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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.16 no.5 Ribeirão Preto Sept./Oct. 2008 



Liver transplantation: evidence for nursing care1



Karina Dal Sasso MendesI; Cristina Maria GalvãoII

University of Sao Paulo at Ribeirao Preto College of Nursing, WHO Collaborating Center for Nursing Research Development, Brazil:
IRN, M.Sc. in Nursing, e-mail:
IIRN, Associate Professor, e-mail:




Evidence-based practice is the adopted theoretical and methodological framework and the integrative literature review was the research method used for this study. This study aimed to search and evaluate evidence available in literature about scientific knowledge on nursing care to adult patients submitted to liver transplantation during the perioperative period. Lilacs, Medline and Cinahl were used for the search, which resulted in a sample of 20 scientific papers. The results evidenced publications on nursing care to prepare the patient, prevent injuries, on the importance of a documentation system, prevention and early detection of complications, as well as education on immunosuppressive therapeutics, patient education and nursing activities in the pre, intra and postoperative periods, and the nurses' role in providing nutritional and emotional support to patients and family members.

Descriptors: perioperative nursing; nursing care; liver transplantation




Liver transplantation is considered one of the most complex procedures in modern surgery. Its process depends on a complete hospital infra-structure, in addition to a competent multi-professional team in the delivery of care to severely debilitated and immunodepressed patients(1). It is used as a resource to guarantee the survival of patients with irreversible hepatic failure, when there is no other form of treatment available(2).

The preparation of the patient is essential in the perioperative period, and the role of the nursing team is determinant for treatment success. Therefore, the nurse is responsible for the planning and implementation of care delivered to patients and families during the liver transplantation process.

Evidence-based practice (EBP) was selected as the theoretical framework for this study. It consists in defining a problem, searching and critically evaluating the obtained results, in order to provide support for the improvement of health care quality and to decrease costs(3).

The integrative literature review is a research method used to gather and analyze available evidence. It aids in the decision making process by providing interventions that can permit a more effective care and better cost/benefit(4). An advantage of this method is the ability to gather data from different types of research designs, including theoretical and empirical literature(4).

Aiming at providing support for nursing care, the goal of this study was to search and evaluate evidence available in the literature on scientific knowledge related to the nursing care delivered to adult patients submitted to liver transplantation in the perioperative period.



The following stages were followed in the elaboration of the integrative review: identification of the topic, sampling or search in the literature, extraction of data from the included studies, evaluation of studies, interpretation of results and synthesis of knowledge or presentation of integrative review(4-5).

The question guiding the review was: what scientific knowledge, related to the nursing care delivered to adult patients submitted to liver transplantation in the perioperative period, has already been produced?

The selection of articles included in the review was performed in the following databases: Medical Literature Analysis and Retrieval System on-line (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Latin American and Caribbean Health Sciences (LILACS), through the keywords: nursing care, perioperative nursing, perioperative care, nursing, preoperative care, preoperative period, intraoperative care, intraoperative period, postoperative care, postoperative period and liver transplantation. To reduce bias during the search, the keywords included in the Medical Subject Headings (MeSH), in the List of Topical Subheadings of CINAHL Information Systems, and those included in the Virtual Health Library - Health Sciences Descriptors were used.

The inclusion criteria were: articles that address the nursing care delivered to the adult patient submitted to liver transplantation in the perioperative period, published between 1994 and 2004 in English, Spanish or Portuguese. The researchers read the title and abstract of each identified article, with the guiding question and adopted inclusion criteria in mind, to select a final sample of 20 articles, which were fully analyzed.

The extraction of data from the articles was performed with the aid of an instrument proposed by a perioperative nurse(6). For the analysis of the research design and level of evidence, concepts proposed by nursing scholars(7-8) were used.

To facilitate the understanding of evidenced results, the articles included in the review were distributed in categories as follows: nursing care in the preoperative (three articles), intraoperative (two articles), and postoperative (seven articles) periods, patient education (one article), the role of nurses (one article), nutritional support (four articles), and emotional support (two articles).



From the 20 articles included in the review, 15 were written by nurses, two by physicians, one by a nutritionist, one had the collaboration of nutritionists and nurses, and one of physicians and nurses.

Regarding the journals' country of origin, ten studies were published in the United States of America (USA), five were published in Spain, two in Ireland, two in Brazil, and one in England. Thus, 13 studies were written in English, five in Spanish and two in Portuguese.

Only three studies from those analyzed were of evidence level II (strong), that is, randomized controlled clinical trials; six studies were of evidence level IV, while four were descriptive exploratory studies, and two were case studies; five studies presented evidence level VI (experience reports); and six studies were literature reviews, which have no evidence level available according to the adopted framework; the knowledge produced by these latter articles was considered important, however, for the planning of care delivered in liver transplantation.

A synthesis of the articles included in the integrative review, distributed in Tables 1, 2, 3, 4 and 5 according to the established thematic categories, is presented below.



The preoperative period of liver transplantation ranges from the moment the patient enters the waiting list of the Health Secretary to receive a liver from a diseased donor to the moment the patient is called to receive the graft in the hospital.

In Brazil, this period is long and currently takes around three years. The patient with a severe hepatic disease can develop several complications, since such disease can compromise several organic systems. In this period, the patient is periodically supervised by a physician in the outpatient clinic and evaluated by a nurse and other professionals from the multidisciplinary team, such as social workers, nutritionists, psychologists and physiotherapists.

