Postoperative Care After Liver  Transplant

Postoperative care & recovery after Liver  transplant

Donor in living donor liver transplant

Recovery from liver transplantation depends on many factors including patients age, overall health, the severity of the liver disease, infections, secondary organ dysfunction or complications before or after the operation. Good understanding of the process, moral support, and encouragement from family, a positive attitude and strong will-power are important elements that can expedite the patients’ recovery.

Recovery in the hospital

Although donors regain consciousness almost immediately post-surgery, they might feel a bit drowsy for the next couple of hours owing to the effects of the anesthesia wearing off. The first night immediately after surgery is spent recuperating at the Surgical Intensive Care Unit where they are closely monitored and cared for by a staff of specialized nurses and doctors. Here they are kept under observation to check for any signs of bleeding, infection or other complications. Most donors are able to get out of bed and start moving within first 2 days days with the help of physiotherapy. Initially, patients need to follow a liquid diet followed by a normal diet in 2 - 5 days.

They are shifted to the ward on day 2 and remain in the hospital for about 6 to 7 days from the day of surgery

Recipient

The first 1 to 2 days, in particular, are extremely critical as this is the stage at which life-threatening complications might occur. Thereon, even the liver function is analyzed at regular intervals with the help of frequent blood tests. Discharge is also dependent on how quickly the patient  can regain strength and how rapidly the liver function blood tests become stable. If the progress that has been made has been deemed satisfactory, the donor will then be shifted to a general ward which is designed especially for recovering liver donors. Catheters and the lines attached to the patients are also removed depending on the recovery and progress made.

Most donors are able to get out of bed and start moving within 2-3 days with the help of physiotherapy. Initially, patients need to follow a liquid diet followed by a normal diet in 2 - 5 days. In the case of patients  where the bile duct has been attached directly with the intestine, the nasogastric tube may be required to be connected longer and there may be a delay in administering a diet plan. While patients usually don’t experience much pain or discomfort after the initial period, pain medications might be administered depending on the donor’s pain threshold. It's a common occurrence for patients to feel confusion or experience irregular sleep patterns occur post-surgery. In such cases, the patient needs to stay calm as this situation tends to resolve itself after a while.  On discharge, patients are usually given a round of anti-rejection medicines, painkillers, vitamins, antibiotics along with some other medicines.

It’s quite common for patients to experience symptoms such as fever, exhaustion, nausea, drowsiness, a loss of appetite, vomiting during the recovery period. There’s nothing to worry about as these symptoms can be easily treated with the help of medicines.

Discharge from the hospital

Once the donor has been discharged from the hospital, the recovery period at home begins. Patients are handed a discharge summary which has detailed instructions on how the recovery should be handled. In addition, the patient as well the family should educate themselves beforehand on the various protocols required after discharge. They should take time to understand the various tests such as blood tests, ultrasounds and chest x-rays which are needed to monitor the liver function regularly. The family should also make themselves familiar with the required precautions and potential warning signs that need to be heeded after discharge.

While it might be an anxious time for everyone involved, at Fortis we have a team of post-op coordinators, physiotherapists and the nutritionists who host counseling sessions to clarify any doubts the patient or the family might have. In case of any unforeseen issues, our liver transplant team is always on hand to help mitigate any potential problems.

The key pointer which needs to be followed is not to over-exert or over-do things. That being said, the donor should also try to stay active as much as possible by walking around the house. By duly following the after-care instructions, the patient will be able to return to a normal lifestyle within a couple of months.

Measures to be undertaken to prevent the onset of infections

Once the surgery is completed, it’s imperative that patients do everything they can in order to prevent an infection. An inhibited infection can hamper the healing process and inadvertently lead to some serious complications. Here are a few measures that one can adopt that will greatly improve the chances of recovering from the operation without an infection:

• For the first few weeks, there should be a limit on the number of visitors visiting the patient. Patients and their family should try and avoid meeting any individuals with any sort of lingering illness or common ailments such as flu, fever, cold, etc. as they might be contagious.

• Care should be taken to thoroughly clean the house with the help of disinfectants.

• Medications and antibiotics should be taken as prescribed and on time.

• The accommodation where the patient is recuperating should ideally be in close proximity to the hospital. Transportation should also be available and ready 24 hours a day. Access to the building should be easy without any obstructions and most importantly, should be clean and hygienic.

• Patients should try and avoid using the help of a wheelchair and instead should try and walk as much as possible to regain strength.

• Care should be taken by the patient to consciously avoid any sort of contact with animals and birds to prevent the chances of contracting any transmissible infections.

• While venturing out of the home should be avoided as much as possible in the first few months, if the patient needs to head out, then he/she should always wear a face mask especially while visiting crowded places such as cinemas, malls, etc. Once the patient gets the green signal, then he/she can resume social activities and recommence normal life.

