Transplant critical care: standards for intensive care of the patient with liver failure before and after transplantation

Delirium Among Adults Undergoing Solid Organ Transplantation

Purpose of Review

To summarize the research on post-operative delirium among patients undergoing solid organ transplantation in efforts to improve recognition, evaluation, and management, as well as highlight areas for future research.

Recent Findings

Delirium is a common complication in patients with organ failure before and after undergoing solid organ transplant (range: 4.7-47%). However, it is frequently unrecognized and underdiagnosed-even among those closely monitored after major surgery-given that its manifestation is often variable and inconsistent. Delirium has multifactorial etiologies comprising of a complex mix of predisposing recipient, donor, and transplant factors, as well as intraoperative and perioperative factors. Evidence suggests that delirium risk increases with presence of a greater number of such risk factors, and can lead to adverse outcomes such as increased hospital length of stay, time in the ICU, time on mechanical ventilators, graft dysfunction, graft loss, and mortality. Though no trials have been conducted among transplant populations specifically, delirium has been shown to be preventable among hospitalized older adults generally. Multicomponent, primary prevention strategies designed to target multiple risk factors of delirium, such as cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration, have been identified as most effective. Whether these approaches translate to improvements in quality of life and long-term health outcomes among patients with organ failure before and after transplantation is yet to be determined.

Summary

Delirium is an important, common, yet potentially preventable complication among patients with organ failure. Future studies are needed to test the efficacy of multicomponent, primary prevention strategies on long-term health outcomes among these vulnerable populations.

Liver transplantation in Italy in the era of COVID 19: reorganizing critical care of recipients

Transplant programs have been severely disrupted by the COVID-19 pandemic. Italy was one of the first countries with the highest number of deaths in the world due to SARS-CoV-2. Here we propose a management model for the reorganization of liver transplant (LT) activities and policies in a local intensive care unit (ICU) assigned to liver transplantation affected by restrictions on mobility and availability of donors and recipients as well as health personnel and beds. We describe the solutions implemented to continue transplantation activities throughout a given pandemic: management of donors and recipients' LT program, ICU rearrangement, healthcare personnel training and monitoring to minimize mortality rates of patients on the waiting list. Transplantation activities from February 22, 2020, the data of first known COVID-19 case in Italy's Emilia Romagna region to June 30, 2020, were compared with the corresponding period in 2019. During the 2020 study period, 38 LTs were performed, whereas 41 were performed in 2019. Patients transplanted during the COVID-19 pandemic had higher MELD and MELD-Na scores, cold ischaemia times, and hospitalization rates (p < 0.05); accordingly, they spent fewer days on the waitlist and had a lower prevalence of hepatocellular carcinoma (p < 0.05). No differences were found in the provenance area, additional MELD scores, age of donors and recipients, BMI, re-transplant rates, and post-transplant mortality. No transplanted patients contracted COVID-19, although five healthcare workers did. Ultimately, our policy allowed us to continue the ICU's operations by prioritizing patients hospitalized with higher MELD without any case of transplant infection due to COVID-19.

Enhanced recovery after surgery protocols in patients undergoing liver transplantation: A retrospective comparative cohort study

INTRODUCTION

Enhanced Recovery after Surgery (ERAS) is a multimodal pathway to overcome the deleterious effect of perioperative stress, and has been applied to different surgeries including liver resection surgery. Explorative studies have shown the safety of some ERAS measures in liver transplantation patients, although no consensus was reached. This study aimed to evaluate the effect of ERAS protocols compared with conventional care in patients undergoing liver transplantation.

METHOD

All patients (aged 16-70) undergoing liver transplantation for their first time in our centers between January 2016 and July 2019 were retrospectively reviewed and included into this cohort study. They were divided into ERAS group and conventional group depending on the perioperative protocols. Operative time, anhepatic phase time, intraoperative blood loss, intraoperative hypothermia, Surgical Intensive Care Unit (SICU) stay, postoperative complications, pain score, postoperative hospital stay, and mortality were compared between the two groups.

