Respiratory management

The duration of mechanical ventilation will be determined by the patient's preoperative condition and perioperative course. Uncomplicated patients should be weaned from mechanical ventilation rapidly, usually within 12 h of surgery. Weaning should start as soon as adequate analgesia has been assured, the graft is producing bile, cerebral function is evidently normal, and the patient is metabolically stable with a resolving base deficit. Caution should be exercised if technical difficulties were experienced during surgery, or there is evidence of continuing blood loss, a metabolic acidosis, a rising prothrombin time, or progressive organ system dysfunction. Patients with fulminant hepatic failure are at risk of cerebral edema for several days, and should be managed appropriately.

Right lower zone opacification on the chest radiograph is a common finding within the first few days after orthotopic liver transplantation. It represents a pleural effusion together with basal collapse, and usually resolves without complications. More substantial fluid collections may require drainage if respiratory function is impaired, particularly in patients with muscle wasting or a poor cough.

Patients with chronic liver disease and those who have undergone orthotopic liver transplantation are susceptible to pulmonary edema. Causes include low intravascular colloid osmotic pressures, endothelial dysfunction leading to acute lung injury, and excessive intravenous fluid loads. Clinical pulmonary deterioration (tachypnea, respiratory distress) often precedes chest radiograph changes, and frequently responds to fluid removal by diuretics or ultrafiltration. Fluid overload is a more common problem in children, and requires meticulous fluid balance charts combined with a high index of suspicion. Positive end-expiratory pressure (PEEP) may be used in intubated patients to reduce shunting, but levels in excess of 10 cmH 2O may reduce cardiac output and graft blood flow.

Late-onset respiratory failure or prolonged ventilator dependence is more common in patients who were severely ill before transplantation and those who have a complicated postoperative course with impaired graft function. The combination of hypoxemia and patchy infiltrates on the radiograph suggests a differential diagnosis of acute lung injury or pulmonary infection. A rapid response to continuous positive airways pressure, PEEP, or inhaled NO in intubated patients suggests fluid overload and pulmonary edema.

Intubated patients are more likely to develop colonization or infection with Gram-negative bacteria or Candida during the first 2 weeks after orthotopic liver transplantation. Patients who have been extubated and then relapse are susceptible to a range of organisms, including Aspergillus. If fungi are suspected, high-dose liposomal amphotericin should be started immediately. Cytomegalovirus and other opportunistic infections may appear after several weeks. Bronchoscopic lavage and brush biopsy should be performed early and repeated if negative. Selective antibiotic digestive decontamination reduces pulmonary infections in intubated patients after orthotopic liver transplantation but does not reduce endotoxemia or organ system failures ( Bion e.L§.L 19.9.4). The use of prophylactic antibiotics should be based on written protocols, and therapy should be guided by close consultation with the infectious disease specialist and/or the microbiologist. Failure to find a specific cause for either acute lung injury or pneumonia is not uncommon, even at autopsy.

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