Question

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

1 Liver Transplantation is used to treat life-threatening ESLD for which no other forms of treatment is available.The success of liver transplantation depends on successful immunosuppression .

2 Despite the success of immunosuppression in reducing the incidence of rejection of transplanted organs,liver transplantation is not routine and may be accompanied by complications related to the lengthy surgical procedure,immuno suppressive therapy,infection ,and the technical difficulties encountered in reconstructing the blood vessels and biliary tract.Long standing systemic problems resulting from the primary liver disease may complicate the preoperative and postoperative course.Previous surgery of the abdomen,including procedures to treat complications of advanced liver disease increase the complexity of the transplantation procedure.The post operative complication rate is high such as bleeding,infection and rejection .

3 Bleeding is common in the postoperative period and may result from coagulopathy,portal hypertension and fibrinolysis caused by ischaemic injury to the donor liver.Hypotension may occur in this phase,secondary to blood loss.Administration of platelets,fresh -frozen plasma or other blood products may be necessary.Hypertension is more common.

Infection is one of the cause of deaths following liver transplantation.Precautions must be taken to prevent health-care associated infections.The nurse uses strict asepsis when manipulating central venous catheters,arterial lines and urine,bile and other drainage systems;obtaining specimens and changing dresses.

Rejection is a primary concern.Liver biopsy and ultrasound may be required to evaluate suspected episodes of rejection.

4

• The patient is maintained in an environment free from bacteria ,viruses and fungi as possible.
• Monitoring of the patients cardiovascular,pulmonary,renal,neurologic and metabolic functions are monitored closely.
• Mean arterial and pulmonary pressures are monitored closely.
• Liver function tests ,electrolyte levels,the coagulation profile ,chest x-ray,Ecg and fluid output are monitored closely,because the liver is responsible for the storage of glycogen and synthesis of protein and clotting factors ,these substances need to be monitored and replaced in the immediate postoperative period.
• Suctioning is performed as required ,as there is a high risk of atelectasis and an altered ventillation-perfusion ratio ,caused by insult to to the diaphragm following the surgical procedure.
• After removal of the endotracheal tube ,the nurse encourages the patient to use an incentive spirometer to decrease the risk of atelectasis.

5 Teach the patient and family about long term measures to promote health is crucial for the success of transplantation and represents an important role of the nurse.The patient and family must understand why they need to adhere to continiously to the therapeutic regimen ,with special emphasis on the methods of administration,rationale and sideffects of the prescribed immunosuprsessive agents.The nurses provide writtn and verbal about how and when to take medications .The patient with a T tube in place must be taught how to manage the tube,drainage and skin care.