RESULTS

A total of 40 and 53 patients were included in the ERAS and conventional groups, respectively. The ERAS group had shorter SICU stay (2 vs. 4 days, p < 0.001) and postoperative hospital stay (14.5 vs. 16 days, p < 0.001) compared with the conventional group. Intraoperative hypothermia rate, postoperative pulmonary complications rate, and postoperative pain score were lower in the ERAS group (p < 0.05). There were no differences in operative time, anhepatic phase time, blood loss, mortality, reintubation, lower extremity venous thrombosis and other complications incidence between the two groups.

CONCLUSION

ERAS procedures effectively improved the patients' recovery, alleviated the suffering and pulmonary complications, and reduced SICU stay and postoperative hospital stay, without increasing incidence of other complications or reintubation. As a safe and feasible choice, ERAS protocols may also have some socioeconomic advantages, which should be addressed in further prospective cohort or clinical trial studies.

Transplant Critical Care: Is there a Need for Sub-specialized Units? - A Perspective

The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.

Delayed introduction of immunosuppressive regimens in critically ill patients after liver transplantation

BACKGROUND

The manipulation of immunosuppression therapy remains challenging in patients who develop infectious diseases or multiple organ dysfunction after liver transplantation. We evaluated the outcomes of delayed introduction of immunosuppression in the patients after liver transplantation under immune monitoring with ImmuKnow assay.

METHODS

From March 2009 to February 2014, 225 consecutive liver recipients in our institute were included. The delayed administration of immunosuppressive regimens was attempted in 11 liver recipients with multiple severe comorbidities.

RESULTS

The median duration of non-immunosuppression was 12 days (range 5-58). Due to the infectious complications, the serial ImmuKnow assay showed a significantly low ATP level of 64±35 ng/mL in the early period after transplantation. With the development of comorbidities, the ImmuKnow value significantly increased. However, the acute allograft rejection developed when a continuous distinct elevation of both ATP and glutamyltranspeptidase levels was detected. The average ATP level measured just before the development of acute rejection was 271±115 ng/mL.

CONCLUSIONS

The delayed introduction of immunosuppressive regimens is safe and effective in management of critically ill patients after liver transplantation. The serial ImmuKnow assay could provide a reliable depiction of the dynamics of functional immunity throughout the clinical course of a given patient.

Avoiding ICU Admission by Using a Fast-Track Protocol Is Safe in Selected Adult-to-Adult Live Donor Liver Transplant Recipients

Background

We evaluated patient characteristics of live donor liver transplant (LDLT) recipients undergoing a fast-track protocol without intensive care unit (ICU) admission versus LDLT patients receiving posttransplant ICU care.

Methods

Of the 153 LDLT recipients, 46 patients were included in our fast-track protocol without ICU admission. Both, fast-tracked patients and ICU-admitted patients were compared regarding donor and patient characteristics, perioperative characteristics, and postoperative outcomes and complications. In a subgroup analysis, we compared fast-tracked patients with patients who were admitted in the ICU for less than 24 hours.

Results

Fast-tracked versus ICU patients had a lower model for end-stage liver disease score (13 ± 4 vs 18 ± 7; P < 0.0001), lower preoperative bilirubin levels (51 ± 50 μmol/L vs 119.4 ± 137.3 μmol/L; P < 0.001), required fewer units of packed red blood cells (1.7 ± 1.78 vs 4.4 ± 4; P < 0.0001), and less fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 5; P < 0.0001) during transplantation. Regarding postoperative outcomes, fast-tracked patients presented fewer bacterial infections within 30 days (6.5% [3] vs 29% [28]; P = 0.002), no episodes of pneumonia (0% vs 11.3% [11]; P = 0.02), and less biliary complications within the first year (6% [3] vs 26% [25]; P = 0.001). Also, fast-tracked patients had a shorter posttransplant hospital stay (10.8 ± 5 vs 21.3 ± 29; P = 0.002). In the subgroup analysis, fast-tracked vs ICU patients admitted for less than 24 hours had lower requirements of packed red blood cells (1.7 ± 1.78 vs 3.9 ± 4; P = 0.001) and fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 4.5; P = 0.0001).

