Question

CASE STUDY 36.1 Patient With a Transplant

Brief Patient History

Mr. V is a 42-year-old man with chronic viral hepatitis C. He has a Model for End-Stage Liver Disease (MELD) score greater than 25. Mr. V is in acute fulminant liver failure and is on the waiting list to receive a liver transplant. Mr. V was hospitalized 2 weeks ago with ascites, hepatorenal syndrome, and hepatic encephalopathy. He has been treated with diuretics, antibiotics, and laxatives. Before transplantation, he remained in the intermediate care unit and was not intubated. He is now undergoing liver transplantation.

Clinical Assessment

Mr. V is admitted to the critical care unit from the operating room after receiving an orthotopic liver transplant. He is intubated and sedated. Mr. V moves all extremities but does not follow commands. He has a nasogastric tube, pulmonary artery catheter, arterial line, urinary catheter, abdominal drain (draining bright red blood), and external biliary drain in place. Continuous renal replacement therapy is in progress.

Diagnostic Procedures

Baseline vital signs include the following: blood pressure of 100/60 mm Hg, heart rate of 118 beats/min (sinus tachycardia), respiratory rate of 20 breaths/min, temperature of 98.3°F, and oxygen saturation of 98%.

Urine output was 75 mL/h and is now 15 mL/h. Central venous pressure is 14 mm Hg, pulmonary artery pressure is 30/16 mm Hg, pulmonary artery occlusion pressure is 18 mm Hg, and intraabdominal pressure is greater than 25 mm Hg.

His current laboratory values include the following:

White blood cell count: 3100 cells/mm3

Hematocrit: 25.3%

Hemoglobin: 8.6 g/dL

Platelet count: 47,000/microliter

Aspartate aminotransferase: 315 units/L

Aminotransferase: 230 units/L

Alkaline phosphatase: 380 units/L

Gamma-glutamyltransferase: 1040 units/L

Total bilirubin: 12.5 mg/dL

Prothrombin time: 21.3 s

International normalized ratio: 2.5

Partial thromboplastin time: 69.9 s

Blood urea nitrogen: 39 mg/dL

Serum creatinine: 1.4 mg/dL

Potassium: 3.8 mEq/L (mmol/L)

Medical Diagnosis

Mr. V is diagnosed with intraabdominal hypertension and abdominal compartment syndrome.

Questions

1. What major outcomes do you expect to achieve for this patient?

2. What problems or risks must be managed to achieve these outcomes?

3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?

4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

5. What possible learning needs do you anticipate for this patient?

6. What cultural and age-related factors may have a bearing on the patient’s plan of care?

Answer 1

Abdominal compartment syndrome occurs when tissue fluid within the peritoneal and retroperitoneal space (either edema, retroperitoneal blood or free fluid in the abdomen) accumulates in such large volumes that the abdominal wall compliance threshold is crossed and the abdomen can no longer stretch.

The abdominal compartment syndrome is a well-known complication after abdominal trauma and is increasingly recognized as a potential risk factor for renal failure and mortality after adult orthotopic liver transplantation (OLT)

When increased compression occurs in such a hollow space, organs will begin to collapse under the pressure. As the pressure increases and reaches a point where the abdomen can no longer be distended it starts to affect the cardiovascular and pulmonary systems. When abdominal compartment syndrome reaches this point without surgery and help of a silo the patient will most likely die. There is a high mortality rate associated with abdominal compartment syndrome.

An abdominal compartment syndrome mainly affects the cardiovascular, renal, and respiratory systems

The outcome of abdominal compartment syndrome strongly correlates with the delay in providing an appropriate management.

1) Outcomes expected.

Mr.v has low WBC count, low hematocrit count, low platelet count, elevated Aspartate aminotransferase,Aminotransferase,Alkaline phosphatase,Gamma-glutamyltransferase, total bilirubin, prothrombin time,Blood urea nitrogen.

The postoperative course in OLT patients ranges from straightforward to extremely complicated, and the outcome depends on the status of the recipient, donor organ, and technical issues in the operation. Complications after liver transplantation can have a significant impact on outcomes and costs of the procedure. Timely diagnosis of alterations in the normal postoperative course is the critical factor to minimize morbidity and mortality and to improve outcomes.

2)Primary Nonfunction,Hepatic Artery Stenosis and Thrombosis,Portal Vein Stenosis and Thrombosis,Hepatic Outflow Obstruction,Biliary Complications,Bleeding,Ascites and Fluid Retention,Infection

3)  Immediately following OLT, the patient to bereturned to the surgical intensive care unit (ICU). In the ICU, he ismaintained on a ventilator until fully conscious and able to breathe on their own while being able to protect their airway. During the ICU stay, there is a need for close attention to management of fluid and electrolytes, which could be significantly abnormal as a result of the prolonged operation and massive fluid shifts.

Immunosuppressive agents, based on specific protocols and on the patient’s renal function, are started early after OLT. Doses are adjusted according to blood levels and functional status of the transplanted liver and renal function. Most patients with an uncomplicated postoperative course and good liver function remain in the ICU for 1 or 2 days before being transferred to an inpatient transplantation unit.

4)Following transfer to a designated transplantation inpatient unit, the patient should be closely followed by the surgical and medical team, as well as by pharmacists, nutritionists, and physical therapists. Fluid and electrolyte status and kidney and liver function need to be monitored at least daily. Dosages of immunosuppressive agents are adjusted according to blood levels and organ function during this period. The pattern of liver function test (LFT) results are monitored for early signs of dysfunction, which can require further study or intervention. Any major alteration in liver function should initiate a series of studies, which may include Doppler ultrasound to evaluate vascular patency of the new liver, bile duct studies (e.g., T-tube cholangiography, endoscopic retrograde cholangiopancreatography [ERCP], percutaneous transhepatic cholangiography) to evaluate any abnormality of the biliary system (e.g., stricture, bile leak, obstruction), and liver biopsy to rule out rejection. Necessary treatments are initiated based on these findings. Usually, in an uneventful recovery, the patient is discharged within 10 to 14 days after OLT and followed as an outpatient.

5)During the transition to an outpatient setting, the patient meets with the post-OLT coordinator and goes through extensive teaching regarding his or her medications and immunosuppressive agents and their potential side effects. The patient receives instructions about the schedule for blood work and follow-up clinic visits. The patient receives a book containing after-discharge instructions, including when and how to notify the transplantation program if he or she feels that there is something wrong, such as abnormal pain, fever, diarrhea, and headaches. The recipient is also instructed about physical activities, diet, and general health maintenance, such as vaccinations, avoidance of sun, and cancer screening

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