You will have a tube in your mouth and throat that is attached to a ventilator, sometimes called a "vent". This machine breathes for you while you are in surgery and during the immediate post-operative period before you are strong enough to breathe on your own. While the tube is in place, you will not be able to talk. When the tube is removed, you will be able to speak again, although your throat may be sore for a while. After the breathing tube is removed, you will need to deep breathe and cough every hour or two. You will also be asked to use a "spirometer" to help you expand your lungs to their fullest.

You will have an IV line in your neck called a pulmonary artery catheter, also referred to as a swan-ganz line. This IV line passes through your blood vessels and into your heart. It is connected to a vital sign monitor that will give information about how your lungs and heart are functioning.

You will also have an arterial line, usually in your wrist. The arterial line is connected to a machine to keep constant record of your blood pressure. From this line the nurse can also easily obtain blood samples.

A nasogastric (NG) tube will be placed in your nose and throat. It is attached to a suction machine that keeps your stomach empty and helps to prevent you from feeling nauseated. It needs to stay in place until your bowels begin to function again. Every day the doctor will listen to your abdomen for the return of bowel sounds to determine when to remove the tube and when you can start taking liquids by mouth.

After surgery, you will have a Foley catheter in your bladder. The Foley catheter automatically drains urine into a bag that hangs on the side of the bed. This catheter will remain in place for several days.

In addition to the Foley catheter, you will have small tubes, called JP (Jackson-Pratt) drains attached to your body. These tubes will drain any blood or fluid that may accumulate around the surgical area. The collection bulbs are emptied every few hours or more often if they are full. The tubes are removed when drainage becomes minimal or as determined by your doctor.

You may or may not have T-tube or other type of drain in your bile duct. The T-tube in your bile duct will drain bile into a small plastic bag outside of your body. The amount and appearance of the bile indicates how well your liver is functioning. The bag is emptied every two hours by your nurse. Usually about a week after surgery, the T-tube will be clamped and the bag removed. You will be able to take a shower 4 to 5 days after surgery and you will need to place a new dressing over the tubing daily. The T-tube will remain in place for 3 - 4 months. At that time a T-tube cholangiogram will be performed. The cholangiogram is an x-ray that uses injected dye to visualize the bile drainage system to be sure there is not a leak. If the test is normal, the T- tube will be removed during an outpatient clinic visit.

When you no longer require SICU care, you will be moved to the transplant floor. Transplant patients have semi-private rooms and visiting hours are from noon to 8:00 p.m. The nurses on the transplant floor are specially trained in taking care of transplant patients. Your medical care is provided by a team of doctors lead by the transplant surgeons. Other specialists make rounds with the team and provide assistance with your day-to-day care.

A Liver Transplant Flow sheet is attached to the wall in your room. Daily test results and medication doses are recorded here. The transplant team members review this information every day on rounds to determine plans for ongoing care. You will be given a post transplant handbook in which to record important blood tests and vital signs. You can start by recording values from the Flow sheet and vital signs from your nurse.

During this recovery time, you will feel better on some days than on others. This is normal. It is important for you and your family to remember that not all patients recover at the same rate. Several complaints are very common, including trouble sleeping, depression, backache, muscle cramps, lack of appetite or feeling full after just a small portion of food.

Several activities are important to your recovery. You will be asked to cough and deep breathe every couple of hours to expand your lungs and prevent pneumonia. Walking is also important. It may be difficult at first, but it will help you to gradually build strength. Walking at least four times a day will help improve circulation and prevent blood clots in your legs. Physical and occupational therapists will help you begin an exercise program.

Fresh flowers, but not potted plants, are allowed in your hospital room on the transplant floor. Tell friends and relatives who may want to send you flowers that you can receive flowers, balloons and cards to brighten up your hospital room, but flowers should not be sent to SICU. After you go home, houseplants and gardening should not be a problem for you, as long as you wear gloves. Pets are also allowed at home, although it is best if you do not have birds in the house. If you have any questions regarding these topics, please let us know.

Learning how to take care of yourself after you go home is very important. You will receive a Post Transplant Handbook and the transplant coordinator will review important information with you before discharge. To make it easier to learn your medications, they will be kept at your bedside so you can practice setting them up. Your nurse will need to see all medications before you take them. You will also be taught to make changes on your medicine card. You will need to take your temperature and blood pressure twice a day after discharge and will also need to weigh yourself every morning, recording these results in your handbook.

Returning to work is different for each person. Physical activity and heavy lifting should not be a problem after you are healed. If you have any questions about other occupational hazards, please discuss them with the transplant physician.

Together, our goal is to return you to a full and productive lifestyle including returning to full-time employment.

Your nurses and doctors will diligently watch for any signs of bleeding after your surgery. In the rare event that bleeding does occur, you may need to return to the operating room so doctors can stop the bleeding.

The nurses and doctors on your health care team will carefully monitor how well your lungs are working. Your breathing tube (and ventilator) is usually removed the day after surgery. If your lungs are not working properly, the ventilator and tube will remain in place until you are able to breathe on your own.

You will receive IV and oral antibiotics while you are in the hospital to prevent infection after surgery. In addition, whenever there are even the slightest signs of infection, cultures will be done and antibiotic treatment may be started. When the IV antibiotics are stopped, they are often replaced with pills. Each pill will be explained to you when you begin taking it.