• Patients should try and adopt healthy eating and eat everything in moderation.

• Patients might be immune suppressed which is why all immune suppression and other medications should be taken as per schedule.

Personal hygiene and wound care

• Patients should wash their hands frequently, thoroughly, and properly with antiseptic solution/soap at all times after using the bathroom and/or after meals. In addition, family members should practice the same guidelines.

• It’s equally important to maintain oral hygiene by brushing teeth twice daily and rinsing the mouth after meals.

• Fingernails should be trimmed to avoid the accumulation of dirt particles between the fingers.

• The dressing should be replaced twice or thrice every week.

• In case of donors with an attached nasogastric tube in the abdomen, this can be removed a few days after getting discharged.

• One should avoid having a bath in a bathtub as the wound shouldn't be soaked in water until it has completely healed. In case the patient is attached with drain bags, one can wipe themselves down with the help of a wet cloth.

• Showers can be taken after a few days as surgical wounds can get wet without increasing the likelihood of infection. The patient can try using waterproof dressings as well. In the meanwhile, care should be taken to change clothes on a daily basis.

• While in all likelihood, self- absorbable stitches will be used during the surgery which does not required to be removed, in case normal staples are used, they can be removed within a couple of weeks post surgery.

• Upon removal of the staples, it's imperative to keep the incision clean and dry at all times. Once the staples are removed, patients can resume daily showers.

• If any puss or fluid oozes out of the incision, there are chances that it might have gotten infected. If such an event were to happen, it's important to contact the transplant team on an immediate basis.

The progress of your surgery will be reported to you during every visit. Our dressing nurses are highly trained in changing the dressings efficiently and taking out the stitches when the time is right.  Accordingly, you will be informed about the condition and the progress of the wound after consultation with the doctor

Diet and nutrition

It’s quite normal for patients to experience a loss of appetite after surgery which is nothing to be alarmed about. It needs to be mentioned that over time, the patient’s appetite starts showing slow but gradual improvements. That said, it is equally important that the patient is put on a high protein diet which will help in the wound healing process as well in liver regeneration. If the need arises, our dietician will gauge your situation and food habits and suggest incorporating certain types of supplements in the diet. In case patients prefer a particular type of meal or cuisine, it’s crucial to run it past the dietician before consumption.

Foods - how to prepare / consume

• Care should be taken to prepare and cook all food items hygienically. Meat, in particular, should be cooked thoroughly.

• All utensils and cutlery should be washed before cooking. It’s equally important to clean and disinfect all kitchen surfaces immediately after preparing food.

• Vegetables & fruits should be washed thoroughly and cooked in clean water before consumptions.

• Drinking water should always be boiled and/or filtered before drinking.

• One should try to avoid eating large meals and instead, space out their meals. Meals should be frequent and served in small portions.

• It’s crucial to stay hydrated by drinking a lot of liquids throughout the day.

• One should live by the adage, ‘eat the fruit and drink the water’. This is because eating fresh fruits and vegetables not only turn out to be a healthier alternative but also help you avoid the high sugar content that’s present in packaged fruit juices.

• Patients suffering from high blood pressure/hypertension should restrict their intake of salt. In all other cases, such restrictions aren’t required.

• It’s recommended following a balanced, low-carb, high-protein diet in appropriately sized portions.

• Eating a calcium-rich diet is a vital part of staying healthy which is why one should try including foods rich calcium, such as skimmed milk, cheese, soya, eggs, chicken, fish

• After a few weeks, once the dietician and transplant team has reviewed your progress, you can resume consuming your normal diet.  

Foods to avoid

• One should avoid eating junk, unprocessed, deep fried and greasy food as they tend to be high in calories and trans fat.

• One should avoid consuming foods that have been unrefrigerated for too long or that have been left overnight.

• Expired packaged foods should be avoided at all costs.

• Avoid eating uncooked food that contains raw eggs and or mayonnaise as patients are at a higher risk of food poisoning as compared to thoroughly cooked foods.

• Similarly, one should avoid eating partially cooked foods, red meat, and or cold meat.

• One should steer clear of overripe fruits as consuming them can cause gastric upset/distress.

• If the blood reports indicate high levels of potassium, then one should avoid consuming potassium-rich foods such as fruit juices/pulp, coconut water, bananas, etc.

• Patients with high blood sugar levels should restrict their sugar intake. Besides, it makes our body susceptible to a variety of disorders and diseases.

Activity and Exercise

While heavy lifting and intense workouts should be avoided for a while post-surgery, it's equally important to stay active – to an extent at least. Here are a few exercise tips which will go a long way in keeping you in the best shape:

• Patients, after getting discharged, should keep themselves active by incorporating routine activities into their daily schedule such as climbing stairs, walking around the house, bending, etc. which will help restore mobility & strength. In addition, regular exercise helps in restoring movement while allowing you to gradually return to everyday activities.

