Liver Transplant Evaluation and Assessment Guide

When a suitable liver is offered, the hepatology consultant or transplant coordinator will call you. This may be any time of the day or night. The transplant may not happen for many hours after this phone call. You will be generally be asked to make your way to the hospital shortly after the call. You have time to pack a bag. It is important that you do not drive recklessly or speed as you make your way into the hospital.

If you arrive during office hours, you will be asked to come to the Admissions area on the ground floor. If it is after hours, you will come to the front desk of the Emergency Department. You will be directed to the Transplant Unit which is located on the 4th floor on Ward 4BT. If you are an inpatient, you will leave for theatre from Ward 4E.

When you are called, you will be told when to stop eating or drinking. For 6 hours before any operation it is important that you must not have anything to eat or drink. When you have an anaesthetic, all the muscles in your body relax. If you have food in your stomach, it can reflux back up into your mouth and even worse, your lungs. This can produce a life-threatening pneumonia. It is alright to take your normal medications with a sip of water any time before surgery. It is also fine to brush your teeth.

The nursing staff will prepare you for surgery. You will be weighed, and have your temperature, blood pressure and pulse checked. The nurse will ask you if there are any implants or metal in your body. We ask this because we need to place an earthing plate on your body during the surgery and need to keep it away from any internal metal.

You will have many tests just before the transplant, including a chest x-ray, ECG, blood work, an alcohol test, groin and nasal swabs. If you have cancer in your liver, you may have a CT scan to make sure the cancer has not gotten worse while you have been waiting for the liver transplant. You will meet one of the junior doctors from the transplant unit who will go through the surgery one more time and make sure you don’t have any current illnesses or infections that will make it risky to go ahead with the transplant.

You will be asked to shower and remove all your clothes and underwear. You will change into a theatre gown and paper underpants. You will be measured and fitted with white, knee high

stockings to prevent clots in the legs. In theatre you will have a pair of pneumatic leg massagers placed on your calves to keep the blood in your legs moving while you are asleep. This prevents clots in the legs. The look is complete with a puffy paper hat. It is a good idea to remove all your jewellery and give it to your support person for safekeeping. Your clothes, glasses and other items will be put into a bag and placed into a locker whilst you are in theatre. You will be reunited with them when you return to your room in the ward or intensive care.

Many people have bacteria living on their skin that have been given special names by hospitals. It is likely you will know this from a previous hospital admission. This does not mean you have an infection. We all have bacteria living in and on our bodies and some are resistant to certain

antibiotics. It is best if these bacteria are not passed onto other patients as it promotes antibiotic resistance. If you are MRSA “golden staph”, VRE, CRE or MRAB positive, then isolation precautions will be taken throughout your stay in the hospital.

If you have false teeth or plates, please leave them in. It makes it easier for the anaesthetist to help you breathe as you go off to sleep. If needed, the anaesthetist will remove them after you are asleep, and they will be returned to you when you wake up.

You will have an ID band placed on your wrist and ankle. You will then go through many repetitive identification checks to make sure we have the right patient and that everyone agrees on the operation you are having done. You will be put on a bed and then you will wait until it is time to go to the operating theatre. You may wait a long time. This may be quite stressful and you can get

hungry. Once we have received confirmation that the liver is suitable, you will have an intravenous line (IV) inserted and the first doses of anti-rejection medicines and antibiotics will be given.

It is important to understand that you can complete all this workup and be waiting to go to surgery only to be told that the transplant has been cancelled. These false starts may happen more than once and can be a real emotional rollercoaster. There are several common reasons for not going ahead with a liver transplant which are helpful for you to know. When a potential organ donor is being evaluated, we do many tests, but the final decision to go ahead with the donation cannot be made until our transplant surgeon has examined the liver. Only then, can we be confident that the liver is healthy and alright to use. Once our surgeon calls to say that the donor liver is acceptable, you will then be taken to the operating theatre, but your own liver is not removed until the ‘new’ liver has arrived at the hospital.

The operating theatre

When everything is ready to proceed, you will be wheeled around to the operating room by a theatre orderly and a nurse. This is where you will say goodbye to your relatives. At the end of the operation, the transplant surgeon will call them, letting them know how things have gone and when they can visit you.

The next stop is the anaesthetic room. This is a small room next to the main operating theatre. You will meet the nurse assisting the anaesthetist. You will then have another identification check, you will be very good at reciting your name by this point. The nurse will check that your consent form is completed.

