Editor’s note: This is Part 3 of a three-part series in which the Jefferson Team explores causes and consequences of liver disease. They follow a patient through initial diagnosis and treatment of liver disease, and discuss subsequent definitive management through liver transplantation and related collaborative care.
- Part 1 discussed causes of liver disease; considerations in listing patients for transplant; and initial education and consent session for transplant evaluation.
Part 2 discussed the role of the liver transplant social worker, transplant pharmacy and staff hepatologist. It also discussed anesthesia for liver transplantation.
- Part 3 focuses on postoperative care following liver transplantation.
Patients undergoing an orthotopic liver transplant (OLT) are a unique population requiring extensive hemodynamic monitoring post operatively. The Surgical Intensive Care Unit (SICU) nursing staff is specifically trained to care for the multifaceted postoperative needs of these patients.
Initially, the SICU charge RN is notified by the hospital operator of the incoming OLT patient. This allows the SICU staff to plan ahead for the patient’s arrival. An intensive care bed is made available as soon as the patient arrives in the operating room for pre-operative line placement.
Therefore, if any complications are to occur and the surgeon must stop the case, the patient can be transported to that bed without delay. After the SICU team is made aware of the start of the case, the room is set up with the appropriate equipment and invasive line set ups. These patients have a Swan Ganz catheter floated through a cordis in the subclavian or internal jugular vein, one or two more cordis lines to allow for rapid fluid and blood product administration, as well as both a radial and femoral arterial line to monitor blood pressure throughout the intraoperative and post-operative period.
Prior to the completion of the surgery, the operating room (OR) nurse will call report to the receiving SICU RN. The patient arrives directly from the operating room to the SICU for post anesthesia recovery care. The anesthesiologist or nurse anesthetist will give an updated report. The SICU nurses work together with the OR team to transition the patient from the OR monitors to the SICU equipment, always ensuring patient safety and continued monitoring. Respiratory therapy is at the bedside to connect the patient to the ventilator with the appropriate settings.
Postoperative care of the OLT patient consists of frequent hemodynamic monitoring including cardiac output/cardiac index and pulmonary capillary wedge pressure monitoring every four hours to determine fluid balance status. More frequent assessment of these numbers will be completed with any intervention related to the patient’s vital signs, intake/output and hemodynamic parameters. Vital signs and intake and output are documented hourly per routine care in the SICU. Any sign of hemodynamic instability prompts the SICU nurse to work alongside the intensive care physicians to determine and administer the appropriate intervention.
If the patient appears to require fluid resuscitation, 500 ml of 5% albumin is utilized for volume replacement. Blood products are not utilized unless the patient is exhibiting overt signs of bleeding and instability. The transplant attending must be made aware of any potential need for blood products. The attending will make the final decision regarding blood product administration. Laboratory work is monitored frequently during the initial recovery and postoperative period. Lactate levels are drawn every two hours until the level has normalized. The hepatic transplant panel laboratory test which includes CBC, PT/PTT, chemistry and electrolyte panels, and liver enzymes is monitored at least every four hours, possibly more often depending on the hemodynamic stability of the patient.
Liver transplant patients have three Jackson Pratt (JP) drains and a biliary T tube placed intraoperatively around the surgical area to allow for fluid, bile and blood drainage from the operative site. The SICU nurse monitors the amount and color of the drainage in the JP drain. The biliary drain is placed in the bile duct to allow bile to drain externally so the nurse can assess color and amount. A foley catheter is in place to closely monitor urine output. A nasogastric tube allows for drainage of the stomach to decrease the risk of aspiration while intubated.
An Alprostadil infusion is initiated after the patient arrives to the ICU when the SBP is greater than 110. Alprostadil, or Prostaglandin, is utilized to maintain patency of the hepatic artery to prevent transplant non function. The drip is initiated at 0.2 mcg/kg/hr for one hour, increased to 0.4 mcg/kg/hr for an hour then increased to a max of 0.6 mcg/kg/hr. The drip remains at 0.6mcg/kg/hr for five days. If at any point the patient does not tolerate the increase in the Alprostadil (a SBP<110), the SICU RN will titrate the medication to the previous dose. Another medication frequently utilized is Dextran 40. Dextran is administered intravenously at a rate of 20ml/hr as a prophylactic treatment to prevent thromboembolic events. Alprostadil and Dextran will be maintained for five days.
Postoperatively, the liver transplant patient is placed on assist control settings on the ventilator. Typically, OLT patients are not sedated in the SICU. Fentanyl 50 mcg q1 hour prn is utilized for pain control. If the patient is anxious or agitated, a Dexmedetomidine (Precedex) infusion can be used for sedation while intubated. When appropriate, the patient is placed on a spontaneous breathing trial by the respiratory therapist and extubated based on ABG results and assessment by the SICU RN and ICU physicians. This can be at any time, as early as a few hours up to 24-48 hours after surgery.
