Perioperative and Immediate Postoperative Care of the Liver Transplant Recipient
The first 72 hours
The anhepatic and reperfusion phases drive most early instability. Reperfusion syndrome - a fall in mean arterial pressure >30% for at least one minute, often with bradycardia, hyperkalemia, hypothermia, and acidosis - occurs in 10-30% of grafts and predicts early graft dysfunction. Management is fluid, calcium, vasopressor support, and correction of potassium and pH, not abandonment of the graft.
Early allograft dysfunction (EAD) is defined by any of: bilirubin ≥10 mg/dL or INR ≥1.6 on postoperative day 7, or AST/ALT >2000 IU/L in the first week. Primary nonfunction is failure of the graft to function at all, with acidosis, rising lactate, and worsening coagulopathy; it requires urgent retransplant. A normal pattern is transaminases peaking within 24-48 hours and falling by roughly half each day.
Immediate care. Extubate early when possible; support with balanced fluids; transfuse to physiologic targets rather than normalizing INR, because post-transplant coagulopathy reflects graft function and rebalanced hemostasis. Start induction immunosuppression, PCP prophylaxis, and CMV prophylaxis by donor/recipient serostatus.
Vascular and biliary surveillance. Doppler ultrasound on day 0-1 and whenever LFTs rise. Hepatic artery thrombosis presents with fever, sepsis, rising transaminases, or biliary leak; the first test is Doppler, then CT angiography or conventional angiography.
Rule of thumb: a rising lactate with falling platelets and worsening acidosis in the first 48 hours is primary nonfunction until proven otherwise - call the surgeon, not the pharmacist.