclosporine or hypomagnesemia and cyclosporine or tacrolimustacrolimus

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Calcium should be measured as free Calcium should be measured as free ionized calcium and kept above 4.4 mg/dL, ionized calcium and kept above 4.4 mg/dL, Transfusion of citrate rich blood products Transfusion of citrate rich blood products results in decreased serum magnesium & results in decreased serum magnesium & calciumcalciumPhosphorus levels should be maintained Phosphorus levels should be maintained above 2.5 mg/dL to avoid respiratory above 2.5 mg/dL to avoid respiratory muscle weakness and altered oxygen muscle weakness and altered oxygen hemoglobin dissociationhemoglobin dissociation

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Central pontine myelinolysis, which may Central pontine myelinolysis, which may result from marked fluctuations in serum result from marked fluctuations in serum sodium levels and osmolality, is an sodium levels and osmolality, is an uncommon cause of a patient not uncommon cause of a patient not regaining consciousness posttransplant regaining consciousness posttransplant

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Glucose homeostasis is necessary because Glucose homeostasis is necessary because steroid administration may result in steroid administration may result in hyperglycemia, which is best managed with hyperglycemia, which is best managed with intravenous insulin because it is short acting and intravenous insulin because it is short acting and easily absorbedeasily absorbedCyclosporine and tacrolimus are diabetogenic Cyclosporine and tacrolimus are diabetogenic immunosuppressants and may alter glucose immunosuppressants and may alter glucose homeostasishomeostasisHypoglycemia is a complication of liver failure, Hypoglycemia is a complication of liver failure, and in the presence of liver dysfunction, glucose and in the presence of liver dysfunction, glucose administration may be necessaryadministration may be necessary

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LactateLactate – Patients with pre-op fulminant hepatic Patients with pre-op fulminant hepatic

failure/necrosis should have lactate levels that failure/necrosis should have lactate levels that trend towards normal after transplantation trend towards normal after transplantation providing their fluid status is adequateproviding their fluid status is adequate

– Elevated lactate levels also are seen in: Elevated lactate levels also are seen in: Hypoperfusion statesHypoperfusion statesLate sepsisLate sepsisPrimary non-function Primary non-function

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E-GI tractE-GI tract

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E-GI tractE-GI tract

H2 H2 blockade, proton pump inhibition, and/or blockade, proton pump inhibition, and/or antacids are used to prevent stress ulcersantacids are used to prevent stress ulcersEndoscopy is performed liberally for any GI Endoscopy is performed liberally for any GI bleeding to determine the etiologybleeding to determine the etiology Nystatin and GI tract decontamination solution Nystatin and GI tract decontamination solution containing gentamicin and polymyxin B are used containing gentamicin and polymyxin B are used in the perioperative period to prevent in the perioperative period to prevent esophageal candidiasis and translocation of esophageal candidiasis and translocation of bacterial pathogensbacterial pathogens

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F-NutritionF-Nutrition

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Patients who are severely malnourished Patients who are severely malnourished should be placed on nutritional should be placed on nutritional supplementation as soon as stable fluid supplementation as soon as stable fluid and electrolyte status and adequate graft and electrolyte status and adequate graft function have been reached function have been reached

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Patients with adequate preoperative Patients with adequate preoperative nutrition can be maintained on routine nutrition can be maintained on routine intravenous fluids until GI tract function intravenous fluids until GI tract function returns (usually 3 to 5 days)returns (usually 3 to 5 days)Enteral nutrition is used as soon as the Enteral nutrition is used as soon as the postoperative ileus resolves, Total postoperative ileus resolves, Total parenteral nutrition (TPN) is indicated parenteral nutrition (TPN) is indicated when the Gl tract is nonfunctional when the Gl tract is nonfunctional

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G-Infection surveillanceG-Infection surveillance

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G-Infection surveillanceG-Infection surveillanceSepsis is a major cause of early mortalityThe most common causes of bacterial The most common causes of bacterial infection after liver transplantation include infection after liver transplantation include – Line sepsisLine sepsis– Urinary tract infectionUrinary tract infection– Infected ascitesInfected ascites– CholangitisCholangitis– PneumoniaPneumonia– Biliary anastomotic leakBiliary anastomotic leak– Intra abdominal abscessIntra abdominal abscess

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Prophylactic antibiotics covering biliary Prophylactic antibiotics covering biliary pathogens are administered for the first 48 pathogens are administered for the first 48 hours after liver transplantationhours after liver transplantation

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If a fever develops in the liver transplant If a fever develops in the liver transplant recipient, a thorough examination should recipient, a thorough examination should be performed:be performed:– Chest x-rayChest x-ray– Cultures of blood, urine, indwelling lines, and Cultures of blood, urine, indwelling lines, and

bile also are necessarybile also are necessary– A T-tube cholangiogram and Doppler A T-tube cholangiogram and Doppler

ultrasonography of the liver can be performed ultrasonography of the liver can be performed to rule out perihepatic fluid collection and to to rule out perihepatic fluid collection and to evaluate hepatic vasculatureevaluate hepatic vasculature

