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ii) Early Postoperative Inpatient Care

Patients are transferred out of the intensive care unit onto the transplant ward as soon as they are extubated and hemodynamically stable. This period is typically 24 to 48 hours and, upon transfer, the patients are encouraged to ambulate. Often, the patients' pretransplant debilitated state does not allow for early ambulation and these patients require special rehabilitation requiring transfer to acute rehabilitation units. However, if the patients are doing well and do not need long-term rehabilitation care, their diet is advanced as tolerated. Standard wound care is administered and the drains are removed, especially if no biliary leak is evident. Of note, the presence of large volumes of ascites in the drains should not result in delay in removing the drains.

In addition to immunosuppressive agents, prophylaxis against Pneumocystis carinii (PCP) is achieved with Bactrim. In patients with an allergy to sulfa-con-taining compounds, pentamidine inhalation and dapsone have been used successfully. Cytomegalovirus (CMV) prophylaxis is achieved with ganciclovir therapy. Most centers have transitioned from the use of intravenous ganciclovir preparations to the recently available oral preparations of ganciclovir. Newer preparations of oral ganciclovir appear to have better absorption and bioavailability kinetics and are likely to replace intravenous ganciclovir for prophylaxis. Of concern, increasing resistance to ganciclovir may dictate the use of anti-cytomegalovirus cocktails in the future especially for preemptive therapy rather than prophylaxis.

Standard antibacterial prophylaxis necessitates coverage of gram negative and anaerobic agents typically present in bile. Gram positive coverage appears to be less important. Finally, antifungal prophylaxis is achieved with swish and swallow of nystatin suspension or other such topical antifungal. In addition, agents such as fluconazole and itraconazole are used in the early postoperative period as prophylaxis against systemic fungal infections. Of note, these latter agents can result in dramatic increases of calcineurin inhibitor levels due to competition with cyto-chrome P450, and therefore, levels need to be monitored closely.

Most patients also receive peptic ulcer disease prophylaxis especially when receiving high-dose steroids in the form of either H2 blockers or proton pump inhibitors. Magnesium supplementation is often necessary in patients who exhibit hypomagnesemia.

In addition to consideration of immunosuppression and prophylaxis, close attention to liver function tests and hematology and biochemistry laboratory values is essential in the first few days following transplantation. Typical problems of thrombocytopenia and mild renal dysfunction may require intervention such as platelet transfusion and optimization of central filling pressures, respectively. Liver function test abnormalities are investigated as outlined above for the immediate postoperative period.

In the case of inability to tolerate oral feedings, enteral feedings via nasoduodenal tube or intravenous hyperalimentation may be important. There are no convincing data to show that routine use of hyperalimentation, either intravenous or enteral, is beneficial in the majority of patients.

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