Principles of Critical Care > Part X. The Surgical Patient > Chapter 90. The Transplant Patient Damon C. Scales, John T. Granton

Organ-Specific Considerations

"During orthotopic liver transplantation, the native organ is removed and replaced by a cadaveric liver. Extracorporeal venovenous bypass is often used during the procedure to decompress the systemic and splanchnic venous systems. Although this may help preserve hemodynamic stability during the operation and decrease intraoperative bleeding problems, potential complications include intraoperative air embolism^73,74 and thromboembolism. The biliary tract will be reconstructed either by creating an end-to-end anastomosis of the donor and recipient common ducts (using a T-tube stent) or by connecting the donor's common duct to the recipient's jejunum. Anastomoses are created between the native and allograft cava (supra- and infrahepatic), portal veins, and hepatic arteries. Removal of the venous clamps leads to reperfusion of the organ, and this will often be associated with hemodynamic instability, coagulopathy, and electrolyte abnormalities (particularly hyperkalemia).Most patients will require mechanical ventilation for the first 24 to 48 hours following the liver transplant procedure. Extubation should not be considered until there is evidence that the allograft is functioning properly and the patient's level of arousal is sufficient to allow for adequate airway protection. This latter consideration is especially important given that anesthetic agents and sedating medications may be cleared more slowly from the circulation by the newly transplanted liver. The need for reintubation in liver transplant patients has been associated with poorer outcomes and even increased..."