• While it's completely normal to experience a little discomfort in the abdomen and around the incision area, one should not put off exercise for solely that reason. Slowly and gradually, you should look to do mild exercises to regain strength. If you still experience discomfort even weeks after the surgery, then you should contact the transplant team immediately.

• Simple and conscious breathing exercises – breathing in deeply and slowly through the nose – will help expand lungs, open up air passages, improve circulation, and make coughing easier to expel out sputum

• Out transplant team comprise of outstanding physiotherapists who help to restore movement and function in your limbs. A series of simple exercises will be taught which will help strengthen the limb muscles, increase the circulation of blood and eliminate the risk of complications such as venous thrombosis. Accordingly, our physiotherapists will develop a customized exercise regime for you which will allow your body to heal and improve overall flexibility and functionality.

• It’s equally important to take adequate rest and sleep well.

• Heavy lifting comes with its dangers and can increase your intra-abdominal pressure and add unwanted stress on your healing tissues. Keeping that in mind, it's important to avoid lifting heavy weights while avoiding any sort of heavy yard work, contact sports, abdominal exercises as well for at least three months' post-surgery. This allows your scar/incisions to heal while also helping prevent the occurrence of hernia in the long-term.

• You can start resuming normal physical activities, weight training, swimming, and performing exercises, three months after your surgery.

Its always advisable to exercise a bit of common sense and use it as your guide before resuming any activity after transplant. Always listen to your body and exercise accordingly. As you start gaining strength and endurance, you will notice that the amount of physical activity will also steadily increase. Set goals for yourself – such as walking a little extra as compared to the previous day. The key is to do everything in moderation and not overdoing anything.  If you have any questions, please feel free to contact the transplant team.

Tests and appointments

Besides regular light exercises, it’s also important that you stick to your follow-up visits and appointments post-surgery. Thereon, the importance of follow-up visits plays after getting discharged from the hospital can’t be overstated as it plays a key role in ensuring the surgery is an overall success. Here are some pointers in that regard:

• In the first month after the surgery, donors should make it a point to follow-up every 5 to 7 days. This will help the team in ascertaining that the patient is doing well while ensuring there aren’t any complications. After that, donors can get them tested and their health status reviewed at 3 months and then 1 year.

• Recipients, on the other hand, will need a life-long follow-up. A transplant is a major, life-changing surgery which is why it's important for them to get themselves reviewed on a timely basis. While the follow-ups will need to be frequent post-surgery, if the transplant team feels adequate progress is being made, then the visits can gradually become infrequent. A schedule will be allocated to the recipient detailing the timings of the visits, medications which require to be taken, the exercise regime which needs to be followed, etc. Once everything is in order, patients are free to travel and email their reports periodically. That said, it's still important for the patients to visit the clinic every 3-6 months to analyze if the liver continues to recover or blood counts are stable.  The ultimate goal is to ensure that the patients are healthy and to check if everything is in order.

• We hold special transplant clinics in selected cities across the country regularly. This makes it convenient for patients and their families to attend these clinics. Please get in touch with our post-transplant coordinator to find out more about the schedule for your city.

• If any problems or unforeseen issues arise, you should immediately contact the transplant team. In case of emergencies or if you're traveling where it's not possible for you to reach out to our transplant team on an immediate basis, it's important to earmark local physicians before-hand so that they are cognizant of your situation and accordingly administer urgent medical care.

• It's important to restrict diet intake, maintain blood sugar levels, monitor blood pressure, limited exercise and administer insulin along with other parameters on a routine basis once you're discharged. Our post-transplant coordinators will sit with you and advise you on the various precautions you need to take and specified instructions you need to follow regarding this. You should also ideally maintain a file that keeps a record of all blood tests, lab reports, medications, etc. in a chronological order which will allow the transplant team to stay on top of your health status during follow-up visits.

• Patients who are in need of dressing changes, physiotherapy or require help with certain injections/medications should make prior arrangements with our transplant team so that we can coordinate the same seamlessly. Our team will make the necessary arrangements to have these qualified people at your disposal so that your recovery goes along smoothly.

Last but not least, always pay attention to all instructions relayed by the transplant team. Stick to your test schedule, take your medications on time and report any sort of problems before they turn serious. This allows us to administer timely treatment, go over any potential medication changes while helping prevent whatever caused the issue from reoccurring.

