Page 546 - ACCCN's Critical Care Nursing

Gastrointestinal, Liver and Nutritional Alterations 523

Orthotopic Liver Transplantation Within the first few months, a split liver will regenerate
Orthotopic liver transplantation (OLTx) is the replace- until it is a full-sized liver; in children it also grows and
ment of the diseased liver. Current surgery times are now develops at the same rate as the children. This technique
6–8 hours, having previously been 12–18 hours. This has significantly reduced the number of children waiting
reduction in surgical time and improvement in technique for liver transplantation, although little impact has been
273,296
has led to reductions in intra- and postoperative made on adult waiting lists.
complications.
Adult Living Donor Liver Transplantation
Two main techniques are used for OLTx: portal bypass or
the piggyback technique. Portal bypass occurs where an Living donor liver transplantation (LDLT) is an estab-
internal temporary portocaval shunt or external veno- lished option for paediatric patients with end-stage
297
venous bypass is used. 289-291 In the piggyback technique, liver disease. This technique involves removal of
the recipient’s inferior vena cava (IVC) is left and the the left lobe from the live donor, usually the recipient’s
donor IVC is piggybacked onto the recipient’s IVC. The parent, which is then transplanted into the child. It is a
advantages of this technique include haemodynamic relatively straightforward procedure, with little risk to the
297,298
stability during the anhepatic phase, reduced operating donor.
times and reduced use of blood products, enabling a Adult-to-adult LDLT involves transplantation of the right
292
shorter length of hospital stay. The use of T tubes, to lobe of the liver from a donor to an adult recipient, offer-
monitor bile outflow, leaks, stenosis, and to provide ing hope to patients with end stage liver disease (ESLD).
direct access to the biliary system to perform controlled The operation has been performed with some success,
cholangiograms and interventional radiographic proce- although there are significant risks to the donor, includ-
dures 293,294 are now not common. It has been shown that ing death and morbidity. 298
there were fewer biliary complications and costs were
reduced (there were fewer radiographic interventions) POSTOPERATIVE MANAGEMENT
without insertion of a T tube. 295
The postoperative management of liver transplant
patients is not dissimilar to other critical care surgical
Split-liver Transplantation patients yet the combination of hepatic-specific
The disparity between the increasing number of people issues and immunosuppressive therapy can make the
on transplant waiting lists and the shortage of donor management challenging.
livers available has led to several innovative strategies.
Split-liver transplantation occurs when the cadaver organ Initial Nursing Considerations
is divided for two recipients, with the larger right segment The initial postoperative care of liver transplant patients
going to an adult and the smaller left lobe to a child (see on return to critical care involves stabilisation, manage-
Figure 19.2). 273,296 The complication rate is higher in split- ment of positive pressure ventilation, continuous haemo-
liver than whole-liver transplants due to biliary leaks and dynamic monitoring and physical assessment, as with all
anastomosis strictures. The risk of complications and the critically ill surgical patients. It is common for patients to
potential for small-sized grafts are taken into consider- be hypertensive post-surgery, displaying systolic blood
ation when selecting a recipient patient for transplant. pressure (SBP) above 160 mmHg with a mean arterial
Furthermore, not all donor livers are suitable for splitting. pressure (MAP) of 110 mmHg. Aggressive treatment is
required due to the risk of stroke, which is compounded
by low platelet counts and abnormal clotting. Once pain
is controlled and excluded as a cause of hypertension,
clonidine or hydralazine is considered. Oliguria is
commonly related to intraoperative fluid losses and
fluid shifts.
Once initial stabilisation is achieved, treatment is gov-
erned by clinical progress. Patients who have uncompli-
cated surgery and return to critical care in a stable
condition with good graft function are rapidly weaned
from mechanical ventilation within 12–24 hours. Typi-
cally, the critical care stay for a routine postoperative liver
transplantation does not exceed 24–48 hours; as long as
physiological systems are maintained, discharge to the
ward can be anticipated. An abdominal CT scan may be
considered at 7–10 days postoperatively or when clini-
cally indicated.
The initial postoperative care is similar for all liver trans-
plant patients. However, progress, stability and discharge
FIGURE 19.2 Split-liver transplantation (Courtesy Australian National from critical care can be affected by the patient’s preop-
Liver Transplantation Unit). erative condition and severity of liver failure. The unique