1
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Giabicani M, Joly P, Sigaut S, Timsit C, Devauchelle P, Dondero F, Durand F, Froissant PA, Lamamri M, Payancé A, Restoux A, Roux O, Thibault-Sogorb T, Valainathan SR, Lesurtel M, Rautou PE, Weiss E. Predictive role of hepatic venous pressure gradient in bleeding events among patients with cirrhosis undergoing orthotopic liver transplantation. JHEP Rep 2024; 6:101051. [PMID: 38699073 PMCID: PMC11060951 DOI: 10.1016/j.jhepr.2024.101051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 01/31/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Background & Aims Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes. The proportion of this risk related to portal hypertension is unclear. Hepatic venous pressure gradient (HVPG) is the gold standard for estimating portal hypertension. The aim of this study was to analyze the ability of HVPG to predict intraoperative major bleeding events during OLT in patients with cirrhosis. Methods We retrospectively analyzed a prospective database including all patients with cirrhosis who underwent OLT between 2010 and 2020 and had liver and right heart catheterizations as part of their pre-transplant assessment. The primary endpoint was the occurrence of an intraoperative major bleeding event. Results The 468 included patients had a median HVPG of 17 mmHg [interquartile range, 13-22] and a median MELD on the day of OLT of 16 [11-24]. Intraoperative red blood cell transfusion was required in 72% of the patients (median 2 units transfused), with a median blood loss of 1,000 ml [575-1,500]. Major intraoperative bleeding occurred in 156 patients (33%) and was associated with HVPG, preoperative hemoglobin level, severity of cirrhosis at the time of OLT (MELD score, ascites, encephalopathy), hemostasis impairment (thrombocytopenia, lower fibrinogen levels), and complications of cirrhosis (sepsis, acute-on-chronic liver failure). By multivariable regression analysis with backward elimination, HVPG, preoperative hemoglobin level, MELD score, and tranexamic acid infusion were associated with the primary endpoint. Three categories of patients were identified according to HVPG: low-risk (HVPG <16 mmHg), high-risk (HVGP ≥16 mmHg), and very high-risk (HVPG ≥20 mmHg). Conclusions HVPG predicted major bleeding events in patients with cirrhosis undergoing OLT. Including HVPG as part of pre-transplant assessment might enable better anticipation of the intraoperative course. Impact and implications Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes but the proportion of this risk related to portal hypertension is unclear. Our work shows that hepatic venous pressure gradient (HVPG), the gold standard for estimating portal hypertension, is a strong predictor of major bleeding events and blood loss volume in patients with cirrhosis undergoing OLT. Three groups of patients can be identified according to their risk of major bleeding events: low-risk patients with HVPG <16 mmHg, high-risk patients with HVPG ≥16 mmHg, and very high-risk patients with HVPG ≥20 mmHg. HVPG could be systematically included in the pre-transplant assessment to anticipate intraoperative course and tailor patient management.
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Affiliation(s)
- Mikhael Giabicani
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Paris, France
| | - Pauline Joly
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Stéphanie Sigaut
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Clara Timsit
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Pauline Devauchelle
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Fédérica Dondero
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - François Durand
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | | | - Myriam Lamamri
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Audrey Payancé
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Aymeric Restoux
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Olivier Roux
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | | | - Shantha Ram Valainathan
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Mickaël Lesurtel
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Emmanuel Weiss
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
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2
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Moore HB, LaRiviere W, Rodriguez I, Brown K, Hadley K, Pomposelli JJ, Adams MA, Wachs ME, Conzen KD, Kennealey PT, Kaplan B, Pomfret EA, Nydam TL. Early predictors of prolonged intensive care utilization following liver transplantation. Am J Surg 2023; 226:829-834. [PMID: 37604748 DOI: 10.1016/j.amjsurg.2023.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Creatinine, bilirubin, and fibrinolysis resistance are associated with multi-organ dysfunction and likely risk factors for prolonged intensive care unit (pICU) stay following liver transplantation (LT). We hypothesize postoperative day-1 (POD-1) labs will predict pICU. METHODS LT recipients had clinical laboratories and viscoelastic testing with tissue plasminogen activator thrombelastography (tPA TEG) to quantify fibrinolysis resistance (LY30) on POD-1. pICU was defined as one week or longer in the ICU. Logistic regression was used to identify the relationship between POD-1 labs and pICU. RESULTS Of 304 patients, 50% went to the ICU, with 15% experiencing pICU. Elevated creatinine (OR 6.6, P < 0.001) and low tPA TEG LY30 (OR 3.7, P = 0.004) were independent predictors of pICU after controlling for other risk factors. A 9-fold increase in the rate of 90-day graft loss (19% vs 2% p < 0.001) was observed patients who had these risk factors for pICU. CONCLUSION Elevated creatine and fibrinolysis resistance are associated with pICU and poor outcomes following LT.