Medications

After you have received your new liver, you will be required to take a combination of different types of medications. At the time of discharge, patients are generally prescribed a round of 10 – 15 medicines, including certain types of injections. During follow-up visits, if the transplant team deems that the patient has made satisfactory progress, the number of medications is accordingly reduced over time. In all likelihood, patients eventually need to take only 1 or 2 anti-rejection medicines after a year or so – not counting those medications which might be needed for any pre-existing illnesses. Therefore, it's imperative that both the patient as well as his/her family familiarize themselves with the type of medicines prescribed:

• Anti-rejection (immunosuppressant) drugs form a vital cog in your recovery and also in ensuring that your liver doesn’t reject the organ. Knowing that the new liver is a foreign entity, immunosuppressant drugs help in lowering the body’s immune response, thus preventing your body from rejecting or damaging the new liver. These drugs need to be taken life-long and also helps in minimizing any side effects of the drugs. Even missing a single dose may increase the likelihood of you having a rejection – even many years after transplant. The only time you should skip a dose is if our transplant team explicitly advised you to do so.

• Medications such as antacids, antibiotics, antifungals & blood thinning medicines help in preventing complications and avoiding side-effects. These need to be taken as per the schedule outlined by the transplant care team.

• You should also try taking certain supplements such as vitamins, calcium, magnesium as it helps in resisting infections, keeping your nerves healthy while helping you achieve the right balance.

• In case you are taking medications for certain pre-existing illnesses such as antiasthmatic, anti-diabetic, anti-hypertensive drugs, these need to be continued along with the new medications.

• Always be stocked up with the required dose of medicines. Ensure that you never run out of medication before getting refills.

• One of the most important things to remember is to stick to the timelines and dosage given to you by the transplant team. Medications should always be taken on time and under no circumstances should the frequency or duration be changed unless explicitly instructed to do so by the transplant team. The timings and the duration for which the medications need to be taken will be relayed to you by the transplant team at the time of discharge and is included in the discharge summary.

• Before taking anti-rejection medicines in the morning such as Tacrolimus, Cyclosporine, Sirolimus, care should be taken to ensure that their drug levels are drawn beforehand. This helps in preventing any side effects while ensuring you get the desired results.

• In the event you happen to miss a particular dose of medication, under no circumstances should that be compensated by taking in a double dose. Normal dose should be resumed even in such scenarios.

• It's been observed that a lot of patients like to self-medicate. It doesn't matter whether the ailment is something as common as a cold or the flu, care should be taken to make sure that you always consult our specialists before introducing any new medications in your schedule. There are always chances of potential side-effects or the likelihood of the new drugs not being compatible with the existing round of medications.  Similarly, in case a patient needs to get vaccinated or immunized, the transplant team needs to be informed before doing so.

• As a patient, it’s your responsibility to be aware of the various side effects of medicines by learning more about them prior to taking them. You can also discuss the same with our transplant team and inform them if you experience any sort of issues after taking certain prescribed medications.

• You must be in a position to easily recognize each medication by its color, shape, and/or size. Several medications tend to bear a similar appearance with only the slightest of differentiating factors.

• For all medications prescribed and taken, a detailed and updated record should always be maintained so that the transplant team remains in the loop.

• You should always remember to take a few extra days’ worth of medication with you whenever you’re traveling.

• You should be aware of the timings for taking certain medications. For instance, some medications are required to be taken with food or on an empty stomach while others need to be taken independently – separate from certain medications in particular.

• There are times when you can forget taking a medication owing to the stresses of day-to-day life. Hence, it's important that one of your family members takes up the responsibility of reminding you even if you forget to do so. This is important as even a single missed dose can have long-lasting and severe implications.

List of Common Medical Abbreviations Describing Medication Frequency

OD: Once a day (at 24 hours’ interval)

BD: Twice a day (at 12 hours’ interval)

TDS: Thrice a day (at 8 hours’ interval)

QID:     Four-time a day (at 6 hours’ interval)

BBF: Before breakfast

HS: At night before going to sleep

A/D: Every alternate day

SOS: Whenever needed

Blood sugars / Insulin

• Your blood sugar levels should also be checked regularly – up to 4 times daily – or as per the instructions given to you by the transplant coordinator. Here are the usually accepted timelines for administering insulin:

Before breakfast: 7 am

Before lunch: 12 pm

Before dinner: 7 pm

2 hours after dinner: 9 pm

• It's important to get your blood levels checked every time before administering insulin to yourself. Further, care should be taken to ensure insulin is taken only before meals

• If your blood sugars levels fall below 100, it’s recommended that you skip that particular dose. However, in such a scenario, you can still continue taking your regular meals.

• If your blood sugars levels go under 80, it’s imperative that you increase your intake of glucose rich-food such as sugar, chocolate, etc. In addition, you should also skip your insulin dose, while continue having your regular meals. Once you follow the above steps, make sure to re-check your blood sugar levels.

• In case your blood sugar spikes over 400, it's highly recommended to take your prescribed insulin dose. In addition, you should continue having your regular meals and get in touch with our transplant team.

Danger/warning signs

Here are some of the prominent warning signs you nee