Post-op Liver Transplant in ICU - Nursing Case Study

Pathophysiology

• Primary mechanism: Post-operative hepatic ischemia-reperfusion injury - The process of organ transplantation necessitates a period of ischemia (loss of blood supply) followed by reperfusion (restoration of blood supply). This can lead to significant damage to the liver cells, leading to inflammation and organ dysfunction. This is a critical concern in the immediate post-operative period and can impact graft survival.

• Secondary mechanism: Immune Rejection - Despite immunosuppressive therapy, the recipient's immune system can recognize the new liver as foreign and launch an immune response. This can lead to acute or chronic rejection. Acute rejection usually occurs within the first few months after transplantation and if not managed, can lead to graft failure.

• Key complication: Infection - Due to the use of immunosuppressive drugs to prevent rejection, post-transplant patients have a compromised immune system, making them highly susceptible to infections. These can be bacterial, vi

Patient Profile

Demographics:

52-year-old male, former construction worker

History:

• Key past medical history: Chronic hepatitis C infection, cirrhosis, recent liver transplantation

• Current medications: Tacrolimus, Mycophenolate Mofetil, Prednisone

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Increasing abdominal pain, decreased urine output, and fever

• Key symptoms: Abdominal distension, fever, fatigue, jaundice, decreased urine output

• Vital signs: Temperature 38.7°C (101.7°F), Blood pressure 95/60 mmHg, Heart rate 110 beats per minute, Respiratory rate 22 breaths per minute, Oxygen saturation 94% on room air

Section 1

Change in Patient Status:

Over the course of the night, the patient's condition begins to deteriorate. His fever spikes to 39.5°C (103.1°F), blood pressure drops to 85/55 mmHg, and heart rate increases to 125 beats per minute. His respiratory rate climbs to 28 breaths per minute and he becomes increasingly confused and lethargic. On physical examination, his abdomen is markedly distended and tender to palpation. His urine output continues to decrease, now recording just 20 mL over the past 4 hours. Additionally, the jaundice appears more pronounced and his skin is noticeably cooler to the touch.

New Diagnostic Results:

Given the patient's worsening condition, further diagnostic tests are carried out. His blood cultures come back positive for Escherichia coli, indicative of a systemic bacterial infection. Liver function tests reveal elevated levels of alanine aminotransferase (ALT) at 120 U/L, aspartate aminotransferase (AST) at 150 U/L, and bilirubin at 3.5 mg/dL, suggesting liver dysfunction. A complete blood count shows leukocytosis with a white blood cell count of 18,000 cells/mm3, further supporting the diagnosis of infection. An ultrasound of the abdomen reveals moderate ascites. These findings, in conjunction with his clinical presentation, suggest the development of sepsis secondary to a bacterial infection, along with signs of possible acute graft rejection and post-operative hepatic ischemia-reperfusion injury.

Section 2

Response to Interventions:

Immediate interventions were initiated to manage the patient's deteriorating condition. Broad-spectrum antibiotics were started empirically to counter the systemic bacterial infection. However, after 24 hours, the patient's fever remained elevated at 39.2°C (102.5°F) and the leukocytosis persisted with a white blood cell count of 17,500 cells/mm3, suggesting that the antibiotics were not effectively controlling the infection. His blood pressure remained low at 87/57 mmHg despite fluid resuscitation, and vasopressor support was initiated.

The patient's liver function tests continued to show abnormal values, with ALT and AST rising to 130 U/L and 160 U/L respectively, and bilirubin increasing to 4.2 mg/dL. The persistently high liver enzymes and progressively worsening jaundice suggested ongoing liver dysfunction, possibly due to acute graft rejection or ischemia-reperfusion injury. Despite attempts to medically manage the ascites with diuretics, the patient's abdomen remained distended and his urine output continued to decrease, with only 15 mL recorded over the last 4 hours. This indicated a possible acute kidney injury secondary to the sepsis and hypotension, necessitating the need for a nephrology consult. The patient's condition clearly required a more aggressive and targeted treatment approach, raising critical questions about the next steps in his management.