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Affiliation(s)
- Hunter B Moore
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA.
| | - Wells LaRiviere
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Ivan Rodriguez
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kristen Brown
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kyndall Hadley
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - James J Pomposelli
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Megan A Adams
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Michael E Wachs
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kendra D Conzen
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Peter T Kennealey
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Bruce Kaplan
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Elizabeth A Pomfret
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
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3
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Aniskevich S, Scott CL, Ladlie BL. The Practice of Fast-Track Liver Transplant Anesthesia. J Clin Med 2023; 12:jcm12103531. [PMID: 37240637 DOI: 10.3390/jcm12103531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Prior to the 1990s, prolonged postoperative intubation and admission to the intensive care unit was considered the standard of care following liver transplantation. Advocates of this practice speculated that this time allowed patients to recover from the stress of major surgery and allowed their clinicians to optimize the recipients' hemodynamics. As evidence in the cardiac surgical literature on the feasibility of early extubation grew, clinicians began applying these principles to liver transplant recipients. Further, some centers also began challenging the dogma that patients need to be cared for in the intensive care unit following liver transplantation and instead transferred patients to the floor or stepdown units immediately following surgery, a technique known as "fast-track" liver transplantation. This article aims to provide a history of early extubation for liver transplant recipients and offer practical advice on how to select patients that may be able to bypass the intensive care unit and be recovered in a non-traditional manner.
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Affiliation(s)
- Stephen Aniskevich
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Courtney L Scott
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Beth L Ladlie
- Department of Anesthesiology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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4
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Rodríguez Laiz GP, Melgar Requena P, Alcázar López C, Franco Campello M, Villodre Tudela C, Bellot García P, Rodríguez Soler M, Miralles Maciá C, Herrera Marante I, Pomares Mas MT, Mas Serrano P, Gómez Salinas L, Jaime Sánchez F, Perdiguero Gil M, Ramia Ángel JM, Pascual Bartolomé S. Fast Track Liver Transplantation: Lessons learned after 10 years running a prospective cohort study with an ERAS-like protocol. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2023.100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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5
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Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All? Pediatr Crit Care Med 2023; 24:174-176. [PMID: 36661423 DOI: 10.1097/pcc.0000000000003140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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6
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Fabes J, Wells G, Abdi Z, Ravi B, Muehlschlegel P, Fortune-Ely M, Krzanicki D, Rahman S, Spiro M. Fast-Track Extubation After Orthotopic Liver Transplant Associates with Reduced Incidence of Acute Kidney Injury and Renal Replacement Therapy: a Propensity-matched Analysis. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2022.100137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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7
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Sharma S, Saner FH, Bezinover D. A brief history of liver transplantation and transplant anesthesia. BMC Anesthesiol 2022; 22:363. [PMID: 36435747 PMCID: PMC9701388 DOI: 10.1186/s12871-022-01904-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/13/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we describe the major milestones in the development of organ transplantation with a specific focus on hepatic transplantation. For many years, the barriers preventing successful organ transplantation in humans seemed insurmountable. Although advances in surgical technique provided the technical ability to perform organ transplantation, limited understanding of immunology prevented successful organ transplantation. The breakthrough to success was the result of several significant discoveries between 1950 and 1980 involving improved surgical techniques, the development of effective preservative solutions, and the suppression of cellular immunity to prevent graft rejection. After that, technical innovations and laboratory and clinical research developed rapidly. However, these advances alone could not have led to improved transplant outcomes without parallel advances in anesthesia and critical care. With increasing organ demand, it proved