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Hepatitis B or C recurs in the liver allograft Hepatitis B or C recurs in the liver allograft following transplantationfollowing transplantation

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Hepatitis B:Hepatitis B:– protocols are currently under investigation using protocols are currently under investigation using

different combinations of hepatitis B Ig, hepatitis B different combinations of hepatitis B Ig, hepatitis B vaccines, lamivudine, retroviral agents, and vaccines, lamivudine, retroviral agents, and monoclonal antibodiesmonoclonal antibodies

– The diagnosis is suspected if the level of liver The diagnosis is suspected if the level of liver transaminases increases, and it is confirmed by transaminases increases, and it is confirmed by biopsybiopsy

– Recurrent disease may be severe enough to lead to Recurrent disease may be severe enough to lead to life-threatening hepatitis and cirrhosislife-threatening hepatitis and cirrhosis

– Strategies to prevent hepatitis B recurrence include:Strategies to prevent hepatitis B recurrence include:The use of lamivudine before transplant to arrest viral The use of lamivudine before transplant to arrest viral replication replication And high-dose hepatitis B Ig and lamivudine after transplantAnd high-dose hepatitis B Ig and lamivudine after transplant

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Hepatitis C:Hepatitis C:– Recurrence after transplant, although it is Recurrence after transplant, although it is

ubiquitous, does not commonly lead to ubiquitous, does not commonly lead to significant problems for many years and is significant problems for many years and is associated with mild transaminitisassociated with mild transaminitis

– Occasionally, hepatitis C recurrence can be Occasionally, hepatitis C recurrence can be early, aggressive, and severeearly, aggressive, and severe

– Antiviral therapy has been used to treat Antiviral therapy has been used to treat hepatitis C recurrence but with very limited hepatitis C recurrence but with very limited successsuccess

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H-Posttransplantation H-Posttransplantation ImmunosuppressionImmunosuppression

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H-Posttransplantation H-Posttransplantation ImmunosuppressionImmunosuppression

Currently, the immunosuppressive Currently, the immunosuppressive agents used to prevent rejection include agents used to prevent rejection include corticosteroids and cyclosporine or corticosteroids and cyclosporine or tacrolimustacrolimusOccasionally, azathioprine or Occasionally, azathioprine or mycophenolate mofetil may be added to mycophenolate mofetil may be added to reduce cyclosporine or tacrolimus doses reduce cyclosporine or tacrolimus doses in patients with renal disease or in patients with renal disease or autoimmune liver diseaseautoimmune liver disease

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I-Kidney dysfunctionI-Kidney dysfunction

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I-Kidney dysfunctionI-Kidney dysfunctionSome degree of kidney dysfunction is very Some degree of kidney dysfunction is very common post-transplant, affecting almost common post-transplant, affecting almost all liver recipientsall liver recipientsAbout 10% develop kidney failure severe About 10% develop kidney failure severe enough to require dialysisenough to require dialysisPostoperative kidney problems that may Postoperative kidney problems that may have been present pretransplant are most have been present pretransplant are most commonly due to HRS or ATNcommonly due to HRS or ATN

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I-Kidney dysfunctionI-Kidney dysfunction

Usually, such problems will improve Usually, such problems will improve posttransplant, but recipients with severe posttransplant, but recipients with severe pretransplant kidney dysfunction are at greater pretransplant kidney dysfunction are at greater risk for persistent kidney impairment risk for persistent kidney impairment posttransplantposttransplantSome patients will require renal tranplantationSome patients will require renal tranplantationOther causes of postoperative renal dysfunction Other causes of postoperative renal dysfunction include: include: – Systemic hypovolemiaSystemic hypovolemia– Drug nephrotoxicityDrug nephrotoxicity– Pre-existing kidney diseasePre-existing kidney disease

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J-Abdominal Compartment Syndrome

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J-Abdominal Compartment Syndrome

Relatively commonIncidence (pressure >25mmHg) ? 31%Major effects on organ function (renal, respiratory, cardiovascular, liver & gut)Multi-factorial etiologyMeasure routinely (bladder, gastric pressure)Laparostomy, only Skin closure

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Main ReferencesMain References– The Washigton Manual of SurgeryThe Washigton Manual of Surgery– Schwartz’s Principles of surgerySchwartz’s Principles of surgery– emedicine websiteemedicine website– Presentations for:Presentations for:

Dr. Dr. Derek ManasDr. Geoffrey SchultzDr. Geoffrey SchultzDr Elizabeth Sizer

– And other articlesThanks for all above mentioned references, for their valuable information, & contribution in improving the health care of liver transplant patients

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Thank YouThank You

Health & Medicine

Post Operative ICU Management of Orthotopic Liver Transplant Patients