Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to medium-income countries

Enhanced recovery after surgery and practical application to liver transplantation

There is a growing support for the use of protocols that incorporate multiple steps aimed at reducing the time patients require to regain health. A recurring limitation is the variable outcomes of these protocols with more or less success at the sites at which they are instituted. This review examines the essential building blocks needed to launch a successful ERAS protocol. It addresses why there are differences in outcome measures between centers such as the length of stay and the cost of care even if the protocols and patient populations are similar.

Anaesthetic management of organ transplant patients

In this paper we will describe anaesthetic management of solid organ and reconstructive transplantation (RT) patients. We will focus on similar underlying principles of reperfusion, ischaemic-reperfusion injury, preconditioning and extracorporeal donor organ preservation. Special concerns for anaesthetic management of these patients need to focus on pre-assessment, pre-operative optimisation, vascular access, fluid management, blood and products replacement, cardiovascular monitoring, use of inotropes and vasoconstrictors, maintaining electrolyte balance and regional anaesthesia. Despite the complexity and long duration of transplant procedures, fast-tracking to the surgical ward after transplantation is becoming more popular and its benefits are well recognised.

Rapid Recovery of Liver Transplantation Recipients by Implementation of Fast-Track Care Steps: What Is Holding Us Back?

A body of scientific studies has shown that early extubation is safe and cost-effective in a large number of liver transplant (LT) recipients including pediatric patients. However, fast-track practices are not universally accepted, and debate still lingers about whether these interventions are safe and serve the patients' best interest. In this article, we focus on reasons why physicians still have a persistent, although diminishing, reluctance to adopt fast-track protocols. We stress the importance of collection/analysis of perioperative data, adoption of a consensus-based standardized protocol for perioperative care, and formation of LT anesthesia focused teams and leadership. We conclude that the practice of early extubation and fast-tracking after LT surgery could help improve anesthesia performance, safety, and cost-effectiveness.

Thrombin activatable fibrinolysis inhibitor as a bleeding predictor in liver transplantation: a pilot observational study

OBJECTIVE

To correlate the levels of thrombin activatable fibrinolysis inhibitor in the immediate postoperative period and at 24 hours postoperatively with the volume of intraoperative bleeding.

METHODS

Twenty-one patients allocated immediately before (elective or emergency) liver transplantation were analyzed. Blood samples were collected for thrombin activatable fibrinolysis inhibitor analysis at three different time points: immediately before liver transplantation (preoperative thrombin activatable fibrinolysis inhibitor), immediately after the surgical procedure (immediate postoperative thrombin activatable fibrinolysis inhibitor), and 24 hours after surgery (thrombin activatable fibrinolysis inhibitor 24 hours after surgery). The primary outcome of the study was to correlate the preoperative and immediate postoperative levels of thrombin activatable fibrinolysis inhibitor with intraoperative blood loss.

RESULTS

There was a correlation between the preoperative thrombin activatable fibrinolysis inhibitor levels and bleeding volume (ρ = -0.469; p = 0.05) but no correlation between the immediate postoperative thrombin activatable fibrinolysis inhibitor and bleeding volume (ρ = -0.062; p = 0.79). No variable included in the linear regression analysis (prehemoglobin, prefibrinogen and preoperative thrombin activatable fibrinolysis inhibitor) was a bleeding predictor. There was a similar trend in the variation between the levels of thrombin activatable fibrinolysis inhibitor at the three different time points and fibrinogen levels. Patients who died within 6 months (14.3%) showed decreased preoperative and immediate postoperative levels of thrombin activatable fibrinolysis compared with survivors (preoperative: 1.3 ± 0.15 versus 2.55 ± 0.53, p = 0.06; immediate postoperative: 1.2 ± 0.15 versus 2.5 ± 0.42, p = 0.007).

CONCLUSION

There was a moderate correlation between preoperative thrombin activatable fibrinolysis inhibitor and intraoperative bleeding in liver transplantation patients, although the predictive role of this variable independent of other variables remains uncertain. Preoperative and immediate postoperative thrombin activatable fibrinolysis inhibitor levels may have a role in the survival prognosis of this population; however, this possibility requires confirmation in further studies with larger sample sizes.

Predicting early discharge from hospital after liver transplantation (ERDALT) at a single center: a new model

BACKGROUND & RATIONALE

Limited information related to Liver Transplantation (LT) costs in South America exists. Additionally, costs analysis from developed countries may not provide comparable models for those in emerging economies. We sought to evaluate a predictive model of Early Discharge from Hospital after LT (ERDALT = length of hospital stay ≤ 8 days). A predictive model was assessed based on the odds ratios (OR) from a multivariate regression analysis in a cohort of consecutively transplanted adult patients in a single center from Argentina and internally validated with bootstrapping technique.