necessary to expand the donor pool, which has been achieved with the use of living donors, split grafts, extended criteria organs, and organs obtained through donation after cardiac death. Given this increased access to organs and organ resources, the number of transplantations performed every year has increased dramatically. New regulatory organizations and transplant societies provide critical oversight to ensure equitable organ distribution and a high standard of care and also perform outcome analyses. Establishing dedicated transplant anesthesia teams results in improved organ transplantation outcomes and provides a foundation for developing new standards for other subspecialties in anesthesiology, critical care, and medicine overall. Through a century of discovery, the success we enjoy at the present time is the result of the work of well-organized multidisciplinary teams following standardized protocols and thereby saving thousands of lives worldwide each year. With continuing innovation, the future is bright.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
| | - Fuat H Saner
- Department of General, Visceral, and Transplant Surgery, Medical Center University Essen, Hufeland 55, 45147, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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8
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The Enhanced Recovery after Surgery (ERAS) Pathway Is a Safe Journey for Kidney Transplant Recipients during the "Extended Criteria Donor" Era. Pathogens 2022; 11:pathogens11101193. [PMID: 36297249 PMCID: PMC9610733 DOI: 10.3390/pathogens11101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are still underused in kidney transplantation (KT) due to recipients’ “frailty” and risk of postoperative complications. We aimed to evaluate the feasibility and safety of ERAS in KT during the “extended-criteria donor” era, and to identify the predictive factors of prolonged hospitalization. In 2010−2019, all patients receiving KT were included in ERAS program targeting a discharge home within 5 days of surgery. Recipient, transplant, and outcomes data were analyzed. Of 454 KT [male: 280, 63.9%; age: 57 (19−77) years], 212 (46.7%) recipients were discharged within the ERAS target (≤5 days), while 242 (53.3%) were discharged later. Patients within the ERAS target (≤5 days) had comparable recipient and transplant characteristics to those with longer hospital stays, and they had similar post-operative complications, readmission rates, and 5 year graft/patient survival. In the multivariate analysis, DGF (HR: 2.16, 95% CI: 1.08−4.34, p < 0.030) and in-hospital dialysis (HR: 3.68, 95% CI: 1.73−7.85, p < 0.001) were the only predictive factors for late discharge. The ERAS approach is feasible and safe in all KT candidates, and its failure is primarily related to the postoperative graft function, rather than the recipient’s clinical status. ERAS pathways, integrated with strict collaboration with local nephrologists, allow early discharge after KT, with clinical benefits.
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9
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Tinguely P, Badenoch A, Krzanicki D, Kronish K, Lindsay M, Khanal P, Wells G, Spiro M, Raptis DA, McCluskey SA. The role of early extubation on short-term outcomes after liver transplantation - A systematic review, meta-analysis and expert recommendations. Clin Transplant 2022; 36:e14642. [PMID: 35266235 DOI: 10.1111/ctr.14642] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early extubation in liver transplantation (LT) and its potential benefits such as reduction in pulmonary complications and enhanced postoperative recovery have been described. The extent of the effect of early extubation on short-term outcomes after LT across the published literature is to the best of our knowledge unknown. OBJECTIVES The objective of this systematic review and meta-analysis was to determine whether early extubation improves immediate and short-term outcomes after LT and to provide expert recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review and meta-analysis on short-term outcomes after early extubation in LT was performed (CRD42021241402), following PRISMA guidelines and quality of evidence (QOE) and recommendations grading using the GRADE approach, derived from an international experts panel. Endpoints were reintubation rates, pulmonary and other complications/organ dysfunction, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS Of 831 screened articles, 20 observational studies with a total of 3573 patients addressing early extubation protocols were included, of which 12 studies compared results after early versus deferred extubation. Reintubation and pulmonary complication rates were lower in the early versus deferred extubation groups (OR 0.29, CI 0.22-0.39; OR 0.17, CI 0.09-0.33, respectively). ICU and hospital LOS were shorter in eight out of eight and seven out of eight comparative studies, respectively. CONCLUSIONS Early extubation after LT is associated with improved short-term outcomes after LT and should be performed in the majority of patients (QOE; Moderate to low | Grade of Recommendation; Strong). Randomized controlled trials using standardized definitions of early extubation and short-term outcomes are needed to demonstrate causality, validate and allow comparability of the results.
