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Post Operative ICU Management of Orthotopic Liver Transplant Patients  S/P Chronic Hepatic Failure Dr. Ahmad Kharrouby PGY...
Introduction <ul><li>The immediate postoperative care for liver recipients involves:  </li></ul><ul><ul><li>(1) stabilizin...
Introduction <ul><li>This initial care should generally be performed in an intensive care unit (ICU) setting because recip...
Introduction <ul><li>Continuous hemodynamic monitoring is important to ensure adequate perfusion of the graft and vital or...
Introduction <ul><li>Hemodynamic instability also may be secondary to the myocardial dysfunction that is often seen early ...
Introduction <ul><li>Fluid management, electrolyte status, and kidney function require frequent evaluation </li></ul><ul><...
Introduction <ul><li>Platelet counts usually decrease in the first week after LT and recover during the second week </li><...
Outline <ul><li>Hemodynamic </li></ul><ul><li>Pulmonary </li></ul><ul><li>Hepatic allograft function </li></ul><ul><ul><li...
A-Hemodynamic
A-Hemodynamic <ul><li>Intravascular volume resuscitation usually is required in the immediate postoperative period seconda...
A-Hemodynamic <ul><li>Avoid Lactated Ringer, & use NSS and other colloid solutions instead, because lactate that is metabo...
A-Hemodynamic <ul><li>Hepatic edema might ensue secondary to aggressive resuscitation & increased intravascular volume, so...
A-Hemodynamic <ul><li>Hypertension is common and should be aggressively treated using nitroprusside </li></ul><ul><li>Diur...
B-Pulmonary
B-Pulmonary <ul><li>Ventilatory support is required postoperatively until the patient  </li></ul><ul><ul><li>Is awake and ...
C-Hepatic allograft function
C-Hepatic allograft function <ul><li>Monitoring of hepatic allograft function begins intraoperatively after revascularizat...
C-Hepatic allograft function <ul><li>Reassessinent of hepatic allograft function continues postoperatively </li></ul><ul><...
C-Hepatic allograft function <ul><li>Satisfactory hepatic allograft function is indicated by an: </li></ul><ul><ul><li>Imp...
C-Hepatic allograft function <ul><li>Early elevations of bilirubin and transaminase levels may be indicators of preservati...
C-Hepatic allograft function <ul><li>After the patient leaves the intensive care unit </li></ul><ul><ul><li>LFTs are obtai...
C-Hepatic allograft function <ul><ul><li>Common Causes: </li></ul></ul><ul><ul><li>Primary nonfunction and initial poor fu...
1-Primary nonfunction and initial poor function <ul><li>The use of UW solution for organ preservation has decreased the in...
1-Primary nonfunction and initial poor function <ul><li>Primary nonfunction is characterized by: </li></ul><ul><ul><li>Hem...
2-Rejection <ul><li>Acute rejection is relatively common after liver transplantation, with 60% of recipients experiencing ...
3-Technical complications <ul><li>A variety of technical problems can lead to liver allograft dysfunction, including:  </l...
<ul><li>Hepatic artery thrombosis </li></ul><ul><li>Incidence of about 3 to 5% in adults and about 5 to 10% in children  <...
<ul><li>Hepatic artery thrombosis </li></ul><ul><li>Acute hepatic artery thrombosis may be treated by attempted thrombecto...
hepatic artery thrombosis, particularly early after transplantation when the allograft is devoid of arterial collaterals, ...
Typical appearance of a liver allograft that failed because of hepatic artery thrombosis leakage of bile
<ul><li>Portal vein stenosis or thrombosis </li></ul><ul><li>Portal vein stenosis or thrombosis is rare </li></ul><ul><li>...
<ul><li>Bile duct obstruction </li></ul><ul><li>Bile duct obstruction is diagnosed by cholangiography </li></ul><ul><li>A ...
4-Recurrent Infection and neoplasm <ul><li>CMV can cause hepatic allograft dysfunction and usually occurs within 8 weeks o...
4-Recurrent Infection and neoplasm <ul><li>Viral hepatitis and malignancy (e.g&quot; hepatoma, cholangiocarcinoma, neuroen...
D-Electrolytes, glucose, and lactate
D-Electrolytes, glucose, and lactate <ul><li>The use of diuretics may result in hypokalemia </li></ul><ul><li>Whereas cycl...
