Brief Patient History

Mr. V is a 56-year-old transgender male with hepatitis. His partner lives with him. He has a long history of chronic back pain and has been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for several years. He was recently started on warfarin for atrial fibrillation. He routinely comes to the clinic since he was diagnosed with hepatitis C. He weighs 452 lbs. He has a Model for End-Stage Liver Disease (MELD) score above 25. Mr. V is in acute fulminant hepatic failure. He has been having difficulty breathing, ascites, asterixis, abdominal distension, shortness of breath, dark amber urine, and hepatic encephalopathy. He has been treated with diuretics, antibiotics, and laxatives. He is now undergoing a liver transplantation.

Clinical Assessment

Mr. V is admitted to the intensive care unit immediately after receiving an orthotopic liver transplant (OLT). He is intubated and sedated. Mr. V moves all extremities but does not follow commands. He has a nasogastric tube, arterial line, urinary catheter, abdominal drain (draining bright red blood), and an external biliary drain in place. Continuous renal replacement therapy is in progress.

Diagnostic Procedures

Baseline vital signs are as follows: blood pressure (BP) of 100/60, heart rate (HR) of 118 beats/min (sinus tachycardia), respiratory rate (RR) of 20 breaths/min, temperature (T) of 98.3°F, and O2 sat of 98%.

Urine output was 55 mL/hr and is now 10 mL/hr for the last two hours. Central venous pressure (CVP) is 14 mm Hg and intraabdominal pressure (IAP) is >25 mm Hg.

His laboratory values are as follows:

• Platelet count: 49 K/µL
• Aspartate aminotransferase (AST/SGOT): 329 units/L
• Aminotransferase (ALT/SGPT): 236 units/L
• International normalized ratio (INR): 2.5
• Partial thromboplastin time: 69.9 sec
• Blood urea nitrogen (BUN): 40 mg/dL
• Serum creatinine: 1.6 mg/dL
• Potassium: 3.9 mM/L
• WBC: 3200 units/L
• Hematocrit (Hct): 25.3%
• Hemoglobin (Hgb): 8.2 g/dL
• Alkaline phosphatase: 384 units /L
• Gamma-glutamyltransferase (GGT): 1042 units /L
• Total bilirubin: 12.5 mg/dL
• Prothrombin time (PT): 21.3 sec

Medical Diagnosis

Intraabdominal hypertension and abdominal compartment syndrome are diagnosed.

Questions

In your initial post, respond to the following:

• What major priorities do you expect to achieve for this patient?
• What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
• Considering his gender and weight, what specific considerations are needed?
• What are some recommendations for a transplant patient on discharge?