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Affiliation(s)
- Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK
| | - Adam Badenoch
- Flinders University, Adelaide, South Australia, Australia.,Department of Anaesthesia and Pain Management, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Dominik Krzanicki
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Martine Lindsay
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gemma Wells
- Department of Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Michael Spiro
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, UK
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK
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10
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Hannon VN, Tinguely P, McKenna GJ, Brustia R, Kaldas FM, Scatton O, Spiro M, Raptis DA, Busuttil RW, Klintmalm GB. New ERAS in liver transplantation - Past, present, and next steps. Clin Transplant 2022; 36:e14625. [PMID: 35238415 DOI: 10.1111/ctr.14625] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023]
Abstract
There are parallels between the history of Enhanced Recovery after Surgery (ERAS) and liver transplantation. Both have been established and advanced by innovative individuals, often going against perceived wisdom and convention. Liver transplantation has traditionally been considered too complex for ERAS pathways, despite a small number of trials showing them to be both safe and of benefit. To date, there are very few randomized controlled trials and cohort studies publishing outcomes on liver transplant patients enrolled in comprehensive ERAS pathways. To progress our field, the 2022 International Liver Transplantation Society's Consensus Conference has created expert panels to analyze the evidence in 32 domains of the liver transplantation pathway using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to generate expert recommendations. These recommendations will be voted on by the international community to gain consensus using the Danish model, and create the ERAS4OLT.org Enhanced Recovery after Liver Transplantation Pathway.
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Affiliation(s)
- Vivienne N Hannon
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | | | - Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Fady M Kaldas
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Paris, France.,Pierre et Marie Curie University, Paris, France
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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11
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Sakai T, Ko JS, Crouch CE, Kumar S, Little MB, Chae MS, Ganoza A, Gómez-Salinas L, Humar A, Kim SH, Koo BN, Rodriguez G, Sirianni J, Smith NK, Song JG, Ullah A, Hendrickse A. Perioperative management of adult living donor liver transplantation: Part 1 - recipients. Clin Transplant 2022; 36:e14667. [PMID: 35435293 DOI: 10.1111/ctr.14667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/06/2022] [Accepted: 03/31/2022] [Indexed: 11/29/2022]
Abstract
Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, University of Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA, USA
| | - Justin Sangwook Ko
- Department of Anesthesiology & Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cara E Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sathish Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael B Little
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX, USA
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Armando Ganoza
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Luis Gómez-Salinas
- Department of Anesthesiology and Pain Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Abhi Humar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sang Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Gyeonggi-do, Republic of Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gonzalo Rodriguez
- Department of Surgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joel Sirianni
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Aisha Ullah
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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12
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Sutton TL, Potter KC, O'Grady J, Aziz M, Mayo SC, Pommier R, Gilbert EW, Rocha F, Sheppard BC. Intensive care unit observation after pancreatectomy: Treating the patient or the surgeon? J Surg Oncol 2022; 125:847-855. [DOI: 10.1002/jso.26800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/21/2021] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas L. Sutton
- Department of Surgery Oregon Heath and Science University (OHSU) Portland Oregon USA
| | | | | | - Michael Aziz
- Department of Anesthesiology and Perioperative Medicine OHSU Portland Oregon USA
| | - Skye C. Mayo
- Division of Surgical Oncology OHSU Department of Surgery Portland Oregon USA
