What are the guidelines for perioperative care in liver transplant patients?

Perioperative Guidelines for Liver Transplantation

The most current and comprehensive perioperative care guidelines for liver transplantation recommend implementing Enhanced Recovery After Surgery (ERAS) protocols with specific interventions across preoperative, intraoperative, and postoperative phases to reduce complications and improve outcomes. 1

Preoperative Care

Patient Assessment and Optimization

• Preoperative counseling should be provided to all patients regarding the upcoming liver transplantation, using brochures and multimedia supports to improve understanding 1
• Nutritional assessment is mandatory before transplantation, with malnourished patients requiring enteral supplementation for at least 7-14 days prior to surgery 1
• Preoperative biliary drainage is recommended for cholestatic liver (bilirubin >50 mmol/l), with percutaneous drainage preferred over endoscopic methods for perihilar cholangiocarcinoma 1
• Smoking cessation should be counseled at least 4 weeks prior to transplantation, and alcohol cessation is recommended for heavy drinkers 4-8 weeks before surgery 1

Prehabilitation

• Prehabilitation should be implemented for high-risk patients (elderly, malnourished, overweight, smokers, or those with psychological disorders) 4-6 weeks before transplantation 1
• The content should include physical exercises, dietary interventions, and anxiety reduction techniques, though specific protocols for liver transplantation are still being established 1

Immediate Preoperative Preparation

• Preoperative fasting should be limited to 2 hours for liquids and 6 hours for solids 1
• Carbohydrate loading is recommended the evening before surgery and 2-4 hours before anesthesia induction to improve insulin resistance 1
• Long-acting anxiolytic medications should be avoided, particularly in elderly patients 1
• Preoperative gabapentinoids and NSAIDs are not recommended; acetaminophen dosing should be adjusted according to the extent of liver resection 1

Intraoperative Management

Infection Prevention

• Antibiotic prophylaxis (typically cefazolin) should be administered within 60 minutes before surgical incision 1, 2
• For complex liver surgery with biliary reconstruction, targeted antibiotic pre-emptive regimen based on preoperative bile culture may be recommended 1
• Skin preparation with chlorhexidine-alcoholic solution is superior to povidone-iodine for reducing surgical site infections 1

Surgical Approach

• When clinically appropriate and with trained teams, laparoscopic approaches are recommended as they reduce postoperative length of stay and complication rates 1
• The choice of incision should be at the surgeon's discretion, though Mercedes-type incisions should be avoided due to higher incisional hernia risk 1

Anesthesia and Monitoring

• Thoracic epidural analgesia is not routinely recommended for open liver surgery in ERAS patients 1
• Maintenance of low central venous pressure (below 5 cmH2O) with close monitoring during hepatic surgery is advocated 1
• Perioperative normothermia should be maintained during liver transplantation to reduce postoperative complications 1
• Steroid administration (methylprednisolone 500 mg) is recommended during transplantation, though caution is needed in diabetic patients 1

Thromboprophylaxis

• Low molecular weight heparin or unfragmented heparin should be administered postoperatively to reduce thromboembolic complications 1
• Intermittent pneumatic compression devices should be used to further decrease thromboembolism risk 1

Postoperative Care

Nutrition and Gastrointestinal Function

• Most patients can eat normal food starting day one after liver transplantation 1
• Postoperative enteral or parenteral feeding should be reserved for malnourished patients or those with prolonged fasting due to complications 1
• Prophylactic nasogastric intubation increases the risk of pulmonary complications and should not be used routinely 1
• An omentum flap to cover the cut surface of the liver reduces the risk of delayed gastric emptying after left-sided hepatectomy 1

Pain Management and Mobilization

• Multimodal analgesia should be used, with wound infusion catheters or intrathecal opiates as alternatives to thoracic epidural analgesia 1
• Early mobilization should be encouraged from the morning after operation until hospital discharge 1
• A multimodal approach to postoperative nausea and vomiting should be implemented, with patients receiving prophylaxis with two antiemetic drugs 1

Fluid Management and Glycemic Control

• Balanced crystalloids should be preferred over 0.9% saline or colloids to maintain intravascular volume and avoid hyperchloremic acidosis or renal dysfunction 1
• Insulin therapy to maintain normoglycemia is recommended to prevent deregulation of liver metabolism and immune function 1

Special Considerations

Drainage

• The evidence regarding prophylactic abdominal drainage after liver transplantation is inconclusive, and no definitive recommendation can be made for or against its routine use 1

Compliance and Audit

• Systematic audit improves compliance and clinical outcomes in healthcare practice, making it essential to document adherence to ERAS protocols 1
• Compliance with the liver ERAS protocol should be documented to allow benchmarking and continuous improvement 1

High-Risk Patients

• Patients with hepatopulmonary syndrome and portopulmonary hypertension require specialized perioperative management strategies 3, 4
• Early postoperative complications can significantly compromise patient survival, with preoperative conditions such as gastrointestinal bleeding, acute renal failure, requirement for catecholamines or mechanical ventilation being major risk factors 5