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KEY POINTS
The main reasons for reoperation after liver transplantation are postoperative bleeding, vascular and biliary complications, and intraabdominal sepsis.
Surgical complications after renal transplantation including graft thrombosis, renal artery stenosis, urinary leak, or urinary obstruction have an incidence of 5% to 10% and remain important causes of graft loss.
After pancreatic transplant, a sudden increase in amylase and lipase with a change in exogenous insulin requirements is predictor of graft ischemia or rejection.
It is important for an intensivist to be familiar with early detection and treatment of infection and immunosuppressive medications and their side effects in the posttransplant patient.
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This chapter discusses early postoperative care, early recognition and management of complications, antimicrobial prophylaxis, and immunosuppressant drugs and their side effects in the management of the posttransplant liver, kidney, pancreas, and small intestine recipient.1,2,3,4,5,6,7,8 Indications for transplantation and preoperative management are not discussed in this chapter.
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POSTOPERATIVE CARE AND CRITICAL CARE AFTER LIVER TRANSPLANTATION
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There are 3 major types of liver transplantation (LT): cadaveric orthotopic LT (OLT), where a whole organ is transplanted from a deceased donor (most common); cadaveric OLT by split LT, where the recipient receives 1 lobe of the liver from a deceased donor; and live donor OLT, where the donor undergoes either a right or left hepatic lobectomy. In the case of split or living donor liver transplants, adult recipients usually receive the larger right lobe; children are ordinarily transplanted the smaller left lobe.
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OLT requires surgical anastomosis of the hepatic artery, portal vein, bile duct, and inferior vena cava from donor to recipient, and postoperative complications are often related to dysfunction at these anastomotic sites.
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Recovery in the Immediate Postoperative Period
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Most of the patients after LT, even after an uncomplicated operating room course, are monitored in the ICU. Uncomplicated cases usually transfer to an inpatient liver transplant unit within 24 to 72 hours but complicated cases may require ICU care for weeks. Fifteen percent to 20% of liver transplant patients are taken back to the operating room during the transplant admission. The main reasons for reoperation include postoperative bleeding, vascular and biliary complications, and intraabdominal sepsis.
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In the ICU, frequent hemodynamic assessments are commonly performed using vital signs and noninvasive monitoring (eg, ultrasonography). A preexisting pulmonary artery catheter is utilized if placed intraoperatively for more hemodynamically challenging cases or those with pulmonary hypertension. Vital signs, intake, output, physical changes in drain output, bile production (if a biliary drain [eg, T-tube] is present), abdominal drain (eg, Jackson–Pratt) output, and any signs of postoperative bleeding are recorded hourly. The initial postoperative level of liver biochemistries, that is, alanine transaminase (ALT), aspartate aminotransferase (AST), and bilirubin, may not correlate with liver function in the ...