The day of the transplant

 

PREPARATION IN THE OPERATING ROOM

You can accompany your child up to the entrance to the operating suite. The anaesthesiologist meets you at the entrance of the operating suite and then accompanies your child into the operating room. Your child is moved from the bed onto a stretcher and then onto the operating table. A mask is placed on his face to give him an oxygen supplementation to breathe. The anaesthesiologist administers the drug intended to anaesthetise your child via an intravenous line. When your child has fallen asleep, a tube will be inserted into the trachea in order to control respiration during the operation. A bladder catheter is placed to drain the urine. A nasogastric tube is inserted through the nose into the stomach to drain stomach secretions. A central venous catheter is inserted into a large vein of the neck or the shoulder to help the anaesthesiologist administer the drugs and fluids during the graft. A small intra-arterial catheter is inserted into an artery of the wrist for blood pressure control. Other intravenous catheters are also inserted into the veins of the arms or the legs so that your child can be given blood and fluids during the graft.

 

THE OPERATION

Your child’s operation starts with the explantation of his diseased liver, when the removal team has returned to the operating suite with a perfect graft. The new liver is positioned and the blood vessels of the donor’s liver are connected with those of the recipient (vascular anastomoses) by suture. Then, the surgeon stitches the bile duct of the new liver to an intestinal loop in order to enable the bile to be drained (biliodigestive anastomosis). The vascular anastomoses performed depend on the type of graft (whole liver or shared liver).

At the end of the operation, the skin around the incision is closed using invisible sutures and covered by a transparent dressing (Tegaderm®) that enables the wound to be observed daily. This dressing normally is not changed for 3 weeks and is removed after this period of time only. A drain comes out of the right side of your child through which the postoperative abdominal secretions are drained. Your child will have a large scar of the shape of a Mercedes star: one part of the scar runs across the abdomen above the navel and the other part is located in the middle of the stomach to the sternum.

Echographies are performed during and at the end of the operation in order to verify the good blood flow in the liver. Your child is then brought from the operating room directly to the paediatric intensive care unit. The nurses of the operating room keep you and your family informed during the procedure, about once every four hours. The surgeon responsible for the graft will talk to you as soon as the child has arrived in the paediatric intensive care unit.

 

THE PAEDIATRIC INTENSIVE CARE UNIT

The intensive care nurses need one hour or more directly after the graft to perform blood analyses and to complete certain examinations. You will only be able to see your child after all the examinations have been completed.

In the intensive care unit, your child normally is “alone” in a room and a nurse responsible for your child alone who is available 24/7 is always present. Visits are unlimited for parents and if you wish so, you can be with your child 24/7. However, we encourage you to also take some time for yourself, to have a rest, to have something to eat and drink and even to just get some fresh air. Visits of persons other than the parents are very limited; regarding visits of brothers and sisters or grandparents, for example, we ask you to speak to your nurse first. In any case, only two visitors are allowed at the same time. The visitors must go to the desk of the intensive care unit before entering the child’s room and respect basic hygiene measures: disinfection of the hands when entering and leaving the room and not touching any observation equipment. Your child must not see any sick visitor. It is forbidden to eat or drink in the room.

Please keep in mind that your child needs much rest as long as he is in the paediatric intensive care unit and that he will have all the time in the world to meet his family and friends after having left the hospital. Sometimes, it is useful to ask a member of the family to keep everybody informed of the development of the situation so that you can devote yourself completely to your child. When it turns out that it is difficult for you to control the number of visitors who want to see your child, ask the nurse to help you.

Directly after the transplant, your child will be kept in artificial sleep, on artificial respiration (with a ventilator) so that he stays calm and free from pain. This artificial sleep may last for 24 hours or more if your child’s condition requires it. Your child is connected to several pieces of observation equipment, the “monitorings”, which measure his vital signs. The nurse of the paediatric intensive care unit regularly checks these vital signs, that is your child’s heart rate, respiratory rate, blood pressure and temperature. They are also displayed on a wall-mounted monitor. A sensor attached to a finger or a toe measures the oxygen content of your child’s blood (pulse oximetry). Heart rate and rhythm are continuously checked by sensors placed on the chest or the back of your child.

Some of the tubes attached to your child have been placed in the operating room. The endotracheal tube or breathing tube that has been inserted through his nose is attached to his cheek using an adhesive tape. This tube is connected to the ventilator and helps the child breathe until his complete awakening. It also enables the supply of supplement oxygen and humidity to help him breathe on his own.

The intravenous lines installed in you child’s arms, legs or neck are to administer drugs or fluid and to feed him. They are also used to take blood samples. The nasogastric tube runs through the nose and descends into the stomach to help remove the digestive juice it produces. The nasogastric suction tube is generally removed 2 to 3 days after the surgical procedure. After this tube has been removed, your child can start to drink. When he tolerates the fluids for about one day, he can then start to consume liquid or solid food (when he ate solid food before the graft). Intravenous nutrition will be stopped as soon as your child eats enough food to ensure consumption of an adequate quantity of nutrients on his own. It is sometimes possible that your child does not immediately manage to eat; in this case, he will have a small nasogastric tube to feed him in the beginning.

Near the scar, there is a drain that comes out of the abdomen on the right side and that leads into a bag. This drain generally is to drain the fluid that is in the abdomen, in the beginning it is red and then it becomes yellowish. A bladder catheter has been inserted to drain the urine; it is removed several days after the graft.

The nurses of the paediatric intensive care unit and the physicians of that unit cooperate closely with the liver transplant team to care for your child. They meet once or twice every day to discuss your child’s condition.

The duration of a child’s stay in the intensive care unit ranges from some days to four weeks. There are a large number of complications and problems that might occur and checks and examinations are carried out very frequently.

After this stay, your child will be transferred to the paediatric surgical ward, that you and your child already know.