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Postoperative management of the child following liver transplantation

RANNA A. ROZENFELD AND Z. LEAH HARRIS

39.1  Introduction

39.2  Postoperative stabilisation and management

39.3  Transplant specifics

References

39.1  INTRODUCTION

The postoperative care of the paediatric patient following liver transplant requires constant surveillance, monitoring and assessment. This requires close coordination among critical care, anaesthesiology, transplant surgery and hepatology. All play an essential role in the patient’s transplant success. The improvement in patient and graft survival is due in part to better intensive care management and monitoring of potential complications, coupled with a multidisciplinary approach in the management of the transplant recipient [1,2]. This teamwork should begin with a formal handoff from the operating room (OR) to the paediatric intensive care unit (PICU) and continue with daily multi-disciplinary rounds involving all services, nursing, pharmacy, nutrition and the family.

39.1.1  Handoff from the operating room

A formal handoff process between the OR team and the critical care team is key to ensuring adequate transfer of information about the patient and the surgical procedure. Team members include the anaesthesiologist and surgeon that performed the case, the critical care team receiving the patient, the hepatology team, bedside nursing, respiratory care and the charge nurse. In our institution, the handoff starts with an introduction of all the members in the room with name, specialty and role in the procedure. The first to speak is the anaesthesiologist, who is in charge of transitioning the intravenous lines, medications and infusions, reporting out the events in the OR and any complications. This is followed by an opportunity for any members of the team to ask questions. Next, the surgeon draws the procedure, including the anastomotic sites, sites of the drains and any surgical concerns. The hepatology team confirms critical points of care. Individuals to be called for the next 24 h are identified clearly.

A checklist may be utilised to ensure that all items are covered (Table 39.1), including but not limited to

1.  Comorbidities – Including a list of home medications with a complete medication reconciliation with the hepatology team.

2.  Medical condition immediately pretransplant – Any recent illnesses, especially viral upper respiratory tract infections. Was the patient an inpatient? Pretransplant nutritional status?

3.  Information about the patient and donor – Cytomegalovirus (CMV) status, Epstein–Barr virus (EBV) status and blood type.

4.  Information about the procedure – Living related, deceased donor, lobes received, venous connections, hepatic outflow obstruction, duct anastomosis, drains in place, cold ischaemia time, estimated blood loss, fluids given, urine output, blood products given, vasoactive infusions received and any surgical complications.

Once the report is shared, the receiving medical team does a preliminary physical exam and reviews their findings with the surgical team. By now, all of the lines and monitors have been transitioned and the bedside nurse is able to ask any questions that may have arisen since first receiving report. The anaesthesia and surgical team members leave once all questions have been addressed.

Table 39.1 Handoff tool/checklist

39.2  POSTOPERATIVE STABILISATION AND MANAGEMENT

39.2.1  Respiratory management

Most paediatric patients will return from the OR intubated and mechanically ventilated. The goal should be to extubate as quickly as medically possible, generally within 48 h. Some children – usually older – will meet extubation readiness criteria in the OR [3]. Factors that determine extubation readiness for all patients include ventilatory parameters, sedation and analgesia requirements and haemodynamics. Excessive sedation or liver dysfunction may require longer ventilation. Extubation is often delayed until the 12-hour assessment of graft function. Prolonged ventilation increases the risk of nosocomial infection and ventilator-associated pneumonia. Age and nutritional status play a role in extubation readiness, as does the transplant type. A small child with a deceased whole liver and abdominal distention is likely to show a minute ventilation characterised by fast rate and small-volume breaths and need more time to extubate. Using the mnemonic SOAP – secretions, oxygenation, airway and parameters – one can determine if a child meets extubation readiness. of all the criteria, parameters is the most difficult to quantify in the weak, malnourished child and is frequently the reason for prolonged intubation.

Pleural effusion is common, and the right side is more frequently affected [4]. These effusions are secondary to the trauma of retraction during surgery, placement of a foreign body in the subphrenic space and transudation of ascitic fluid across the diaphragm [4]. These effusions can generally be managed with diuretics and fluid restriction [5] and rarely require pleurocentesis and drainage. Children who develop pleural effusions may have longer ventilator requirements [6]. Caution must be used in overdiuresis, as this haemoconcentration increases blood viscosity and may impact small-calibre anastomoses. The child will likely tolerate the effusion and diurese themselves within a short time, if the pleural effusions are minimal and have been weaned to an FiO₂ of <0.4. If there is concern that the effusion is infectious, care must be taken in considering a thoracentesis versus a chest tube, as splinting and pain will impair spontaneous breathing and can complicate extubation assessments.

Atelectasis is a common problem, especially in young children, and contributes to respiratory distress and difficulty weaning from mechanical ventilation. Diaphragmatic dysfunction is associated with prolonged ventilatory requirement and prolonged PICU stay [6] and may require diaphragmatic plication. Some groups are utilising noninvasive ventilation [7] for children who have respiratory insufficiency postextubation, as a means of support. This may decrease the need for reintubation, although caution is required in utilising a full face mask, as this will also be associated with abdominal distention from gastric air trapping and can lead to worsening abdominal embarrassment and compromised ventilator effort. Monitoring includes oxygen saturation, capnography and arterial blood gas analysis (Table 39.2). In the extubated patient, incentive spirometry every 2 h is highly effective in addressing issues of atelectasis and maintaining improved oxygenation and ventilation.

39.2.2  Fluid, electrolyte and acid–base status

Postoperatively, patients are often fluid overloaded due to intraoperative fluid administration. Monitoring should include heart rate, central venous pressure (CVP), arterial pressure, urine output, total fluids in and total fluids out (Table 39.2). In the child with significant ascites and increased JP^* drainage posttransplant, there may be an associated decrease in urine output. Maintaining euvolaemia is best accomplished by fluid replacement strategies matching JP drainage with millilitre/millilitre fluid replacement intravenously. Drainage from the abdominal drains should be measured hourly. This can be an early indicator of intra-abdominal bleeding, coagulopathy or issues with vascular anastomoses. It is important to follow fluid status and electrolytes closely in the postoperative period. Being aware of and proactive for impending renal impairment is the key. Altered perfusion coupled with impaired venous return preoperatively and intraoperatively, renal vasoconstriction secondary to calcineurin inhibitors (CNIs) and the delivery of nephrotoxic drugs all put the kidney at risk for insufficiency.

Table 39.2 Postoperative monitoring

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