| | - Rodney Pommier
- Division of Surgical Oncology OHSU Department of Surgery Portland Oregon USA
| | - Erin W. Gilbert
- Department of Surgery Oregon Heath and Science University (OHSU) Portland Oregon USA
| | - Flavio Rocha
- Division of Surgical Oncology OHSU Department of Surgery Portland Oregon USA
| | - Brett C. Sheppard
- Department of Surgery Oregon Heath and Science University (OHSU) Portland Oregon USA
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13
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Immediate Postoperative Extubation Decreases Pulmonary Complications in Liver Transplant Patients. Transplantation 2021; 105:2018-2028. [PMID: 32890127 DOI: 10.1097/tp.0000000000003450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fast-track anesthesia in liver transplantation (LT) has been discussed over the past few decades; however, factors associated with immediate extubation after LT surgery are not well defined. This study aimed to identify predictive factors and examine impacts of immediate extubation on post-LT outcomes. METHODS A total of 279 LT patients between January 2014 and May 2017 were included. Primary outcome was immediate extubation after LT. Other postoperative outcomes included reintubation, intensive care unit stay and cost, pulmonary complications within 90 days, and 90-day graft survival. Logistic regression was performed to identify factors that were predictive for immediate extubation. A matched control was used to study immediate extubation effect on the other postoperative outcomes. RESULTS Of these 279 patients, 80 (28.7%) underwent immediate extubation. Patients with anhepatic time >75 minutes and with total intraoperative blood transfusion ≥12 units were less likely to be immediately extubated (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.26-0.89; P = 0.02; OR, 0.11; 95% CI, 0.05-0.21; P < 0.001). The multivariable analysis showed immediate extubation significantly decreased the risk of pulmonary complications (OR, 0.34; 95% CI, 0.15-0.77; P = 0.01). According to a matched case-control model (immediate group [n = 72], delayed group [n = 72]), the immediate group had a significantly lower rate of pulmonary complications (11.1% versus 27.8%; P = 0.012). Intensive care unit stay and cost were relatively lower in the immediate group (2 versus 3 d; P = 0.082; $5700 versus $7710; P = 0.11). Reintubation rates (2.8% versus 2.8%; P > 0.9) and 90-day graft survival rates (95.8% versus 98.6%; P = 0.31) were similar. CONCLUSIONS Immediate extubation post-LT in appropriate patients is safe and may improve patient outcomes and resource allocation.
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Haque ME, Badenoch AD, Orlov D, Selzner M, McCluskey SA. Predicting Early Extubation After Liver Transplantation: External Validation and Improved Generalizability of a Proposed Fast-track Score. Transplantation 2021; 105:2029-2036. [PMID: 32932344 DOI: 10.1097/tp.0000000000003452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early extubation of liver transplantation recipients is a cornerstone of fast-track (FT) pathways. Identifying suitable candidates has previously been accomplished using perioperative variables to develop a FT probability score. The objective of this study was to externally validate a proposed FT score. METHODS Following Research Ethics Board approval, data were extracted on liver transplants conducted at a single center from 2009 to 2017. Data extracted included patient characteristics, intraoperative variables, and postoperative outcome variables. The proposed FT score utilized 9 variables: age, gender, body mass index, model of end-stage liver disease, retransplant, preoperative hospital admission, blood transfusion, operative time, and vasopressor use. We calculated the FT score in our cohort, and assessed the discrimination and calibration of the model. Score performance was explored by subgroup analyses, customization and altering the outcome definition. RESULTS The FT score was found to predict higher rates of successful FT than was observed in the external cohort (n = 1385) and had reduced discrimination (area under the receiver operating curve, 0.711; 95% confidence interval, 0.682-0.741) compared with the original internal validation cohort (area under the receiver operating curve, 0.830; 95% confidence interval, 0.789-0.871; P < 0.0001). Discrimination was improved by customizing the transfusion (P < 0.0001) components of the simplified score or by level 1 customization of all regression model coefficients (P < 0.0001). A time-based definition of FT (early extubation) did not alter the accuracy of the prediction score (P = 0.914), improving the model's generalizability. CONCLUSIONS The proposed FT score may help identify patients suitable for early extubation and FT pathways after liver transplantation in conjunction with clinical judgment.