D-Electrolytes, glucose, and lactate <ul><li>Calcium should be measured as free ionized calcium and kept above 4.4 mg/dL, ...
D-Electrolytes, glucose, and lactate <ul><li>Central pontine myelinolysis, which may result from marked fluctuations in se...
D-Electrolytes, glucose, and lactate <ul><li>Glucose homeostasis is necessary because steroid administration may result in...
D-Electrolytes, glucose, and lactate <ul><li>Lactate   </li></ul><ul><ul><li>Patients with pre-op fulminant hepatic failur...
E-GI tract
E-GI tract <ul><li>H2  blockade, proton pump inhibition, and/or antacids are used to prevent stress ulcers </li></ul><ul><...
F-Nutrition
F-Nutrition <ul><li>Patients who are severely malnourished should be placed on nutritional supplementation as soon as stab...
F-Nutrition <ul><li>Patients with adequate preoperative nutrition can be maintained on routine intravenous fluids until GI...
G-Infection surveillance
G-Infection surveillance <ul><li>Sepsis is a major cause of early mortality </li></ul><ul><li>The most common causes of ba...
G-Infection surveillance <ul><li>Prophylactic antibiotics covering biliary pathogens are administered for the first 48 hou...
G-Infection surveillance <ul><li>If a fever develops in the liver transplant recipient, a thorough examination should be p...
G-Infection surveillance <ul><li>Hepatitis B or C recurs in the liver allograft following transplantation </li></ul>
G-Infection surveillance <ul><li>Hepatitis B: </li></ul><ul><ul><li>protocols are currently under investigation using diff...
G-Infection surveillance <ul><li>Hepatitis C: </li></ul><ul><ul><li>Recurrence after transplant, although it is ubiquitous...
H-Posttransplantation Immunosuppression
H-Posttransplantation Immunosuppression <ul><li>Currently, the immunosuppressive agents used to prevent rejection include ...
I-Kidney dysfunction
I-Kidney dysfunction <ul><li>Some degree of kidney dysfunction is very common post-transplant, affecting almost all liver ...
I-Kidney dysfunction <ul><li>Usually, such problems will improve posttransplant, but recipients with severe pretransplant ...
J-Abdominal Compartment Syndrome
J-Abdominal Compartment Syndrome <ul><li>Relatively common </li></ul><ul><li>Incidence (pressure >25mmHg) ? 31% </li></ul>...
Main References <ul><ul><li>The Washigton Manual of Surgery </li></ul></ul><ul><ul><li>Schwartz’s Principles of surgery </...
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Post Operative ICU Management of Orthotopic Liver Transplant Patients

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Transcript of "Post Operative ICU Management of Orthotopic Liver Transplant Patients "

  1. 1. Post Operative ICU Management of Orthotopic Liver Transplant Patients S/P Chronic Hepatic Failure Dr. Ahmad Kharrouby PGY2, Surgery Surgical Intensive Care Unit
  2. 2. Introduction <ul><li>The immediate postoperative care for liver recipients involves: </li></ul><ul><ul><li>(1) stabilizing the major organ systems (e.g., cardiovascular, pulmonary, and renal); </li></ul></ul><ul><ul><li>(2) evaluating graft function and achieving adequate immunosuppression </li></ul></ul><ul><ul><li>(3) monitoring and treating complications directly and indirectly related to the transplant </li></ul></ul>
  3. 3. Introduction <ul><li>This initial care should generally be performed in an intensive care unit (ICU) setting because recipients usually require mechanical ventilatory support for the first 12 to 24 hours </li></ul><ul><li>The goal is to maintain: </li></ul><ul><ul><li>adequate oxygen saturation </li></ul></ul><ul><ul><li>acid-base equilibrium </li></ul></ul><ul><ul><li>stable hemodynamics </li></ul></ul>
  4. 4. Introduction <ul><li>Continuous hemodynamic monitoring is important to ensure adequate perfusion of the graft and vital organs </li></ul><ul><li>Hemodynamic instability occurring early posttransplant is usually due to fluid imbalance, but the presence of ongoing bleeding must first be excluded </li></ul>
