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INDICATIONS FOR LIVER TRANSPLANT

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  • Biliary atresia often following the Kasai procedure

  • Metabolic diseases

    • Alpha-1-antitrypsin deficiency

    • Tyrosinemia

    • Wilson's disease

    • Urea cycle defects

    • Hemochromatosis

    • Glycogen storage disease

  • Fulminant hepatic failure (see Chapter 66)

    • Infection

    • Toxin

    • Drug ingestion

  • Hepatic malignancy

  • Chronic liver disease

  • End-stage liver disease

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CONTRAINDICATIONS FOR LIVER TRANSPLANT

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  • Absolute contraindications

    • Unresectable hepatic malignant tumor

    • Uncontrollable extrahepatic sepsis

    • Neurologic devastation (arrived by consensus, as stage IV hepatic encephalopathy can mask brain death)

  • Relative contraindications

    • Acceptable alternative medical therapy

    • Expected suboptimal outcome

    • Impairment of other organ systems that would compromise function of the graft

    • Major systemic infection

    • Cancer with a high postsurgical recurrence rate

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OPERATIVE TECHNIQUE

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  • Recipient hepatectomy phase

  • Anhepatic phase

  • Reperfusion phase

    • Arterial anastomoses

    • Biliary reconstruction

    • Hemostasis

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TYPES OF TRANSPLANTS

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  • Reduced size graft

  • Split liver graft

  • Living related donor transplantation

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POSTOPERATIVE MANAGEMENT

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RESPIRATORY MANAGEMENT

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  • Most pediatric patients will return from the operating room intubated and mechanically ventilated.

  • The goal should be to extubate as quickly as medically possible, generally within 48 hours.

  • Factors that determine extubation readiness for all patients include ventilatory parameters, sedation and analgesia requirements, and hemodynamics.

  • Extubation is often delayed until the 12-hour assessment of graft function.

  • Prolonged ventilation increases the risk of nosocomial infection and ventilator-associated pneumonia.

  • Age and nutritional status play a role in extubation readiness, as does the transplant type.

  • Pleural effusion is common, and the right side is more frequently affected. These effusions can generally be managed with diuretics and fluid restriction and rarely require pleurocentesis and drainage.

  • Atelectasis is a common problem, especially in young children, and contributes to respiratory distress and difficulty weaning from mechanical ventilation.

  • Diaphragmatic dysfunction is associated with prolonged ventilatory requirement and prolonged PICU stay and may require diaphragmatic plication.

  • Monitoring includes oxygen saturation, capnography, and arterial blood gas analysis (Table 67-1).

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Table Graphic Jump Location
TABLE 67-1

Postoperative Liver Transplant Monitoring

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CARDIOVASCULAR MANAGEMENT

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  • Patients should be monitored with invasive and noninvasive blood pressure monitoring and central venous pressure monitoring, as well as heart rate monitoring (Table 67-1).

  • Hemodynamic instability in the early postoperative period is contributed to by acid–base status, fluid status, and bleeding issues.

  • A small percentage of patients will have evidence of bacterial translocation intraoperatively (taking down an old Roux-en-Y, manipulating bowel) and present with a sepsis-like picture.

  • Maintaining good flow ...

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