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Affiliation(s)
- Mohammed E Haque
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Adam D Badenoch
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - David Orlov
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Markus Selzner
- Department of General Surgery, University of Toronto and Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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15
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Tinguely P, Morare N, Val ARD, Berenguer M, Niemann CU, Pollok JM, Raptis DA, Spiro M. Enhanced recovery after surgery programs improve short-term outcomes after liver transplantation - A systematic review and meta-analysis. Clin Transplant 2021; 35:e14453. [PMID: 34382235 DOI: 10.1111/ctr.14453] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/26/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022]
Abstract
This systematic review aimed to investigate the available quality of evidence (QOE) of enhanced recovery after surgery (ERAS) for liver transplantation (LT) on short-term outcomes, grade recommendations and identify relevant components for ERAS protocols. A systematic review and meta-analysis were conducted on short-term outcomes after LT when applying comprehensive ERAS protocols (>1 ERAS component) versus control groups (CRD42021210374), following the GRADE approach for grading quality of evidence and strength of recommendations. Endpoints were morbidity, mortality, length of stay and readmission rates after ERAS for LT. Of 858 screened articles, two randomized controlled trials, 2 prospective and 1 retrospective cohort studies were included (2002 - 2020). Frequent ERAS components were early extubation and postoperative antibiotic, fluid and nutrition management. Overall complications were reduced in ERAS versus control cohorts (OR 0.4 (CI 0.2, 0.7), with no significant differences in mortality and hospital readmission rates. Intensive care unit and hospital length of stay were shorter in ERAS groups (percentage decrease, 55% and 29%, respectively). QOE for individual outcomes was rated moderate to low. ERAS protocols in LT are related to improved short-term outcomes after liver transplantation (Quality of Evidence; Moderate to low | Grade of Recommendation; Strong), but currently lack standardization. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Pascale Tinguely
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, United Kingdom
| | - Nolitha Morare
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, United Kingdom
| | - Alejandro Ramirez-Del Val
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, United Kingdom
| | - Marina Berenguer
- Liver Unit, Ciberehd, IIS La Fe, Hospital Universitario y Politécnico La Fe & Universidad Valencia, Valencia, Spain
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA.,Department of Surgery, Division of Transplantation, University of California San Francisco, San Francisco, CA, USA
| | - Joerg M Pollok
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, United Kingdom.,Division of Surgery & Interventional Science, University College London, United Kingdom
| | - Dimitri A Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, United Kingdom.,Division of Surgery & Interventional Science, University College London, United Kingdom
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, NHS Foundation Trust, London, United Kingdom.,Division of Surgery & Interventional Science, University College London, United Kingdom
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16
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Enhanced recovery in liver transplantation: A value-based approach to complex surgical care. Surgery 2021; 170:1830-1837. [PMID: 34340822 DOI: 10.1016/j.surg.2021.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/27/2021] [Accepted: 07/02/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Value-based healthcare focuses on improving outcomes relative to cost. We aimed to study the impact of an enhanced recovery pathway for liver transplant recipients on providing value. METHODS In total, 379 liver recipients were identified: pre-enhanced recovery pathway (2017, n = 57) and post-enhanced recovery pathway (2018-2020, n = 322). The enhanced recovery pathway bundle was defined through multidisciplinary efforts and included optimal fluid management, end-of-case extubation, multimodal analgesia, and a standardized care pathway. Pre- and post-enhanced recovery pathway patients were compared with regard to extubation rates, lengths of stay, complications, readmissions, survival, and costs. RESULTS Pre- and post-enhanced recovery pathway recipient model for end-stage liver disease score and balance of risk scores were similar, although post-enhanced recovery pathway recipients had a higher median donor risk index (1.55 vs 1.39, P = .003). End-of-case extubation rates were 78% post-enhanced recovery pathway (including 91% in 2020) versus 5% pre-enhanced recovery pathway, with post-enhanced recovery pathway patients having decreased median intraoperative transfusion requirements (1,500 vs 3,000 mL, P < .001). Post-enhanced recovery pathway recipients had shorter median intensive care unit (1.6 vs 2.3 days, P = .01) and hospital stays (5.4 vs 8.0 days, P < .001). Incidence of severe (Clavien-Dindo ≥3) complications during the index hospitalization were similar between pre-enhanced recovery pathway versus post-enhanced recovery pathway groups (33% vs 23%, P = .13), as were 30-day readmissions (26% vs 33%, P = .44) and 1-year survival (93.0% vs 94.5%, P = .58). The post-enhanced recovery pathway cohort demonstrated a significant reduction in median direct cost per case ($11,406; P < .001). CONCLUSION Implementation of an enhanced recovery pathway in liver transplantation is feasible, safe, and effective in delivering value, even in the setting of complex surgical care.
