Page 16 - HPB Handbook - May 30 2022 (Flipbook) v2

Page 16 of 22

The presentation is often modified by the post-op state, and therefore very few patients will present with the classical
syndrome. In the assessment of any post-op patient who is acutely unwell you must ask: ‘how do I know this patient has not
had a pulmonary embolism?’ It is often difficult to answer this, especially if there is no alternative diagnosis obvious -
discuss the need for a CT chest scan with the fellow or staff (see also section on ‘consultations’)

Treatment with LMWH, (Enoxaparin 1.5 mg/kg SC daily,) is more convenient than intravenous heparin. The problem in a
post-op patient is that the effect cannot be ‘turned off’ if the patient bleeds. DO NOT commence this therapy over
intravenous heparin until the treating consultant has been involved in discussion.

Central Venous Line
CVCs should be inspected daily, for redness, and for the condition of the dressing. The fever chart should also be considered.
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CVCs put in at the start of a case by the anaesthetist should be removed by the 5 post-operative day if at all possible. Lines
put in under optimal conditions can stay in for 7 days.
If line sepsis is a potential problem:
 take BC X2 via the line
 take BC X2 peripherally
 remove CVC, and culture tip
 achieve peripheral access
 examine heart for murmur, nails, fundi, FWTU etc.
 consider need for anti-fungal Rx

COMMON OPERATIONS - Perioperative Management
Liver Resection
The majority of liver resection patients will have a smooth and uncomplicated course. However, residents must be fastidious
and diligent with post op care of these patients to identify uncommon but potentially fatal complications. Most liver resection
patients will be admitted to the SDU for 1-2 days. The most common early problems are related to low urine output
secondary to intraoperative blood loss and the maintenance of a low CVP during the operation. Judicious administration of
intravenous crystalloids is usually adequate, however, post-op bleeding must always be considered in this setting.

Post-operative Fluid Management in Patients with Cirrhosis
The fluid management of patients with cirrhosis requires special attention in the post-operative period due to the physiologic
changes associated with chronic liver disease including decreased oncotic pressure, portal hypertension and peripheral
vasodilation. Patients with cirrhosis retain sodium and water, particularly in the extravascular space, leading to fluid overload
with increased total body water but intravascular hypovolemia. To avoid these complications we tend to fluid restrict patients
with cirrhosis while avoiding pre-renal dysfunction.

Specific Guidelines for Patients with Cirrhosis:
-Patients should be overall IV fluid restricted and low-normal urine output should be tolerated (0.3-0.5cc/kg.hr) providing
renal function (serum Cr) remains stable.
-Limit maintenance IV fluids to 75cc/hr. (or less depending on body weight) for first 24 hours post op; then decrease
aggressively. Aim to saline lock IV by POD3 or 4 as the patient tolerates.
-Management of IV fluids should be done predominantly through boluses to allow better management of total fluid balance.
-Limit boluses of crystalloid to 1-1.5L of NS per 24hrs in the first 72 hours.
-Further IV fluid resuscitation should be given in the form of colloid
-5% Albumin if patient is TBW depleted
-25% Albumin if patient is TBW overloaded
-After 72hrs, patients may require diuretics (with or without 25% albumin) to assist in post-op diuresis. Furosemide +
spironolactone (women) or amiloride (men) can be titrated accordingly.
-Check with HPB fellow or staff for guidance if necessary.

In general, it is not necessary or appropriate to administer colloids (e.g. FFP) for a low urine output or to ‘correct’ a rising
INR. Close monitoring of INR (see standard postop order cards) is a useful indicator of hepatic reserve and hepatic function