Post Operative Care
Recovery from liver transplantation depends on many factors including patients’ age, overall health, severity of 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 in patients’ recovery.
In The Hospital
Donors wake up immediately after surgery, although they might feel drowsy for a few hours. They are able to get out of bed in 1 - 2 days and made to walk in 2 - 3 days. Various lines, catheters and drains are removed as they recover. Generally, they can have liquid diet followed by normal diet in 2 - 5 days, shifted to the ward in 1 - 2 days and discharged in 5 - 7 days. Pain medicines are given depending on their pain threshold. Some patients prefer to take pain medicines before walking or any exercise that may trigger pain or just before going to sleep for a comfortable night. On discharge, they are generally given painkillers and vitamins. Most donors will have an uneventful recovery although some might have mild problems such as fever, loss of appetite, nausea or even vomiting because of slow bowel movement after surgery, which can be treated easily and resolves over time.
Patients (recipients) are kept on a ventilator overnight and it is removed when they are fully awake. Patients are closely monitored for any bleeding, infection or other complications. First 24 - 48 hours are critical and their condition and liver function are monitored by doing frequent blood tests. Various lines, catheters and drains are removed as they make progress / recover over 3 - 4 days. Patients are given liquid diet followed by normal diet in 2 - 5 days. In patients where the bile duct has been joined directly with the intestine, the naso-gastric tube may be kept longer and diet may be delayed. Patients are helped out of bed in 1 - 2 days; they participate in the physiotherapy program, walk in 4 - 5 days and gradually become more active. Patients should actively do incentive spirometry to prevent collapse of lungs, prevent lung infections and recover faster. Patients should learn to support their incision with a pillow when coughing. Patients generally do not have a lot of abdominal pain after surgery although they may experience back and shoulder pain because of lying down on the operating table for a prolonged time. Patients are given pain medicines as per their need. Some patients may be confused, agitated or have mood changes because of the effect of sedatives or disturbance in sleep pattern after surgery, it generally resolves in a few days. Patients are shifted to the ward in 3 - 5 days and remain in hospital for about 10 - 15 days. At discharge, patients receive anti-rejection medicines, antibiotics and some other medicines.
In both donors and recipients, blood tests, ultrasound and chest x-ray are done regularly to monitor liver function and recovery as per standard protocol. Patients families are generally updated about their progress by the transplant team once a day or more often, if appropriate. While it is natural for patients and families to be anxious, questions for the transplant team should be asked during the counselling sessions or during ward rounds. Visiting hours and the number of visitors is restricted to prevent infections.
Discharge From The Hospital
While the patient recovers from the operation, the family should take the opportunity to learn about precautions to be taken after discharge, understand the schedule for testing and follow-up appointments, become familiar with medicines, learn about the warning signs of potential problems and understand the mechanism to contact the liver transplant team round the clock in case of urgent problems. We have daily group counselling sessions for both the patients and the donors and the relatives where they are counselled by our post op coordinators, physiotherapists and the nutritionists. Attending these sessions will help in discharge planning.
At the time of discharge, patients will get a discharge summary with detailed instructions about testing and medication schedule, which should be discussed with the transplant coordinator. Patients also get a copy of the investigation chart, blood sugar and blood pressure monitoring chart, which they should be familiar with and learn how to fill.
After discharge, patients are required to undergo tests and visit post-transplant clinic every 5 - 7 days. They should therefore stay in the vicinity of the hospital for 4 - 6 weeks after discharge. The house where the patient would be staying after discharge should be prepared.
Prevention of Infections
- The house should be thoroughly cleaned with disinfectants
- The accommodation should be close to the hospital with available transportation 24 hrs a day, there should not be too many stairs and the locality should be neat and clean.
- Patients are encouraged to walk and avoid using a wheel chair
- The number of visitors should be restricted for a few weeks
- Patients should avoid meeting people who are ill and report any illnesses / fever / flu / cold / persistent cough / pain in abdomen / loose motions or transmissible infections or infectious diseases such as influenza, pneumonia, chicken pox, hepatitis etc.