Conclusions

Fast-track of selected patients after LDLT is safe and feasible. An objective score to perioperatively select LDLT recipients amenable to fast track is yet to be determined.

Octogenarian donors in liver transplantation grant an equivalent perioperative course to ideal young donors

BACKGROUND

Use of grafts from very old donors for liver transplantation is controversial.

AIM

To compare the perioperative course of patients receiving liver grafts from young ideal vs octogenarian donors.

METHODS

Analysis of the perioperative course of patients receiving liver grafts from young, ideal (18-39 years) vs octogenarian (≥80years) deceased donors between 2001 and 2014.

RESULTS

346 patients were studied: 179 (51.7%) received grafts aged 18-39 years whereas 167 (48.3%) received a graft from a donor aged ≥80years. Intra-operative cardiovascular (p=0.2), coagulopathy (p=0.5) and respiratory (p=1.0) complications and incidence of reperfusion syndrome (p=0.3) were similar. Patients receiving a young graft required more fresh frozen plasma units (p≤0.03) but did not differ for the need of packed red cells (p=0.2) and platelet (p=0.3) transfusions. Median ICU stay was identical (p=0.4). Patients receiving octogenarian vs young grafts did not differ in terms of death or re-transplant (p=1.0) during the ICU stay. Similar cardiovascular, respiratory, renal, infectious and neurological postoperative complication rates were observed in the two groups.

CONCLUSIONS

Octogenarian donors in liver transplantation grant an equivalent perioperative course to ideal young donors.

Critical Care of the Liver Transplant Recipient

Patient survival following orthotopic liver transplantation has greatly increased following improvements in surgical technique, anesthetic care, and immunosuppression. The critical care of the liver transplant recipient has paralleled these improvements, largely thanks to input from multidisciplinary teams and institution-specific protocols guiding management and care. This article provides an overview of the approach to critical care of the postoperative adult liver transplant recipient outlining common issues faced by the intensivist. Approaches to extubation and hemodynamic assessment are described. The provision of appropriate immunosuppression, infection prophylaxis, and nutrition is addressed. To aid prompt diagnosis and treatment, intensivists must be aware of postoperative complications of bleeding, primary nonfunction, delayed graft function, vascular thromboses, biliary complications, rejection, and organ dysfunction.

Avoiding stay in the intensive care unit after liver transplantation: a score to assign location of care

Select liver transplantation (LT) recipients in our program are transferred from operating room to postanesthesia care unit for recovery and extubation with transfer to the ward, completely eliminating an intensive care unit (ICU) stay. Developing a reliable method to determine patients suitable for fast-tracking would be of practical benefit to centers considering this practice. The aim of this study was to create a fast-tracking probability score that could be used to predict successful assignment of care location after LT. Recipient, donor and operative characteristics were assessed for independent association with successful fast-tracking to create a probability score. Of the 1296 LT recipients who met inclusion criteria, 704 (54.3%) were successfully fast-tracked and 592 (45.7%) were directly admitted to the ICU after LT. Based on nine readily available variables at the time of LT, we created a scoring system that classified patients according to the likelihood of being successfully fast-tracked to the surgical ward, with an area under the curve (AUC) of 0.790 (95% CI: 0.765-0.816). This score was validated in an independent group of 372 LT with similar AUC. We describe a score that can be used to predict successful fast-tracking immediately after LT using readily available clinical variables.

