LIVER TRANSPLANTATION Lyn Crellin Paediatric Liver Transplant ...

LIVER TRANSPLANTATION

Lyn Crellin Paediatric Liver Transplant CoordinatorRoyal Children’s Hospital Victorian Liver Transplant Unit

Transplantation: history

First Adult Transplant 1963

Austin Health First adult transplant 1988

Royal Children’s Hospital First paediatric transplant 1995

Liver Transplantation, 2008

Parizhshskaya M.& Jaffe (2007) In Fine R. et al, Eds. Pediatric Solid Organ Transplantation, 92nd Ed) Cambridge University Press Cambridge

Transplantation: numbers & survival

Royal Children’s Hospital Average transplants per year 7- 8 Total LRLT 1 Total number of transplants 57

Survival 1 Year 95% Overall 86%


Hardikar et al (2002) Pediatric Surgery International, 354-356


Transplantation: diagnostic Groups

Biliary Atresia 32% Metabolic Disease

26% Acute Hepatic Necrosis

26% Other 16%

Hardikar et al (2002) Pediatric Surgery International, 354-356

Pre-transplant Phase: indications for transplant

End Stage Liver Disease Deteriorating LFT’s ↓Synthetic function & clotting Growth Portal Hypertension Ascites

↑splenomegaly Severe haematemesis/malaena


Tiao G. et al, (2007) Liver Transplantation, In Suchy F. et al, Eds. Liver Disease in Children. (3rd Ed. )Cambridge University Press


Pre-transplant Phase: contraindications for transplant

Severe systemic sepsis Extrahepatic malignancy Irreversible:

brain injurymajor congenital

anomolies multisystem organ failure

Kamath Binita M., & Rand Elizabeth B., (2007) Evaluation of the Candidates. In. Fine Richard N., et al. Ed. Paediatric Solid Organ Transplantation (2nd. Ed.) Blackwell Publishing Massachusetts

Pre-transplant Phase: assessment & activation

Clinical assessment Education Patient & family meet the transplant team Transplant team meet the patient & family Decision making Name placed on waiting list Need to be able to contact parents 24

hours a day


Transplant Phase: assessment of donor

Brain death certification Consent for donation Blood group, measurements History of critical incident Medical history Social History Investigations Intra-operative inspection


Transplant Phase: donor – critical event

Asystole Hypotension Hypovolaemia Hypoxia Hypoperfusion Electrolyte disturbance


Phongsamran, P. (2004) Progress in Transplantation 14(2), 105-111

Transplant Phase: selection of recipient

ABO match Physical size (weight, height, girth) Medical condition Age


Transplant Phase: techniques

Whole organs Cut down organs Split organs Living related donations Cell transplants


Otte J, Pediatric (2002) Transplantation, 6, 378-387

Post Transplant Phase: complications

Primary non functionHaemorrhageRejectionVascular Thrombus

Stricture

Biliary Leak Stricture

Infection


Parizhshskaya M. & Jaffe R. (2007) In Fine R. et al, Eds. Pediatric Solid Organ Transplantation, (2nd Ed) Cambridge University Press Cambridge

Post Transplant Phase: primary non function

Cause Age Weight Inotropes Ventilation Electrolyte imbalance Cold Ischaemic Time

Liver Transplantation, 2008Phongsamran, P. (2004) Progress in Transplantation 14(2), 105-111

Post Transplant Phase: primary non function

Prevention & Management Careful management of the donor Careful selection of donors Optimal organization of retrieval &

transplant Symptomatic support – no cure


Phongsamran, P. (2004) Progress in Transplantation 14(2), 105-111

Post Transplant Phase: haemorrhage

Cause Coagulopathy Anticoagulant therapy +/- Cut down surface of liver Large Incision


Post Transplant Phase: haemorrhage

Prevention & Management Observation of incision, puncture sites, losses

and body fluids Accurate measurement of drain tube losses Observation of vital signs & skin colour Monitoring of coagulation Cessation/reduction of anticoagulant therapy +/- Blood transfusions


Post Transplant Phase: rejection

Acute rejection Chronic rejectionDays - months Months - years

Cause: Introduction of foreign tissue Activation of immune system – cellular &

humoral


Parizhshskaya M. & Jaffe R. (2007) In Fine R. et al, Ed. Pediatric Solid Organ Transplantation, (2nd Ed.) Cambridge University Press Cambridge


Signs & Symptoms Deteriorating Liver enzymes ? fever & neutropaenia ? Bile flow ?Ascites & peripheral oedema ?RUQ painDiagnosis Biopsy


Parizhshskaya M. & Jaffe R. (2007) In Fine R. et al, Eds. Pediatric Solid Organ Transplantation, (2nd Ed) Cambridge University Press Cambridge


Prevention & Management ABO Match & negative leukocyte match Triple immunosuppression therapy Aggressive treatment of acute episodes Steroid pulses, OKT, other Close observation of clinical status &

results Education & support of parents Re-transplant Liver Transplantation, 2008

Post Transplant Phase: infection

Cause: Immunosuppression therapy Long anaesthetic and ventilation Multiple site – lines, incision, tubes Transmission from donor Reactivation of infections ie CMV, EBV