The intraoperative period of liver transplantation is considered one of the most complex moments in the process because, most of the times, the receiver already presents several complications due to the primary disease. Additionally, several factors influence success in this period, among them the conditions of the donated liver, time of ischemia until the new liver implantation, intense hemorrhages that accompany the procedure, and other anesthetic-surgical intercurrences(12-13). In this scenario, interventions implemented by the nurse to prevent lesions are relevant, such as the use of devices to assure adequate surgical positioning and to avoid the occurrence of pressure ulcers.

After the recovery of vital and hepatic functions, patients are kept in a special hospitalization unit for a few days until they are in conditions for discharge. Thus, nursing care in the postoperative period focuses on the implementation of interventions directed at the prevention or early detection of the more frequent complications, such as surgical (Hemoperitoneum, biliary and vascular complications), graft (primary graft failure, acute rejection) and general complications (respiratory, cardiovascular, renal, hematological, metabolic, digestive, and infectious)(14-17). These complications partially depend on the patient's conditions before the liver transplantation.

The administration of medication is an essential activity for the nurse involved in a liver transplantation program. This activity permeates the perioperative period and involves not only the administration of drugs per se, but also a process of education in health, which provides patients, and their families, information to correctly use the medicament therapy at home with the smallest risk possible, especially in relation to the immunosuppressive drugs.

The emergence of immunosuppressive drugs (such as cyclosporine  and tacrolimus) is one of the factors permitting increased life expectancy after liver transplantation, by fighting rejection of the transplanted organ. The nursing team needs to know the indication, mechanisms of action, advantages and disadvantages, administration routes, side effects and necessary care regarding the use of this therapy(20).

Teaching patients is a nurse's difficult task because it demands the implementation of interventions that cause changes in the patients' life style, affecting their personal values and beliefs. For the patient to achieve an independent life style after the transplantation, the nurse should provide knowledge related to nutrition, medication, monitoring of vital signs, and registration of information. The education promotes the development of cognitive, psychomotor and attitudinal abilities, with which patients and families can guarantee the continuity of care and an active participation in the treatment(21).

Nurses work on the pre, intra and postoperative periods of liver transplantation, with specific activities, whether in the outpatient clinic, in the hospitalization unit, in the surgical unit or in the intensive therapy unit. The planning, implementation and evaluation of care in transplanted patients are part of the coordinating nurse's role. This professional acts as a link in the multidisciplinary team's communication, and effective communication is essential in care delivery to patients and families(22). Although the nurse is only one of the members contributing to the care for patients with liver transplantation, his role is essential for treatment success.

Patients who present a terminal hepatic disease and have the liver transplantation as the only option to obtain cure or survival, usually present an aggravated nutritional state. The liver is the organ responsible for synthesizing and storing several vital nutrients for the metabolism. However, it does not exert its functions adequately when sick, which reflects on the nutrition of patients who await a transplantation. Patients can present malnutrition, lose weight because of poor ingestion of food, poor absorption of nutrients, and impaired hepatic function, which aggravates their health state.

Malnutrition has to be treated before transplantation, so that chances of a positive result are increased and chances of any postoperative complications are decreased(23). This problem is treated by the multidisciplinary team: the nutritionist evaluates the minimum nutritional conditions for the patient to bear the surgical stress, while the social worker evaluates the patient's socio-economic conditions to assure the family has the means to acquire adequate food. The psychologist, on the other hand, evaluates the patient's emotional state and factors that can lead to non-adherence to an appropriate diet; it is the physician's role to prescribe medication, or even the use of an enteral or parenteral diet. Finally, the nurse frequently evaluates the development of the patient's nutritional state, observing and recording physiological functions, verifying weight and waist circumference, acceptance of the diet and preferences(24-26).

The nurse, as a member of the multidisciplinary team, spends most time with patients and is the element capable of keeping an affective bond with patients and families, especially in a liver transplantation program in which the whole process involves a long period of time. Thus, patients establish with nurses a relationship of trust, respect, and freedom to share their anxiety and fears. Many of them experience moments of anguish, anxiety, fantasy and doubts, because they do not know how the whole transplant process will develop. Myths and beliefs related to the organ that will be implanted, gender, age, the donor origin, a potential rejection that can end the dream of having a normal life, all these elements and others influence the emotional state of those awaiting a liver transplantation. Therefore, the multidisciplinary team plays an essential role in clarifying all patients' and families' doubts and questions. The psychologist's role in this process is essential, as well as that of the nurse, because the nurse can, through exchange of information, bring new elements for the psychological and, many times, psychiatric treatment, because some patients develop disorders that require specialized treatment(27-29).



After this integrative review was carried out, the relevance of the nurse's role in liver transplantation programs became clear. This professional is responsible for the management of care delivered to patients and families and performs care, administrative, educational and research activities, which are of fundamental importance for the success of liver transplantation. Thus, the researchers consider the fundamental importance of research development and/or the use of its results to support clinical practice and, in this scenario, evidence-based practice has a lot to offer.



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Recebido em: 27.12.2007
Aprovado em: 8.8.2008



1 Article extracted from Master Dissertation

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