Anesthesia for Liver Transplantation

Orthotopic liver transplantation is the only definitive treatment for end-stage liver disease. More than 6000 procedures are performed in the United States annually with excellent survival rates. The shortage of donor organs leads to continued interest in techniques to enlarge the potential donor pool. Patients presenting for liver transplant suffer from important cardiovascular, respiratory, renal, neurological, and gastroenterological comorbidity. In the Western world, liver failure is increasingly caused by steatohepatitis, and transplant candidates are thus becoming older and more comorbid. The role of the transplant anesthesiologist is highly important in the preoperative assessment, intraoperative management, and postoperative care of these complex and sick patients. Appropriate investigation and management of comorbidities such as coronary artery disease and portopulmonary hypertension is controversial and differs between programs. The transplant procedure is a major surgery, and although massive transfusion is no longer commonplace, there is potential for significant hemodynamic instability, coagulopathy, and metabolic disturbance. Liver transplant surgery can be divided into the preanhepatic phase, the anhepatic phase, and the reperfusion phase, with important anesthetic considerations at each point.  An understanding of the surgical techniques used for vascular exclusion of the liver and the role of venovenous bypass is crucial for the anesthesiologist. Recent trends in perioperative care include the use of antifibrinolytic drugs and point-of-care coagulation tests, intraoperative renal replacement therapy, and “fast-track” extubation and postoperative care. Care of patients with fulminant hepatic failure or those receiving split-liver grafts requires special consideration.

Anesthesia for liver transplantation in US academic centers: institutional structure and perioperative care

Investigators at a single institution have shown that the organization of the anesthesia team influences patient outcomes after liver transplant surgery. Little is known about how liver transplant anesthesiologists are organized to deliver care throughout the United States. Therefore, we collected quantitative survey data from adult liver transplant programs in good standing with national governing agencies so that we could describe team structure and duties. Information was collected from 2 surveys in a series of quantitative surveys conducted by the Liver Transplant Anesthesia Consortium. All data related to duties, criteria for team membership, interactions/communication with the multidisciplinary team, and service availability were collected and summarized. Thirty-four of 119 registered transplant centers were excluded (21 pediatric centers and 13 centers not certified by national governing agencies). Private practice sites (26) were later excluded because of a poor response rate. There were minimal changes in the compositions of the programs between the 2 surveys. All academic programs had distinct liver transplant anesthesia teams. Most had set criteria for membership and protocols outlining the preoperative evaluation, attended selection committees, and were always available for transplant surgery. Fewer were involved in postoperative care or were available for patients needing subsequent surgery. Most trends were associated with the center volume. In conclusion, some of the variance in team structure and responsibilities is probably related to resources available at the site of practice. However, similarities in specific duties across all teams suggest some degree of self-initiated specialization.

Is a mandatory intensive care unit stay needed after liver transplantation? Feasibility of fast-tracking to the surgical ward after liver transplantation

The continuation of hemodynamic, respiratory, and metabolic support for a variable period after liver transplantation (LT) in the intensive care unit (ICU) is considered routine by many transplant programs. However, some LT recipients may be liberated from mechanical ventilation shortly after the discontinuation of anesthesia. These patients might be appropriately discharged from the postanesthesia care unit (PACU) to the surgical ward and bypass the ICU entirely. In 2002, our program started a fast-tracking program: select LT recipients are transferred from the operating room to the PACU for recovery and tracheal extubation with a subsequent transfer to the ward, and the ICU stay is completely eliminated. Between January 1, 2003 and December 31, 2007, 1045 patients underwent LT at our transplant program; 175 patients were excluded from the study. Five hundred twenty-three of the remaining 870 patients (60.10%) were fast-tracked to the surgical ward, and 347 (39.90%) were admitted to the ICU after LT. The failure rate after fast-tracking to the surgical ward was 1.90%. The groups were significantly different with respect to the recipient age, the raw Model for End-Stage Liver Disease (MELD) score at the time of LT, the recipient body mass index (BMI), the retransplantation status, the operative time, the warm ischemia time, and the intraoperative transfusion requirements. A multivariate logistic regression analysis revealed that the raw MELD score at the time of LT, the operative time, the intraoperative transfusion requirements, the recipient age, the recipient BMI, and the absence of hepatocellular cancer/cholangiocarcinoma were significant predictors of ICU admission. In conclusion, we are reporting the largest single-center experience demonstrating the feasibility of bypassing an ICU stay after LT.