Tiao G. et al, (2007) Liver Transplantation, In Suchy F. et al, Eds. Liver Disease in Children. (3rd Ed.) Cambridge University Press


Signs & Symptoms: Fever, tachycardia, tachypnoea, pain Redness, or exudate, at puncture sites,

incision skin or mucous membranes Inflammatory markers in blood




Prevention & Management Prophylactic antibiotics, antifungals, antivirals Routine monitoring of blood, fluids, swabs Aggressive investigation/treatment of

infections Inspection of puncture sites, incision, skin

creases, mucous membranes, losses Aseptic technique Isolation ward Exclusion of staff/visitors with illnessesTiao G. et al, (2007) Liver Transplantation, In Suchy F. et al, Eds. Liver Disease in Children. (3rd Ed.) Cambridge University Press

Post Transplant Phase: vascular - thrombosis, or stenosis

Cause Cold ischaemic time Postoperative hypercoagulable state Small diameter of blood vessels Anastomosis – scar tissue Technical difficulties at transplant



Post Transplant Phase: vascular - thrombosis, or stenosis

Signs & Symptoms Abnormal coagulation &/or

deteriorating LFT’s Coagulopathy Albumin Ascites & losses from drain tube Low/absent flow on Doppler U/S Bile leakSoltys Kyle et al . (2007) Post-Transplant Management. In. Fine R. et al, Eds. Pediatric Solid Organ Transplantation, (2nd Ed.) Cambridge University Press Cambridge

Post Transplant Phase: vascular -thrombosis, or stenosis

Prevention & Management Monitor coagulation & LFT’s Administration of anticoagulants, Dextran, AT 111 Regular Doppler U/S’s Monitor for losses or ascites Prompt response to changes Vascular dilatation +/- Stent Thrombectomy or vascular reconstruction Re-transplantation


Soltys Kyle et al . (2007) Post-Transplant Management.(2007) In Fine R. et al, Eds. Pediatric Solid Organ Transplantation, (2nd Ed.) Cambridge University Press Cambridge

Post Transplant Phase: biliary leak, stenosis

Cause Stricture at anastomotic site Healing at anastomotic site Infection Ischaemia Diagnosis Cholangiogram


Parizhshskaya M. & Jaffe R. (2007) In Fine R. et al, Eds. Pediatric Solid Organ Transplantation, (2nd Ed.) Cambridge University Press Cambridge


Signs & Symptoms Abdominal distension +/- pain Deteriorating LFT’s Sepsis drainage from bile tube Bile stained fluid, abdominal drain Flow demonstrated on cholangiogram


Soltys Kyle et al . (2007) Post-Transplant Management. (2007) In Fine R. et al, Eds. Pediatric Solid Organ Transplantation, ( 2nd Ed.) Cambridge University Press Cambridge


Prevention & Management T-tube to splint anastomosis Optimal surgical techniques Monitor LFT’s Monitor temperature Monitor pain Percutaneous dilatation, +/- insertion of stent Laparotomy & re-anastomosis


Soltys Kyle et al . (2007) Post-Transplant Management. (2007) In Fine R. et al, Eds. Pediatric Solid Organ Transplantation, (2nd Ed.) Cambridge University Press Cambridge

Post Transplant Phase: pain

Cause Large incision Drain tubes & infusion sites Anxiety


Post Transplant Phase: pain

Prevention & Management Administration of narcotics & sedation Careful assessment of pain Partnership with parents Recruitment of pain team Re-assurance Gradual withdrawal of pain relief



Post Transplant Phase: medications

Immuno-suppression

Therapy

AntiviralAntifungalAntibiotic

Hypotensive Agents Minerals

AnticoagulantsVitamins

Post Transplant Phase: psychosocial

Parental Concerns Potential for rejection Complications from medication Financial implications Overprotection Role/identity changes Lifestyle


Byers W., et al, 1988 Liver Transplantation Therapy for Children: Part 2. Lournal of Pediatric Gastroenterology and Nutrition. 7: 797-815

Post Transplant Phase: psychosocial

Prevention & Management Communication & information - open Education - verbal & printed Ready access to team Partnership with parents Social worker – financial & other resources Introduction to other parents Parents support group Referral to community agencies


Post Transplant Phase: discharge planning

Education Medications T-tube Infection control Management inter-current illness Lifestyle Equipment Referral community agencies



Transplantation - nursing care summary

Meticulous monitoring of haemodynamic, respiratory, cardiovascular and clinical status

Prompt interventions Pain management Psychosocial support Education Discharge planning Ongoing support & supervision

Post Transplant Phase: long term implications

Rejection Complications & side effects of medications Medical reviews/investigations Outcomes have improvedTransplantation Offers a good quality of life

But Exchanges one chronic illness for another


LIVER TRANSPLANTATION Lyn Crellin Paediatric Liver Transplant ...

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