  5. 5. Introduction <ul><li>Hemodynamic instability also may be secondary to the myocardial dysfunction that is often seen early in the reperfusion phase, but which may persist into the early postoperative period </li></ul><ul><li>The usual treatment is to optimize preload and afterload, and to use inotropic agents such as dopamine or dobutamine if necessary </li></ul>
  6. 6. Introduction <ul><li>Fluid management, electrolyte status, and kidney function require frequent evaluation </li></ul><ul><li>Serum transaminase levels will usually </li></ul><ul><ul><li>Rise during the first 48 to 72 hours post-transplant secondary to preservation injury </li></ul></ul><ul><ul><li>Then should fall rapidly over the next 24 to 48 hours </li></ul></ul><ul><ul><li>Normalize in 1 week </li></ul></ul>
  7. 7. Introduction <ul><li>Platelet counts usually decrease in the first week after LT and recover during the second week </li></ul><ul><li>This may be caused by platelet sequestration in the liver and spleen due to preservation injury &/or hypersplenism </li></ul><ul><li>Once the liver has recovered, as manifested by the return of bilirubin to normal levels, the platelet count increases </li></ul>
  8. 8. Outline <ul><li>Hemodynamic </li></ul><ul><li>Pulmonary </li></ul><ul><li>Hepatic allograft function </li></ul><ul><ul><li>Primary nonfunction and initial poor function </li></ul></ul><ul><ul><li>Rejection </li></ul></ul><ul><ul><li>Technical Complications </li></ul></ul><ul><ul><ul><li>Hepatic artery thrombosis </li></ul></ul></ul><ul><ul><ul><li>Portal vein thrombosis </li></ul></ul></ul><ul><ul><ul><li>Bile duct obstruction </li></ul></ul></ul><ul><ul><li>Recurrent infection and neoplasm </li></ul></ul><ul><li>Electrolytes, glucose, and lactate </li></ul><ul><li>GI Tract </li></ul><ul><li>Nutrition </li></ul><ul><li>Infection Surveillance </li></ul><ul><li>Post transplantation Immunossuppression </li></ul><ul><li>Kidney dysfunction </li></ul><ul><li>Abdominal compartment syndrome </li></ul>
  9. 9. A-Hemodynamic
  10. 10. A-Hemodynamic <ul><li>Intravascular volume resuscitation usually is required in the immediate postoperative period secondary to: </li></ul><ul><ul><li>Third-space losses </li></ul></ul><ul><ul><li>Increased body temperature </li></ul></ul><ul><ul><li>Vasodilatation </li></ul></ul><ul><li>Adequate perfusion is assessed by: </li></ul><ul><ul><li>Left and right heart filling pressures </li></ul></ul><ul><ul><li>Cardiac output </li></ul></ul><ul><ul><li>Urine output </li></ul></ul><ul><ul><li>Absence of metabolic acidosis </li></ul></ul><ul><ul><li>Sequential Hemoglobin levels </li></ul></ul>
  11. 11. A-Hemodynamic <ul><li>Avoid Lactated Ringer, & use NSS and other colloid solutions instead, because lactate that is metabolised in the liver will be already elevated </li></ul>
  12. 12. A-Hemodynamic <ul><li>Hepatic edema might ensue secondary to aggressive resuscitation & increased intravascular volume, so aim to CVP 6-10 to minimize increased hepatic vein pressures & sinusoidal congestion that impair graft perfusion & exacerbate reperfusion injury </li></ul>
  13. 13. A-Hemodynamic <ul><li>Hypertension is common and should be aggressively treated using nitroprusside </li></ul><ul><li>Diuretics may be required to remove excess fluid acquired intraoperatively, but they may result in hypokalemia </li></ul><ul><li>Serial hematocrits and transfuse accordinglly </li></ul><ul><li>Correction of bleeding parameters using FFPs, platelet transfusions, and even Desmopressin and factor 7 infusions to be done accordingly </li></ul>
  14. 14. B-Pulmonary
  15. 15. B-Pulmonary <ul><li>Ventilatory support is required postoperatively until the patient </li></ul><ul><ul><li>Is awake and alert </li></ul></ul><ul><ul><li>Is able to follow commands and protect the airway </li></ul></ul><ul><ul><li>Is able to maintain adequate oxygenation and ventilation </li></ul></ul><ul><li>Infectious and noninfectious pulmonary complications can occur in up to 75% of liver recipients </li></ul><ul><li>TRALI is common in these patients </li></ul>