- Patients should avoid contact with animals and birds to prevent infection
- For the first 2 to 3 months, patients are advised to wear a mask and avoid crowded public places like malls, cinemas, restaurants, department stores, etc. After this patients can attend social events and live a normal life.
Personal Hygiene and Wound Care
- Frequent hand washing with soap, especially before eating, should be practiced by all family members and hand-washing with antiseptic solution after using the bathroom
- Oral hygiene should be maintained by brushing teeth daily rinsing mouth after eating
- Finger nails should be trimmed
- After discharge, dressing might need change 2 - 3 times a week
- Few donors / patients may be discharged with a drain tube in the abdomen, which is removed few days after discharge
- While one has wound dressings and drain bags, body should be cleaned with a wet towel only, fresh washed clothes should be worn daily
- Once the wound heals and bags are removed, patients / donors can use waterproof dressings and take normal bath before every dressing change
- Donor stitches / staples are generally removed within 2 - 3 weeks and recipients within 3 - 4 weeks, unless absorbable stitches are used which do not need removal
- Once the staples are removed, incision should be kept clean & dry. Patients / donors can take a daily shower or normal bath
- If the incision oozes some fluid or if the dressing nurse says that there is some infection in the wound, please insist that the nurse speaks to the transplant team immediately
- The dressing nurses are trained and will evaluate the condition of wound, decide the frequency of dressing changes and timing of staples / stitches removal, in consultation with the doctor
Diet and Nutrition
- Patients’ may have loss of appetite after surgery. The appetite slowly improves with time. However, it is important to take a high protein diet to help with wound healing and liver regeneration. If necessary, the dietician advises supplements in diet. If patients have preference for a certain type of meal or cuisine, they should check with the dietician.
Foods - How to Prepare / Consume
- Food should be cooked hygienically
- Wash utensils well before cooking
- Wash and cook in clean water
- Use boiled / filtered water
- Eat small frequent meals
- Drink plenty of liquids; intake is not restricted, as before transplant
- Salt restriction is not necessary unless one has high blood pressure
- Eat plenty of fresh fruits and green leafy vegetables after washing well and peeling off their skin
- Consume a balanced, low-fat high-protein diet
- Take foods rich in calcium, such as skimmed milk, cheese, soya, eggs, chicken, fish
- In a few weeks, patients can resume eating as they did before the transplant
Food to avoid
- Avoid deep fried or greasy foods
- Do not eat food left overnight
- Avoid raw eggs or mayonnaise
- Avoid partially cooked foods
- Avoid red meat
- Avoid cold meat
- Avoid overripe fruits
- Do not consume expired packaged foods
- If potassium is high, avoid foods such as banana, coconut water, fruit juices / pulp
- If blood sugar is high, avoid sweets and fruits such as mangoes
Activity and Exercise
- At the time of discharge, patients are generally allowed active walking and routine activities like bending or climbing stairs. Regular exercise increases energy level, strengthens muscles and makes one feel more active.
- It is common to experience weakness and mild abdominal discomfort at the site of the operation, especially with movements for the first few weeks to months after transplant. Do not postpone exercising because of this reason, in case one has severe discomfort with movements, talk to the transplant team.
- Perform deep breathing exercise to expand lungs and help cough out sputum.
- The physiotherapist will teach limb exercises, so that limb muscles are strengthened, blood circulation is increased and the risk of complications such as venous thrombosis is reduced.
- Speak to transplant physiotherapists to progressively increase the level of exercise and optimize the exercise schedule.
- Take adequate rest and sleep
- Avoid lifting heavy weights (> 5 kgs), including babies, or performing abdominal exercises for first 3 months to allow the scar to mature and prevent hernia in the long term.
- After 3 months, one can resume normal physical activities; perform any exercises, including abdominal exercises, weight training and swimming. These will help strengthen abdominal muscles and flatten the tummy.