Patient chosen is a 36yr old male pseudonym ‘Frank’ chosen for the purpose of confidentiality. Frank was day one post re- do orthotic liver transplantation (OLT) with roux -en-y anastomosis. He had his initial OLT for Primary sclerosing cholangitis secondary to auto-immune hepatitis preformed 5 days previously and required and urgent re-do transplant due to Hepatic vein thrombosis not responsive to conservative treatment. Prior to his re-do transplant he had required CRRT due to acute kidney injury(AKI) related to large blood loss of 2.5litre due to coagulopathy related to liver failure. He was currently receiving CRRT. Frank has a past medical history of auto immune hepatitis, Ulcerative colitis (total colectomy with ileostomy formation in 08 with recurrent adhesions, stomal varices, osteoporosis, Left bundle branch block (Asymptomatic). He is a single man with both his elderly parents NOK.He was unable to work due to long term illness and lives with his parents 10miles away from the hospital.
Autoimmune hepatitis is a chronic hepatitis characterised by auto immune features, generally including the presence of circulating autoantibodies and a high serum globulin concentration (Krawitt 2006). This results in the body initialling in error an immune response to the liver cells and causing inflammation damage and death of the liver cells. Primary sclerosing cholangitis is the inflammation, scarring and death of the bile ducts.Ulcerative colitis is one of the risk factors
Hepatic artery thrombosis occurs in estimated 2.5% of liver transplants with aprox 50% requiring retransplantation(Stange et al 2003). It was in franks case diagnosed following routine ultrasound of liver ducts and Doppler to assess blood flow from the hepatic arteries. ARF in liver disease is common and can occur due to renal hypo perfusion or increased renal vascular resistance. (Betrosian et al 2007) and occurs in aproximatley 23% of chronic liver failure patients (Agarwal et al 2009)
Frank has a GCS of 9/15. He had previously been on sedation and analgesia. But was currently having a sedation vacation as recommended by kress et al (2000). He was eye opening to pain and obeying commands. Richmond agitation score(RASS) was -2 light sedation. On respiratory assessment Frank was intubated and ventilated on Pressure support ventilation (PSV)requiring minimal support of PS 8 PEEP 5 fio2 .24. ABG supported adequate ventilation and oxygenation. Respiratory rate 16 regularly work of breathing was normal and relaxed. Lung fields clear on auscultation. Productive cough on suctioning aseptically using size 12 (Pederson et al) Cuff inflated at 30cmh2 (Stewart et al) with Achieving adequate tidal volumes of 6mls per Kg as recommended by ARDs net 2000.
. Frank was maintaining a mean arterial pressure of 68mmg on 28 mc/hr. of Noradrenaline which was administered through a dedicate lumen of a central line and labelled accordingly. The MAP of 65mgh was identified patient parameter as recommended by le Doux as cited in Delinger et al 2009 to ensure adequate perfusion of the vital organs including renal perfusion. Alarms were set within patients parameters. Pulmonary artery flotation catheter was in situ with systolic 21mmgh, diastolic 9mmgh MAP 13 svo2 76% and estimated cardiac output 8.8 wedge pressure of 6 mmgh as performed by intensives. Central venous pressure of 3mmgh. Lines were transduced a phlebosatic axis, pressure 300mmgh. PAFC secured at pillow sutures secure syringe deflated and locked measured as 60cm...