  16. 16. C-Hepatic allograft function
  17. 17. C-Hepatic allograft function <ul><li>Monitoring of hepatic allograft function begins intraoperatively after revascularization </li></ul>
  18. 18. C-Hepatic allograft function <ul><li>Reassessinent of hepatic allograft function continues postoperatively </li></ul><ul><li>initially occurring every 6 hours </li></ul>
  19. 19. C-Hepatic allograft function <ul><li>Satisfactory hepatic allograft function is indicated by an: </li></ul><ul><ul><li>Improving coagulation profile </li></ul></ul><ul><ul><li>Decreasing transaminase levels </li></ul></ul><ul><ul><li>Normal blood glucose </li></ul></ul><ul><ul><li>Hemodynamic stability </li></ul></ul><ul><ul><li>Adequate urine output </li></ul></ul><ul><ul><li>Bile production </li></ul></ul><ul><ul><li>Clearance of anesthesia </li></ul></ul>
  20. 20. C-Hepatic allograft function <ul><li>Early elevations of bilirubin and transaminase levels may be indicators of preservation injury </li></ul><ul><li>The peak levels of SGOT and SGPT usually are less than 2,000 units/L and should decrease rapidly over the first 24 to 48 hours postop. </li></ul>
  21. 21. C-Hepatic allograft function <ul><li>After the patient leaves the intensive care unit </li></ul><ul><ul><li>LFTs are obtained daily </li></ul></ul><ul><ul><li>Bile is inspected daily </li></ul></ul><ul><ul><li>A T-tube cholangiogram may be obtained to ensure adequate biliary drainage and to rule out extravasation </li></ul></ul><ul><li>It is important to correctly diagnose the cause of liver dysfunction, because each cause has its own unique treatment </li></ul>
  22. 22. C-Hepatic allograft function <ul><ul><li>Common Causes: </li></ul></ul><ul><ul><li>Primary nonfunction and initial poor function </li></ul></ul><ul><ul><li>Rejection </li></ul></ul><ul><ul><li>Technical Complications </li></ul></ul><ul><ul><ul><li>Hepatic artery thrombosis </li></ul></ul></ul><ul><ul><ul><li>Portal vein thrombosis </li></ul></ul></ul><ul><ul><ul><li>Bile duct obstruction </li></ul></ul></ul><ul><ul><li>Recurrent infection and neoplasm </li></ul></ul><ul><li>The most common causes of early graft loss include primary nonfunction and hepatic artery thrombosis </li></ul>
  23. 23. 1-Primary nonfunction and initial poor function <ul><li>The use of UW solution for organ preservation has decreased the incidence of primary nonfunction </li></ul><ul><li>For poorly understood reasons, however, 1% to 9% of transplanted livers fail immediately after the surgery </li></ul>
  24. 24. 1-Primary nonfunction and initial poor function <ul><li>Primary nonfunction is characterized by: </li></ul><ul><ul><li>Hemodynamic instability </li></ul></ul><ul><ul><li>Poor quantity and quality of bile </li></ul></ul><ul><ul><li>Renal dysfunction </li></ul></ul><ul><ul><li>Failure to regain consciousness </li></ul></ul><ul><ul><li>Increasing coagulopathy </li></ul></ul><ul><ul><li>Persistent hypothermia </li></ul></ul><ul><ul><li>Lactic acidosis in the face of patent vascular anastomosis (as demonstrated by Doppler ultrasonography) </li></ul></ul><ul><li>Without re-transplantation, death ensue </li></ul>
  25. 25. 2-Rejection <ul><li>Acute rejection is relatively common after liver transplantation, with 60% of recipients experiencing at least one cell-mediated or acute rejection episode </li></ul><ul><li>However, rejection is an extremely uncommon cause of graft loss because it can be treated by increasing immunosuppression (increase corticostroids dose) </li></ul>
  26. 26. 3-Technical complications <ul><li>A variety of technical problems can lead to liver allograft dysfunction, including: </li></ul><ul><ul><li>Hepatic artery stenosis or thrombosis </li></ul></ul><ul><ul><li>Portal vein stenosis or thrombosis </li></ul></ul><ul><ul><li>Biliary tract obstruction </li></ul></ul><ul><ul><li>Bile duct leak </li></ul></ul><ul><ul><li>Hepatic vein or vena caval thrombosis </li></ul></ul>