The first day after surgery, an ultrasound will be done to verify that the blood flow in the blood vessels in and around the liver are open with no clots present. If the ultrasound shows any problem areas, the surgeons will discuss the problem and any necessary treatment with you.

Bile production is an important indication that your liver is working. Depending on your situation, a T-tube may be placed in the bile duct during surgery which will allow bile to drain into a drainage bag. Bile production will be observed and measured every two hours. If bile production is not normal or changes, tests will be done to determine the cause.

One week after surgery, a T-tube cholangiogram will be performed to view the internal bile ducts. Dye is injected in the T-tube and the bile ducts are examined on x-ray. If narrowing is present it can sometimes be corrected by an endoscopic procedure. Surgery is occasionally necessary to correct the problem.

Blood tests and urine samples that measure kidney function will be watched closely. Kidney function can be affected by liver disease, and many transplant patients have decreased kidney function even before transplant. Important anti-rejection medications, Cyclosporine and Tacrolimus, can also decrease kidney function. Immediately after surgery, medications will be carefully adjusted to allow your kidneys to function as well as possible. If necessary, dialysis will be performed until your kidneys recover function.

The process of your immune system trying to fight off the new liver is called rejection. Rejection is a normal response of your immune system to the transplanted organ. Many patients experience an episode of rejection at one point or another after transplant. Medicine is given to prevent your immune system from rejecting your new liver. Blood tests are also done to measure liver function. If the blood test results are abnormal liver biopsies may be performed to look at the liver tissue under the microscope. However, an abnormal liver test could mean something other than rejection.

There are many ways for your doctor to treat a rejection episode. One way is to increase the immunosuppressive medications you are already taking. Another way is to administer OKT3 to you intravenously at the hospital. Nearly all episodes of rejection are successfully treated and most are treated on an outpatient basis.
 

It is extremely important for you to keep in mind that liver transplant surgery is a major surgery. It is not like having your appendix removed. You may be extremely weak after your surgery, and you will need someone to stay with you, 24 hours a day, for a variable period of time after surgery. This may be a family member or friend. The degree of weakness you experience will depend upon your physical condition prior to surgery. It also depends upon how well your surgery went and if you had any complications. Listed below are some of the activities you will need the most help with.

• Getting up and moving around
• Taking care of your incision
• Remembering your medications - which ones to take at what time, and how many of each
• Transportation to the lab twice a week and physician appointments (once a week for the first 2 - 3 months)
• Performing activities of daily living including bathing and dressing
• Preparing meals and remembering the importance of eating balanced diet and adhering to dietary restrictions (if there are any)

You need someone to be available and to help you during this recovery period. Even though you think you can handle everything yourself, you can see from the above list that you will need someone who is going to be there for you. Remember, in most cases this may be a temporary arrangement. The plan is that you get back to the point where you can take care of yourself and, if possible, return to work.

If it is determined that you need extensive physical therapy and assistance with activities of daily living, you may be discharged to a rehabilitation facility. If you are in a situation where you can be cared for at home, in-home physical therapy and nursing care can be arranged for you. Many of these arrangements depend both on your needs and your insurance.

The average length of hospitalization is 10 - 14 days. If you live outside of the Cincinnati area, you may need to remain in a hotel or with relatives near the hospital for a short time after discharge. You will have scheduled blood tests twice a week on Monday and Thursday. You will need to call these results in to the Liver Transplant Office. The transplant coordinator will discuss your schedule of outpatient tests, office visits and liver biopsies and when you can plan on returning to your own home. Once you return home, your local (referring) doctor will be seeing you regularly. In addition, the surgeon and the transplant coordinators will be reviewing all information you submit to the Transplant Office. You will need to come in to see the surgeons in the outpatient office frequently. If you do not have a family doctor, it is important to find one and establish a relationship with him or her. This will enable the doctor to be more familiar with your case and to follow you after your transplant.

If tests indicate a change in liver function, you may need to have a liver biopsy. The biopsy results will show the condition of the bile ducts, blood vessels and any signs of rejection.

As mentioned before, you will receive a post transplant handbook that contains information about medications and how to take care of yourself after transplant. You will learn to take your temperature, blood pressure and weight. After you are discharged, you will need to call these results in to the Transplant Office along with your lab results whenever you have lab tests done. As you progress, the frequency of blood tests will decrease.

All transplant patients require yearly routine physical examinations for life. Women must remember to have a pap smear and mammogram once a year after transplant. Men need a testicular and prostate examination and a PSA (prostatic specific antigen) test over age 50. These exams are performed by your family doctor as cancer screening procedures.

It is normal to wonder how your life will change when you receive a liver transplant. As you regain strength after the transplant surgery, you will probably find that you feel better than you have felt in some time. Most people are able to return to an active life including full time employment, raising their families and traveling, with only minor alterations in lifestyle. The time required to return to normal varies from patient to patient. Some patients recover after a month, some after a few months and some after six months or a year. It is important to discuss your expectations and goals with the transplant team.

It is also important for you to collect and review as much information as possible about liver transplant. By understanding what you will experience, you and your family can assist in making the best decision possible for your situation.

The medical social worker will work with you and your family to determine what your discharge arrangements will be. Sometimes home nursing is ordered to help you recuperate at home. Occasionally, patients need to enter a rehabilitation facility to regain their strength. The medical social worker will help to make the arrangements for this placement if it is needed.