After hemodynamic stability has been achieved, and the liver transplant team as well as the ICU physicians believes the patient is recovering appropriately, the Swan Ganz catheter will be removed and the cordis line in the subclavian or intrajugular will be changed over a wire to a triple lumen central venous catheter. The remaining cordis lines and the femoral arterial line will be removed. Teaching regarding incentive spirometry, coughing and deep breathing, mobility after surgery, and immunosuppressant therapy will begin at this time. With stable vital signs, adequate intake and output, and removal of advanced hemodynamic monitoring lines the patient will then be moved to the step down unit. With each patient transfer following transplant, the patient is moving closer to hospital discharge and home. Close attention is paid to activity, activity tolerance, assessing for complications such as bleeding, infection or biliary complications as well as nutrition.
Liver disease pre-transplant creates challenges for nutritional state due to decreased protein levels in the blood. This can impair wound healing, blood glucose levels and increase infection risk in this already immune-compromised patient population. Optimizing nutrition post-transplant is also vital for the same reasons in addition to this vulnerable population requiring additional caloric intake and protein to replace depleted muscle mass and provide optimal fuel for effective participation in physical/occupational rehabilitation. For this reason, the role of transplant dietitian is a vital member of the overall multidisciplinary team.
Malnutrition is a common issue for end stage liver disease patients regardless of the cause of their disease. Complications of liver disease such as ascites, early satiety and loss of appetite, encephalopathy and alteration in nutrient metabolism, are some of the complications that can affect the nutritional status of the patient.
According to Johnson et al., it is estimated that malnutrition is present in at least 50% and up to 90% of patients with cirrhosis. It is crucial to identify malnutrition early and initiate aggressive nutrition interventions to prevent further complications. Early interventions may improve patient outcomes and reduce complications after liver transplant. The dietitian plays an integral role in working with this population to improve their nutritional status before transplant.
The dietitian completes a nutrition screening by reviewing subjective and objective data to determine the patient’s risk for malnutrition. A comprehensive nutrition assessment is the next step that is completed, by reviewing the medical, nutrition and social histories; laboratory data and anthropometric measurements. The goal of the nutrition assessment is to provide adequate calories and protein to prevent further malnutrition.
Once the patient receives their transplant, new complications may arise because of immunosuppressant and other medications that are prescribed to protect the graft. These complications includes, but not limited to diabetes or NODAT (new onset diabetes after transplant), excessive weight gain, hypertension, and hyperlipidemia. The dietary restrictions post-transplant may vary based on the patient’s co-morbidity prior to transplant. If no other co-morbidity, most patients are encouraged to follow a diet low in fat and sodium, rich in fruits and vegetable, lean meats and low fat dairy. Portion size control in the post-transplant phase- (greater than 3 months after transplant) is important in preventing excessive weight gain. Physical activity also plays an important role in managing a patient’s weight, as well as diabetes and hypertension.
In addition to following a healthy diet and staying active, it is critical for post-transplant patients to take precautions to avoid foodborne illness. The patient should avoid raw or undercooked eggs, meat, meat products and seafood, as well as washing all fruits and vegetables well before eating. The patient is also educated about food and drug interactions as well as, avoiding herbals and supplements that were not prescribed by the transplant team. Nutrition monitoring continues throughout the life of the recipient, as the post-transplant complications may occur many years after transplant.
With close attention to optimal physical and psychological recovery, nutritional state, balancing of immune-modulating medications the patient (and their family) become ready for discharge. Their trajectory of care is not yet over. The patient and family are cared for by the post-transplant coordinator. The post-transplant coordinator provides discharge teaching including teaching related to medications, clinic follow-up, nutrition, when/how to contact the transplant team and follows lab results and follow-up diagnostics to monitor immune system drug levels as well as identify possible complications.
The journey of care before and following liver transplantation is a marathon rather than a sprint and becomes part of the life stories we share with patients and their families. Often, when members of the multidisciplinary team meet with a patient and their family, the patient may be very ill, perhaps near death. The multidisciplinary transplant team walks with that patient and family through these vulnerable times, guiding them to recovery.
Michelle McKay is a staff nurse on the Surgical Intensive Care Unit at Thomas Jefferson University Hospital, Philadelphia. Carlene Bowen is a transplant dietitian for the Division of Transplant Services at Thomas Jefferson University Hospital.
Richard Arbour, MSN, RN, CCRN, CNRN, CCNS, CCTC, FAAN, is a neuroscience/critical care clinical nurse specialist at Lancaster General Hospital in Lancaster, Pa. He is a critical care advanced practice nurse, educator and researcher in Philadelphia. He coordinated the content from the specialties represented in this multidisciplinary grand rounds to make a contribution to furthering the understanding of the multidisciplinary nature of the transplant process.