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17
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Enhanced Recovery after Surgery: History, Key Advancements and Developments in Transplant Surgery. J Clin Med 2021; 10:jcm10081634. [PMID: 33921433 PMCID: PMC8069722 DOI: 10.3390/jcm10081634] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 12/13/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) aims to improve patient outcomes by controlling specific aspects of perioperative care. The concept was introduced in 1997 by Henrik Kehlet, who suggested that while minor changes in perioperative practise have no significant impact alone, incorporating multiple changes could drastically improve outcomes. Since 1997, significant advancements have been made through the foundation of the ERAS Society, responsible for creating consensus guidelines on the implementation of enhanced recovery pathways. ERAS reduces length of stay by an average of 2.35 days and healthcare costs by $639.06 per patient, as identified in a 2020 meta-analysis of ERAS across multiple surgical subspecialties. Carbohydrate loading, bowel preparation and patient education in the pre-operative phase, goal-directed fluid therapy in the intra-operative phase, and early mobilisation and enteral nutrition in the post-operative phase are some of the interventions that are commonly implemented in ERAS protocols. While many specialties have been quick to incorporate ERAS, uptake has been slow in the transplantation field, leading to a scarcity of literature. Recent studies reported a 47% reduction in length of hospital stay (LOS) in liver transplantation patients treated with ERAS, while progress in kidney transplantation focuses on pain management and its incorporation into enhanced recovery protocols.
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18
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Rodríguez-Laiz GP, Melgar-Requena P, Alcázar-López CF, Franco-Campello M, Villodre-Tudela C, Pascual-Bartolomé S, Bellot-García P, Rodríguez-Soler M, Miralles-Maciá CF, Más-Serrano P, Navarro-Martínez JA, Martínez-Adsuar FJ, Gómez-Salinas L, Jaime-Sánchez FA, Perdiguero-Gil M, Díaz-Cuevas M, Palazón-Azorín JM, Such-Ronda J, Lluís-Casajuana F, Ramia-Ángel JM. Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol. World J Surg 2021; 45:1262-1271. [PMID: 33620540 PMCID: PMC8026463 DOI: 10.1007/s00268-021-05963-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 01/14/2023]
Abstract
Introduction Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results.
Patients and methods Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.
Results A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. Conclusion Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care
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Affiliation(s)
- Gonzalo P Rodríguez-Laiz
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain.
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain.
| | - Paola Melgar-Requena
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Cándido F Alcázar-López
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Mariano Franco-Campello
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
| | - Celia Villodre-Tudela
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Sonia Pascual-Bartolomé
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Pablo Bellot-García
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - María Rodríguez-Soler
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Cayetano F Miralles-Maciá
- Hepatology and Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Patricio Más-Serrano
- Pharmacy and Pharmacokinetics, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - José A Navarro-Martínez
- Anesthesiology and Surgical Critical Care, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Luis Gómez-Salinas
- Anesthesiology and Surgical Critical Care, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | | | - Miguel Perdiguero-Gil
- Nephrology and Renal Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - María Díaz-Cuevas
- Nephrology and Renal Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | | | - José Such-Ronda
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - José M Ramia-Ángel
- Hepatobiliary Surgery and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain
- ISABIAL (Alicante Institute for Health and Biomedical Research, Alicante, Spain
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19
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Croome KP, Livingston D, Croome S, Keaveny AP, Taner CB, Nakhleh R. Sequential Protocol Biopsies Post-Liver Transplant From Donors With Moderate Macrosteatosis: What Happens to the Fat? Liver Transpl 2021; 27:248-256. [PMID: 37160014 DOI: 10.1002/lt.25867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/05/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022]
Abstract