  27. 27. <ul><li>Hepatic artery thrombosis </li></ul><ul><li>Incidence of about 3 to 5% in adults and about 5 to 10% in children </li></ul><ul><li>May occur in the early post transplantation period and may lead to: </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Hemodynamic instability </li></ul></ul><ul><ul><li>Rapid deterioration of the patient, </li></ul></ul><ul><ul><li>Marked elevation of the transaminases </li></ul></ul><ul><ul><li>Associated bile leak soon after liver transplantation due to the loss of the bile ducts' main vascular supply </li></ul></ul>
  28. 28. <ul><li>Hepatic artery thrombosis </li></ul><ul><li>Acute hepatic artery thrombosis may be treated by attempted thrombectomy </li></ul><ul><li>If this is unsuccessful, retransplantation is needed, </li></ul><ul><li>Hepatic artery thrombosis that occurs long after liver transplantation may produce intra- and extrahepatic bile duct strictures and may be an indication for elective retransplantation </li></ul><ul><li>Occasionally, hepatic artery thrombosis is completely asymptomatic </li></ul>
  29. 29. hepatic artery thrombosis, particularly early after transplantation when the allograft is devoid of arterial collaterals, results in selective necrosis of the Biliary tree and surrounding connective tissue
  30. 30. Typical appearance of a liver allograft that failed because of hepatic artery thrombosis leakage of bile
  31. 31. <ul><li>Portal vein stenosis or thrombosis </li></ul><ul><li>Portal vein stenosis or thrombosis is rare </li></ul><ul><li>When it occurs, the patient's condition may deteriorate rapidly, with: </li></ul><ul><ul><li>Profound hepatic dysfunction </li></ul></ul><ul><ul><li>Massive ascites </li></ul></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Hemodynamic instability </li></ul></ul><ul><li>Although surgical thrombectomy may be successful, urgent re-transplantation is often necessary </li></ul><ul><li>Late portal vein thrombosis may allow normal liver function but usually results in variceal bleeding and ascites </li></ul>
  32. 32. <ul><li>Bile duct obstruction </li></ul><ul><li>Bile duct obstruction is diagnosed by cholangiography </li></ul><ul><li>A single short bile duct stricture may be treated by either percutaneous or retrograde balloon dilation </li></ul><ul><li>A long stricture, ampullary dysfunction, or failed dilation necessitates revision of the biliary tract anastomosis </li></ul><ul><li>Fever and abdominal pain in the early post transplantation period should raise the possibility of biliary anastomotic disruption, which requires urgent surgical revision </li></ul>
  33. 33. 4-Recurrent Infection and neoplasm <ul><li>CMV can cause hepatic allograft dysfunction and usually occurs within 8 weeks of transplantation </li></ul><ul><ul><li>Diagnosis is made by liver biopsy, with CMV inclusion bodies being found with light microscopy or by PCR in peripheral blood </li></ul></ul><ul><ul><li>Treatment consists of decreasing baseline immunosuppression and administering ganciclovir (5 mg/kg every 12 hours via central venous access for 3 weeks) </li></ul></ul>
  34. 34. 4-Recurrent Infection and neoplasm <ul><li>Viral hepatitis and malignancy (e.g&quot; hepatoma, cholangiocarcinoma, neuroendoc:rine tumors) can recur in the hepatic allograft but are uncommon in the early post-transplantation period </li></ul><ul><ul><li>The clinical presentation includes elevations on liver function tests </li></ul></ul><ul><ul><li>The diagnosis is made by liver biopsy </li></ul></ul><ul><ul><li>Imaging studies (e.g., CT scan, liver ultrasonography) are important for following patients transplanted for neoplasms </li></ul></ul>
  35. 35. D-Electrolytes, glucose, and lactate
  36. 36. D-Electrolytes, glucose, and lactate <ul><li>The use of diuretics may result in hypokalemia </li></ul><ul><li>Whereas cyclosporine or tacrolimus toxicity may cause hyperkalemia </li></ul><ul><li>Transfusion of citrate rich blood products results in decreased serum magnesium & calcium </li></ul><ul><li>Magnesium levels are maintained above 2 mg/dL (0,82 mmol/L) because the seizure threshold is lowered bv the combination of hypomagnesemia and cyclosporine or tacrolimus </li></ul>
