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1100 PART 10: The Surgical Patient

TABLE 115-13 Postoperative Management of Liver Transplant Recipients Calcineurin Inhibitors Multiple trials have attempted to delineate which
calcineurin inhibitor (tacrolimus or cyclosporine) is superior for the
Postoperative assessment of graft Serial measurements of INR, lactate, total bilirubin, liver transplant population. After multiple meta-analysis and systemic
function glucose to assess function; transaminases reviews, both are felt to be very effective. In one trial, tacrolimus was
Ventilation Lung-protective ventilator management superior with regard to preventing acute rejection, steroid resistant
Consideration for early extubation a rejection, and graft loss; however, diabetes was more commonly seen. 88,89
The issue surrounding the use of calcineurin inhibitors in the setting
Fluid and hemodynamics Cautious fluid administration of renal failure is especially challenging as sicker patients are being
Maintain low central venous pressure prioritized based on their renal function. A strategy of low-dose tacroli-
Hyperdynamic circulation may persist postoperatively mus or delayed low-dose tacrolimus has been found in some studies to
minimize renal injury. Ongoing research is exploring the added benefit
90
Monitor for evidence of bleeding
of cyclosporine in HCV patients as it has been shown to inhibit HCV
Immunosuppressive medications Maintenance: triple drug therapy with a calcineurin replication in vitro. 91
inhibitor, an antiproliferative, and a corticosteroid
Sirolimus (Rapamycin) While problems have been expressed with wound
Antimicrobial prophylaxis See Infectious Disease section healing in a variety of different solid organ transplants, in the liver
a Ongoing clinical trials. transplant population sirolimus has been associated with lower rates
92
of hepatocellular carcinoma posttransplantation. Ongoing prospec-
tive studies are attempting to further elucidate the interaction between
hepatocellular carcinoma growth and sirolimus.
may benefit from insertion of a pulmonary artery catheter to assist with
the management of the portopulmonary hypertension and cardiac dys- ■ POSTOPERATIVE COMPLICATIONS
function that is often present (Table 115-13).
Common complications following liver transplant are outlined below
Mechanical Ventilation: Although high levels of PEEP may contribute and in Table 115-14.
to a reduction in venous drainage from the liver, practically, the use of
PEEP should be guided by the needs of the patient. Most patients who Primary Graft Nonfunction: Primary graft nonfunction refers to a failure of
present to the intensive care unit can be extubated once there is evidence the transplanted liver early in the postoperative period. The characteristics
of improving graft function and their hemodynamic status, fluid balance of this devastating complication include minimal bile output, refractory
and pain are adequately controlled. In the absence of complications, coagulopathy, progressive elevation of transaminases, acidosis, hypogly-
refractory ascites or pleural effusions, most patients are extubated on the cemia, and cerebral edema. The incidence is likely only between 3% and
93,94
95
same or first post-operative day. Indeed, one of the most recent advance- 5%, but the associated mortality rate may be higher than 20%.
ments in postoperative care is the movement toward early extubation. Several considerations exist if the graft fails to work postoperatively. The
Multiple single institutional studies have suggested that early airway possibility of vascular complications should be entertained and excluded
96
extubation is a safe practice that theoretically may minimize the risk of with Doppler ultrasonography. Investigations to detect severe infection
developing ventilator-associated complications. Ongoing larger multi- or acute rejection should be initiated. If all these tests fail to elucidate the
84
center trials are currently underway regarding the benefit and establish- cause of graft failure, primary graft nonfunction is the likely cause.
ing criteria for fast tracking patients to early extubation. Vascular Complications: The incidence of vascular complications fol-
lowing liver transplant ranges from 8% to 14%. These develop most
97
Immunosuppression—Special Considerations for Liver Transplant: Most cen-
ters use a combination of two to three different maintenance immuno-
suppressive drugs to prevent rejection. Calcineurin inhibitors remain the TABLE 115-14 immediate Complications Post-Liver Transplant by System
mainstay of immunosuppression in liver transplant. The section on immu- Neurologic Residual cerebral edema/hepatic encephalopathy
nosuppression outlines general principles for all transplants; however, Calcineurin inhibitor toxicity (tremors, delirium seizures, posterior
some unique considerations for liver transplant are worth highlighting. reversible encephalopathy syndrome)
Glucocorticoids Unlike the lung transplant population, most centers aggres- Seizures (multifactorial)
sively attempt to taper and eventually discontinue glucocorticoids within Cardiovascular Hyperdynamic circulation
6 months to 1-year posttransplant. Immune-mediated conditions such Vasoplegia syndrome
as autoimmune hepatitis, primary biliary cirrhosis, and primary scleros-
ing cholangitis are conditions, however, in which long-term low-dose Pulmonary Residual hepatopulmonary syndrome
glucocorticoids are continued given that the immune-mediated graft Pneumonia
rejection is higher with these conditions. Alternatively, an approach to Pleural effusions
85
rapid tapering of glucocorticoids is taken in hepatitis C virus patients Atelectasis
(HCV) as glucocorticoids have been shown to be associated with Hepatic Primary nonfunction
increases in HCV replication. It is believed that this is due to either a Hepatic artery thrombosis, portal vein thrombosis
direct impact on enhanced replication or more effective replication in Biliary leak
light of higher immunosuppression. While many centers choose to taper Acute rejection
steroids slowly, multiple trials have looked into steroid free immunosup- Recurrence of primary disease (autoimmune/viral)
pression. In one recent meta-analysis of 21 randomized controlled trials, Intra-abdominal infections
HCV patients in the glucocorticoid-free protocol (with the replacement Renal Prerenal (volume depletion/bleeding)
of an alternative agent) appeared to benefit with overall lower rates of Acute tubular necrosis (intra-/postoperative hemodynamic changes)
HCV recurrence, acute graft hepatitis, and treatment failure. A small Immunosuppressant drug toxicity
86
randomized controlled trial demonstrated no difference in rejection Residual hepatorenal syndrome
and similar 1-, 3-, and 5-year survival in patients treated with cortico- Abdominal compartment syndrome
steroids compared to those who underwent corticosteroid taper by 6
months in exchange for an alternative regimen in 39 patients. A more Infectious Intra-abdominal surgical site infections
87
definitive recommendation awaits the results of ongoing clinical trials Invasive or local candidiasis
(http://clinicaltrials.gov/ct2/show/NCT00286871). Biliary tract infections

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