Section 3

Change in Patient Status:

Over the next 24 hours, the patient's condition worsened further. His temperature spiked to 40.1°C (104.2°F), and his blood pressure dropped to 80/50 mmHg, even with increased vasopressor support. His respiratory rate increased to 28 breaths per minute, and oxygen saturation declined to 88% on room air, suggesting possible sepsis-induced acute respiratory distress syndrome (ARDS). His confusion intensified, with a Glasgow Coma Scale (GCS) score dropping to 10, indicating a significant alteration in his level of consciousness.

New Diagnostic Results:

The nephrology team recommended an urgent renal ultrasound, which revealed increased echogenicity and reduced corticomedullary differentiation, consistent with acute kidney injury. His serum creatinine increased from 1.2 to 2.6 mg/dL, and blood urea nitrogen rose to 36 mg/dL. Meanwhile, a diagnostic paracentesis was performed that showed a serum-ascites albumin gradient (SAAG) of 1.1 g/dL, suggesting portal hypertension as the likely cause of the ascites. Gram stain of the ascitic fluid revealed gram-negative rods, indicating spontaneous bacterial peritonitis (SBP). Furthermore, his liver function tests worsened, with ALT and AST rising to 200 U/L and 240 U/L respectively, and bilirubin reaching 6 mg/dL, reinforcing the possibility of acute graft rejection. These findings necessitated urgent re-evaluation of current management strategies and raised the question of whether further surgical intervention was needed.

Section 4

Response to Interventions:

Despite the ongoing vasopressor support and broad-spectrum antibiotic administration, the patient's hemodynamic instability continued with persistent hypotension and tachycardia. The patient was subsequently started on continuous renal replacement therapy (CRRT) due to oliguria and worsening uremia. The intensivist also initiated mechanical ventilation considering the increasing work of breathing and deteriorating oxygen saturation. Ventilator settings were adjusted to a lower tidal volume (6 ml/kg) and increased positive end-expiratory pressure (PEEP) (10 cmH2O) to improve oxygenation, reflecting the ARDSnet protocol.

Antibiotics were escalated to meropenem due to the gram-negative rods found in the ascitic fluid. Given the rising liver enzymes and bilirubin, along with the patient's drastic clinical deterioration, the hepatology team was consulted. They recommended a liver biopsy to definitively diagnose acute graft rejection. Following this, the patient was given a high dose of methylprednisolone to counter potential immune-mediated graft rejection. The team also discussed the possibility of plasmapheresis in the event of confirmed rejection. This response to interventions created a new pathway in the patient's journey, requiring vigilant monitoring and assessment for any immediate improvement or further deterioration. The team was also concerned about the potential for new complications, such as ventilator-associated pneumonia, CRRT-related hemodynamic instability, and steroid-induced hyperglycemia.

Section 5

Change in Patient Status:

Over the next 48 hours, the patient's condition began to show signs of further deterioration. Despite aggressive treatment, the patient remained hypotensive with a blood pressure of 90/50 mmHg and tachycardic with a heart rate consistently above 120 beats per minute. He also became increasingly febrile, with a temperature spiking to 38.5°C. His oxygen saturation levels continued to decrease, requiring an increase in FiO2 to 60% on the ventilator. The patient's urine output remained minimal despite CRRT, and his uremia persisted with a BUN of 60 mg/dL and serum creatinine rising to 2.9 mg/dL.

New Diagnostic Results:

The liver biopsy results came back, confirming the team's suspicion of acute graft rejection. The hepatology team's recommendation for high-dose steroids was thus validated. Meanwhile, the patient's blood cultures revealed the presence of Klebsiella pneumoniae, a gram-negative bacterium known to cause severe infections. A chest X-ray also showed new infiltrates, raising the possibility of ventilator-associated pneumonia. The patient's blood glucose levels were also markedly elevated, reading at 250 mg/dL, indicating steroid-induced hyperglycemia. The patient's lab results also showed a significant increase in liver enzymes (AST 450 U/L, ALT 600 U/L) and total bilirubin (15 mg/dL), hinting at further liver dysfunction. These new findings suggested a complex interplay of medical issues requiring a multi-faceted course of action.