Extraoperative management of the liver transplant patient

Advances in liver transplantation have made the procedure an accepted therapeutic measure for patients with end-stage liver disease. This report is based on the authors experience on the first adult liver transplant in Singapore. The anaesthetic management is a challenge as patients are in long-standing hepatic failure with derangements of cardiovascular, renal, pulmonary, central nervous, and haematological systems. Therefore, individual preoperative assessment must incorporate a thorough understanding of these pathophysiologic phenomena and their interactions with anaesthetic drugs. Similarly, the postoperative care of the recipient will require intensive critical monitoring of all vital organ, systems and aggressive intervention to support failing organ systems. The important early concerns in the immediate postoperative period (less than 72 hours) include bleeding and graft function. After the first 72 hours, if the liver is functioning and the patient is not bleeding, it is a period of repair for the organ systems which were damaged prior to or during the transplant procedure. Intravenous nutrition is begun, and the immunosuppression maintenance dose is established. During the first three weeks, most of the technical causes of graft dysfunction, sepsis, and acute rejection become apparent. The distinction between rejection and infection continues to be an enigma, and requires rapid differentiation as the modes of therapy are totally different. The role of anaesthesiologists in the extraoperative care of the liver transplant recipient involves awareness and interdisplinary communication.