  37. 37. D-Electrolytes, glucose, and lactate <ul><li>Calcium should be measured as free ionized calcium and kept above 4.4 mg/dL, Transfusion of citrate rich blood products results in decreased serum magnesium & calcium </li></ul><ul><li>Phosphorus levels should be maintained above 2.5 mg/dL to avoid respiratory muscle weakness and altered oxygen hemoglobin dissociation </li></ul>
  38. 38. D-Electrolytes, glucose, and lactate <ul><li>Central pontine myelinolysis, which may result from marked fluctuations in serum sodium levels and osmolality, is an uncommon cause of a patient not regaining consciousness posttransplant </li></ul>
  39. 39. D-Electrolytes, glucose, and lactate <ul><li>Glucose homeostasis is necessary because steroid administration may result in hyperglycemia, which is best managed with intravenous insulin because it is short acting and easily absorbed </li></ul><ul><li>Cyclosporine and tacrolimus are diabetogenic immunosuppressants and may alter glucose homeostasis </li></ul><ul><li>Hypoglycemia is a complication of liver failure, and in the presence of liver dysfunction, glucose administration may be necessary </li></ul>
  40. 40. D-Electrolytes, glucose, and lactate <ul><li>Lactate </li></ul><ul><ul><li>Patients with pre-op fulminant hepatic failure/necrosis should have lactate levels that trend towards normal after transplantation providing their fluid status is adequate </li></ul></ul><ul><ul><li>Elevated lactate levels also are seen in: </li></ul></ul><ul><ul><ul><li>Hypoperfusion states </li></ul></ul></ul><ul><ul><ul><li>Late sepsis </li></ul></ul></ul><ul><ul><ul><li>Primary non-function </li></ul></ul></ul>
  41. 41. E-GI tract
  42. 42. E-GI tract <ul><li>H2 blockade, proton pump inhibition, and/or antacids are used to prevent stress ulcers </li></ul><ul><li>Endoscopy is performed liberally for any GI bleeding to determine the etiology </li></ul><ul><li>Nystatin and GI tract decontamination solution containing gentamicin and polymyxin B are used in the perioperative period to prevent esophageal candidiasis and translocation of bacterial pathogens </li></ul>
  43. 43. F-Nutrition
  44. 44. F-Nutrition <ul><li>Patients who are severely malnourished should be placed on nutritional supplementation as soon as stable fluid and electrolyte status and adequate graft function have been reached </li></ul>
  45. 45. F-Nutrition <ul><li>Patients with adequate preoperative nutrition can be maintained on routine intravenous fluids until GI tract function returns (usually 3 to 5 days) </li></ul><ul><li>Enteral nutrition is used as soon as the postoperative ileus resolves, Total parenteral nutrition (TPN) is indicated when the Gl tract is nonfunctional </li></ul>
  46. 46. G-Infection surveillance
  47. 47. G-Infection surveillance <ul><li>Sepsis is a major cause of early mortality </li></ul><ul><li>The most common causes of bacterial infection after liver transplantation include </li></ul><ul><ul><li>Line sepsis </li></ul></ul><ul><ul><li>Urinary tract infection </li></ul></ul><ul><ul><li>Infected ascites </li></ul></ul><ul><ul><li>Cholangitis </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Biliary anastomotic leak </li></ul></ul><ul><ul><li>Intra­abdominal abscess </li></ul></ul>
  48. 48. G-Infection surveillance <ul><li>Prophylactic antibiotics covering biliary pathogens are administered for the first 48 hours after liver transplantation </li></ul>
  49. 49. G-Infection surveillance <ul><li>If a fever develops in the liver transplant recipient, a thorough examination should be performed: </li></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>Cultures of blood, urine, indwelling lines, and bile also are necessary </li></ul></ul><ul><ul><li>A T-tube cholangiogram and Doppler ultrasonography of the liver can be performed to rule out perihepatic fluid collection and to evaluate hepatic vasculature </li></ul></ul>
