Table 9.15. Helpful signs of hepatic function in the intraoperative period

1. Restoration of hemodynamic stability

2. Good renal function evidenced by adequate urine output

3. Stabilization of acid-base status

4. Normalization of the coagulation system

5. Normalization of body temperature

6. Maintenance of proper glucose metabolism

7. Adequate bile production

8. Good texture and color of the liver

However, the first 6 to 12 hours (immediate postoperative period) provide more definitive evidence of liver function. The best indicators of early graft function include normalization of Factor V levels, prothrombin time, and transaminases. In addition, clearance of lactic acidosis, awakening from the anesthetized state, and good renal function provide further affirmation of liver function (Table 9.16).

2. Postoperative Bleeding

Significant coagulopathy can be present following revascularization of the liver and can be attributed to fibrinolysis, heparin-like effect, and platelet and coagulation factor deficiencies. Under normal circumstances, with a functioning graft, coagulopathy is reversed by the time of abdominal closure. However, complete hemostasis may not be fully achieved at time of closure despite the best of efforts, especially if the recipient is hypothermic and if the operation has been long, difficult, and bloody. This scenario has become uncommon, but can nevertheless occur, especially in the setting of a dysfunctional graft. Under these circumstances, it may be preferable to place appropriate drains or even packs, close the abdomen, and return the patient to the intensive care unit. Close attention to ongoing bleeding despite correction of coagulopathy is essential. This can be achieved with a combination of hemodynamic monitoring, serial hematocrit determinations, and overall condition of the patient including urine output and measuring of drainage output. It may also be helpful to perform hematocrit determinations on the drain fluid. If ongoing bleeding, despite correction of coagulopathy and rewarm-ing of the patient, is suspected, especially if hemodynamic instability and oliguria are present, the patient should be returned to the operating room for evacuation of hematoma and identification of ongoing bleeding. At this time, generalized oozing may have improved so that specific bleeding sites can be more easily identified and oversewn, especially in the bare area. The presence of a dry operative field at the time of abdominal closure however should not be viewed as evidence that postoperative bleeding cannot occur. Postoperative bleeding should be considered highly in the differential diagnosis of hypotension and oliguria in the immediate postoperative period even in patients in whom a dry field was achieved intraoperatively.

3. General Considerations

Hemodynamic stabilization is guided by the usual clinical assessments of adequate organ and tissue perfusion. Of note, patients with cirrhosis typically ex-

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