RESULTS

ERDALT was applicable in 34 of 289 patients (11.8%). Variables independently associated with ERDALT were MELD exception points OR 1.9 (P = 0.04), surgery time < 4 h OR 3.8 (P = 0.013), < 5 units of blood products consumption (BPC) OR 3.5 (P = 0.001) and early weaning from mechanical intubation OR 6.3 (P = 0.006). Points in the predictive scoring model were allocated as follows: MELD exception points (absence = 0 points, presence = 1 point), surgery time < 4 h (0-2 points), < 5 units of BPC (0-2 points), and early weaning (0-3 points). Final scores ranged from 0 to 8 points with a c-statistic of 0.83 (95% CI 0.77-0.90; P < 0.0001). Transplant costs were significantly lower in patients with ERDALT (median $23,078 vs. $28,986; P < 0.0001). Neither lower patient and graft survival, nor higher rates of short-term re-hospitalization and acute rejection events after discharge were observed in patients with ERDALT. In conclusion, the ERDALT score identifies patients suitable for early discharge with excellent outcomes after transplantation. This score may provide applicable models particularly for emerging economies.

Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation

BACKGROUND

The ability to predict transfusion requirements may improve perioperative bleeding management as an integral part of a patient blood management program. Therefore, the aim of our study was to evaluate preoperative thromboelastometry as a predictor of transfusion requirements for adult living donor liver transplant recipients.

METHODS

The correlation between preoperative thromboelastometry variables in 100 adult living donor liver transplant recipients and intraoperative blood transfusion requirements was examined by univariate and multivariate linear regression analysis. Thresholds of thromboelastometric parameters for prediction of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusion requirements were determined with receiver operating characteristics analysis. The attending anesthetists were blinded to the preoperative thromboelastometric analysis. However, a thromboelastometry-guided transfusion algorithm with predefined trigger values was used intraoperatively. The transfusion triggers in this algorithm did not change during the study period.

RESULTS

Univariate analysis confirmed significant correlations between PRBCs, FFP, platelets or cryoprecipitate transfusion requirements and most thromboelastometric variables. Backward stepwise logistic regression indicated that EXTEM coagulation time (CT), maximum clot firmness (MCF) and INTEM CT, clot formation time (CFT) and MCF are independent predictors for PRBC transfusion. EXTEM CT, CFT and FIBTEM MCF are independent predictors for FFP transfusion. Only EXTEM and INTEM MCF were independent predictors of platelet transfusion. EXTEM CFT and MCF, INTEM CT, CFT and MCF as well as FIBTEM MCF are independent predictors for cryoprecipitate transfusion. Thromboelastometry-based regression equation accounted for 63% of PRBC, 83% of FFP, 61% of cryoprecipitate, and 44% of platelet transfusion requirements.

CONCLUSION

Preoperative thromboelastometric analysis is helpful to predict transfusion requirements in adult living donor liver transplant recipients. This may allow for better preparation and less cross-matching prior to surgery. The findings of our study need to be re-validated in a second prospective patient population.

Intraoperative care of the transplant patient

Patients undergoing abdominal organ transplantation have extensive comorbidities that can affect many organ systems including the cardiovascular system. Intraoperative anesthesia care can be very challenging and requires thorough understanding of the disease specific physiology as well as knowledge of the comorbidities and the surgical procedure. There is no approach to intraoperative anesthesia care that will work equally well for every center but standardization of protocols for each transplant center will improve patient care and safety and ultimately contributes to superior outcomes. In this article we provide background and suggestions that will help with the development of standardized protocols for intraoperative management.

Clinical practice of early extubation after liver transplantation

BACKGROUND

Anesthetic practices such as early tracheal extubation facilitate postoperative recovery. Early extubation after liver transplantation has been adopted by some centers in the recent two decades. No universal clinical guidelines are used and questions remain. This review aimed to address the current status of early extubation after liver transplantation.

DATA SOURCES

A literature search of MEDLINE and ISI Web of Knowledge databases was performed using terms such as liver transplantation, early extubation, immediate tracheal extubation, fast tracking or fast track anesthesia and postoperative tracheal extubation. Additional papers were identified by a manual search of the references in the key articles.

RESULTS

Review of the available literature provided an insight into the definition, evolution, advantages and risks of early extubation, and anesthetic techniques that prompt early extubation in liver transplant patients. Early extubation has proved to be feasible and safe in these patients, but the outcomes are still uncertain.

CONCLUSIONS

Early extubation after liver transplantation is feasible, safe and cost-effective in the majority of patients and has been increasingly accepted as an option for conventional postoperative ventilation. Comprehensive and individualized evaluation of the patient's condition before extubation by an experienced anesthesiologist is the cornerstone of success. Understanding of its effect on the outcome remains incomplete. In the future, additional trials are required to establish universal early extubation guidelines and to determine its benefits for patients and practitioners.

Liver transplantation: Advances and perioperative care

Liver transplantation is one of the treatments for many-life threatening liver diseases. Numerous advances in liver transplant surgery, anaesthesia and perioperative care have allowed for an increasing number of these procedures. The purpose of this review is to consider some of the important advances in perioperative care of liver transplant patients such as pre-operative evaluation, intraoperative monitoring and management and early extubation. A PubMed and EMBASE search of terms “Anaesthesia” and “Liver Transplantation” were performed with filters of articles in “English”, “Adult” and relevant recent publications of randomised control trial, editorial, systemic review and non-systemic review were selected and synthesized according to the author's personal and professional perspective in the field of liver transplantation and anaesthesia. The article outlines strategies in organ preservation, training and transplant database for further research.