  50. 50. G-Infection surveillance <ul><li>Hepatitis B or C recurs in the liver allograft following transplantation </li></ul>
  51. 51. G-Infection surveillance <ul><li>Hepatitis B: </li></ul><ul><ul><li>protocols are currently under investigation using different combinations of hepatitis B Ig, hepatitis B vaccines, lamivudine, retroviral agents, and monoclonal antibodies </li></ul></ul><ul><ul><li>The diagnosis is suspected if the level of liver transaminases increases, and it is confirmed by biopsy </li></ul></ul><ul><ul><li>Recurrent disease may be severe enough to lead to life-threatening hepatitis and cirrhosis </li></ul></ul><ul><ul><li>Strategies to prevent hepatitis B recurrence include: </li></ul></ul><ul><ul><ul><li>The use of lamivudine before transplant to arrest viral replication </li></ul></ul></ul><ul><ul><ul><li>And high-dose hepatitis B Ig and lamivudine after transplant </li></ul></ul></ul>
  52. 52. G-Infection surveillance <ul><li>Hepatitis C: </li></ul><ul><ul><li>Recurrence after transplant, although it is ubiquitous, does not commonly lead to significant problems for many years and is associated with mild transaminitis </li></ul></ul><ul><ul><li>Occasionally, hepatitis C recurrence can be early, aggressive, and severe </li></ul></ul><ul><ul><li>Antiviral therapy has been used to treat hepatitis C recurrence but with very limited success </li></ul></ul>
  53. 53. H-Posttransplantation Immunosuppression
  54. 54. H-Posttransplantation Immunosuppression <ul><li>Currently, the immunosuppressive agents used to prevent rejection include corticosteroids and cyclosporine or tacrolimus </li></ul><ul><li>Occasionally, azathioprine or mycophenolate mofetil may be added to reduce cyclosporine or tacrolimus doses in patients with renal disease or autoimmune liver disease </li></ul>
  55. 55. I-Kidney dysfunction
  56. 56. I-Kidney dysfunction <ul><li>Some degree of kidney dysfunction is very common post-transplant, affecting almost all liver recipients </li></ul><ul><li>About 10% develop kidney failure severe enough to require dialysis </li></ul><ul><li>Postoperative kidney problems that may have been present pretransplant are most commonly due to HRS or ATN </li></ul>
  57. 57. I-Kidney dysfunction <ul><li>Usually, such problems will improve posttransplant, but recipients with severe pretransplant kidney dysfunction are at greater risk for persistent kidney impairment posttransplant </li></ul><ul><li>Some patients will require renal tranplantation </li></ul><ul><li>Other causes of postoperative renal dysfunction include: </li></ul><ul><ul><li>Systemic hypovolemia </li></ul></ul><ul><ul><li>Drug nephrotoxicity </li></ul></ul><ul><ul><li>Pre-existing kidney disease </li></ul></ul>
  58. 58. J-Abdominal Compartment Syndrome
  59. 59. J-Abdominal Compartment Syndrome <ul><li>Relatively common </li></ul><ul><li>Incidence (pressure >25mmHg) ? 31% </li></ul><ul><li>Major effects on organ function (renal, respiratory, cardiovascular, liver & gut) </li></ul><ul><li>Multi-factorial etiology </li></ul><ul><li>Measure routinely (bladder, gastric pressure) </li></ul><ul><li>Laparostomy, only Skin closure </li></ul>
  60. 60. Main References <ul><ul><li>The Washigton Manual of Surgery </li></ul></ul><ul><ul><li>Schwartz’s Principles of surgery </li></ul></ul><ul><ul><li>emedicine website </li></ul></ul><ul><ul><li>Presentations for: </li></ul></ul><ul><ul><ul><li>Dr. Derek Manas </li></ul></ul></ul><ul><ul><ul><li>Dr. Geoffrey Schultz </li></ul></ul></ul><ul><ul><ul><li>Dr Elizabeth Sizer </li></ul></ul></ul><ul><ul><li>And other articles </li></ul></ul><ul><li>Thanks for all above mentioned references, for their valuable information, & contribution in improving the health care of liver transplant patients </li></ul>
  61. 61. Thank You
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