There will be 2 anaesthetists looking after you and if they haven’t met you earlier, they will say hello and go through your medical history again.

You will already have an IV in, so there is nothing else that will go in your body while you are awake. You will then be taken into the main operating theatre. This can be a confronting place. There may be several people in the room, all wearing masks, talking and preparing the theatre. They are all there to look after you.

Most operating theatres are set up in a certain way. There will be an anaesthetic machine with lots of the monitors to keep an eye on you. There will be tables filled with surgical instruments, ready to perform your transplant. There will also be nurses preparing this equipment and counting each and every instrument to ensure that we have everything we need. There may also be junior

medical staff and orderlies. The operating table is in the middle of the room beneath the big lights. They will not be turned on until you are asleep. The operating table is narrow and cold. It is narrow because we need to stand close to you to operate and it won’t be cold for long because during the surgery you will covered with a heating blanket.

The trolley you are on will be placed beside the operating table and if you are mobile, you will be asked to move yourself across and onto it. If you are in pain or not mobile, we will slide you across to the operating table on a special board or float you over on a noisy hover mattress. A lot of activity will then happen around you. We will place padded boards on the side of the bed for you to rest your arms on. Your leg massagers will be hooked up and switched on and you will feel gentle compression on your calves.

You will have 3 stickers placed on your forehead. This helps the anaesthetist monitor how deeply asleep you are. Sticky dots to monitor your heart beat will be placed on your chest. Fluid will be hooked up to your IV line and a clip that reads your pulse placed on your finger. A blood pressure cuff will be wrapped around your arm and the first time it takes your blood pressure, it will inflate very tightly. It will only do that once.

You may already be feeling happy, drowsy or talkative as the anaesthetist may have given you a relaxing medication via the IV. You will not go to sleep yet, but it is unlikely you will remember anything after this until you wake up in intensive care.

The Anaesthetic

Sometimes knowing what happens during an anaesthetic really helps you relax and realize that you are well taken care of while you are asleep. Many people’s greatest fear is the anaesthetic. They worry about vomiting afterward, being aware during surgery and not waking up. Whilst these things very rarely occur, having an anaesthetic is actually far safer than anything you have already done that day, like driving into the hospital.

Once you are asleep, the anaesthetic team will work on your for about 2 hours before the transplant operation can begin.

General anaesthetic consists of 3 phases

1. Going to sleep – similar to taking off in a plane.

Just before you go to sleep, the anaesthetic nurse will ask you to breathe into a mask and fill your lungs with oxygen. This makes sure that you have the maximal amount of oxygen in your blood.

This does not put you to sleep. A white medication called Propofol is then given through your IV. The anaesthetist will ask you to keep your eyes open. As this medication goes into your veins, it can cause a stinging sensation in your arm. This is normal and does not damage you. After this injection you will be asleep in about 10 seconds. Your breathing will temporarily stop and the anaesthetist will take over your breathing for you by blowing oxygen into your lungs. As soon as you are asleep the anaesthetist will give a medication that stops your muscles moving. This has many functions. It allows your throat to relax so the anaesthetist safely place the breathing tube into the windpipe. It also relaxes your abdominal muscles and makes surgery on the abdomen easier. If you have false teeth, they will be removed at this point and returned to you in recovery.

As soon as the muscle relaxer has worked, the anaesthetist will use a special tool called a laryngoscope. This is a smooth spatula with a light that is inserted over your tongue and deep into your throat. The anaesthetist will be able to see your vocal cords and beyond this is your trachea or windpipe. A specially designed hollow tube is placed down the spatula and into the windpipe. A balloon on the end of the tube is inflated by the nurse to fully occlude your airway and stop any vomit or secretions from entering your windpipe.

This is often the trickiest part of the anaesthetic and your life can depend on it. There are many signs the anaesthetist will look for before you go to sleep to predict whether getting this tube down will be difficult or not. If you have a small jaw, previous difficulties with intubation, neck problems, difficulty opening your mouth, the anaesthetist will be ready with a different strategy to get the tube down your throat safely. Because your breathing is our number one priority, occasionally putting the breathing tube down can result in damage to your teeth or cuts to your lips. All care is taken and this is uncommon. Having a tube in your throat can leave it sore and dry for a day or too. This is temporary. You have also have a swollen uvula, the dangly bit at the back of your throat for a few days.