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Table 9.16. Helpful signs of hepatic function in the immediate postoperative period

1. Hemodynamic stability

2. Awakening from anesthesia

3. Clearance of lactate

4. Resolution of hypoglycemia

5. Normalization of coagulation profile

6. Resolution of elevated transaminases

7. Bile of sufficient quantity and golden brown in color hibit hemodynamic parameters consistent with those of a septic patient including high cardiac output and low systemic vascular resistance. These hemodynamic conditions may persist for several weeks following transplantation, and may require vasoconstrictive agents for optimal management.

Pulmonary management consists of appropriate ventilatory support with manipulation of respiratory rate, tidal volume, positive end expiratory pressure, and optimal oxygenation. Serial blood gases are used to monitor progress. The patient is typically extubated as soon as he/she is awake and exhibits a good inspiratory effort with adequate vital capacity. Early extubation leads to speedier recovery. However, massive fluid shifts and preoperative generalized debilitation may delay extubation. Once the patient is extubated, careful attention to incentive spirom-etry and the liberal use of chest physical therapy can help prevent the development of atelectasis and pneumonia. The nature of the incision combined with the state of debilitation of the patient are likely reasons why pulmonary complications are common in the postoperative period. In addition, the common presence of a right-sided pleural effusion in these patients may further delay pulmonary recovery. The importance of pulmonary care following extubation cannot be overstated.

Laboratory testing includes careful attention to glucose levels and electrolyte status. In addition to the usual attention to sodium and potassium, magnesium levels are typically low and magnesium supplementation is required. Ionized calcium determinations should be frequent and ionized calcium should be normalized. In addition, normalization of transaminases and prothrombin time or Factor V levels should be expected in the first 24 hours. If a T-tube is used, the quality of the bile can provide a helpful hint of good liver function. Finally, a baseline doppler ultrasound to assess patency of the hepatic artery in particular should be performed within the first 24 hours of transplantation.

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