The number of steatotic deceased donor livers encountered has continued to rise as a result of the obesity epidemic. Little is known about the histological characteristics of moderately macrosteatotic livers over time in the recipient following liver transplantation (LT). All recipients undergoing LT at Mayo Clinic Florida with donor livers with moderate macrosteatosis (30%-60%) from 2000-2017 were identified (n = 96). Routine protocol liver biopsies were performed 1-week and 6-months following LT. All liver donor and protocol biopsies were read by an experienced liver pathologist. Of the 96 moderate macrosteatosis LTs, 70 recipients had post-LT protocol liver biopsies available and comprised the study cohort. Median donor allograft macrosteatosis at the time of transplant was 33% (IQR, 30%-40%) compared with 0% (IQR, 0%-2%) at 1-week (P < 0.001) and 0% (IQR, 0%-0%) at 6-months (P < 0.001) following LT. Biopsies at 1-week post-LT displayed pericentral necrosis in 57.1% of recipients and lipopeliosis in 34.3% of recipients. In the 6-month post-LT biopsies, cholestasis was seen in 3 (4.3%) of the recipients, whereas grade 2 fibrosis was seen in 6 recipients (8.6%). Graft survival at 5 years in the present cohort was 74.0%. Moderate macrosteatosis (30%-60%) in the donor allograft demonstrates complete reversal on liver biopsies performed as early as 7 days following LT and remains absent at 6-months following LT. Both pericentral necrosis and lipopeliosis are common features on day 7 biopsies. Despite these encouraging findings, the perioperative risks of using these livers (postreperfusion cardiac arrest and primary nonfunction) should not be understated. Long-term graft survival is acceptable in patients who are able to overcome the immediate perioperative risk of using moderately steatotic donor livers.
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Affiliation(s)
| | | | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Raouf Nakhleh
- Department of Laboratory Medicine and Pathology, Mayo Clinic Florida, Jacksonville, FL
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20
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El Kassas M, Alboraie M, Al Balakosy A, Abdeen N, Afify S, Abdalgaber M, Sherief AF, Madkour A, Abdellah Ahmed M, Eltabbakh M, Salaheldin M, Wifi MN. Liver transplantation in the era of COVID-19. Arab J Gastroenterol 2020; 21:69-75. [PMID: 32439237 PMCID: PMC7214343 DOI: 10.1016/j.ajg.2020.04.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
Liver transplantation is considered the ultimate solution for patients with end-stage chronic liver disease or acute liver failure. Patients with liver transplant need special care starting from preoperative preparation, surgical intervention ending with postoperative care. Transplanted patients have to receive immunosuppressive therapy to prevent rejection. Such a state of immune suppression could predispose to different types of infections in liver transplant recipients. Currently, the world is suffering a pandemic caused by a new strain of the coronavirus family called COVID-19. Certain infection control precautions are needed to protect immunocompromised and vulnerable patients, including liver transplant candidates and recipients from acquiring COVID-19 infection. Restricting non-transplant elective surgical procedures, managing transplant patients in separate outpatient clinics, and in-patient wards can prevent transmission of infection both to patients and healthcare workers. Telemedicine can help in the triage of patients to screen for symptoms of COVID-19 before their regular appointment. Management of immunosuppressive therapy and drug-drug interactions in liver transplant recipients infected with COVID-19 should be cautiously practiced to prevent rejection and effectively treat the underlying infection. In this report, we are trying to summarize available evidence about different aspects of the management of liver transplant candidates and recipients in the era of COVID-19.
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Affiliation(s)
- Mohamed El Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt.
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Nermeen Abdeen
- Tropical Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Shimaa Afify
- Gastroenterology Department, National Hepatology And Tropical Medicine Research Institute, Cairo, Egypt
| | - Mohammad Abdalgaber
- Gastroenterology and Hepatology Department, Police Authority Hospitals, Giza, Egypt
| | - Ahmed F Sherief
- Tropical Medicine Department, Ain Shams University, Cairo, Egypt
| | - Ahmad Madkour
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | | | | | | | - Mohamed-Naguib Wifi
- Internal Medicine Department, Hepatogastroenterology Unit, Kasr Al-Ainy School Of Medicine, Cairo University, Cairo, Egypt
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21
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Xu Q, Zhu M, Li Z, Zhu J, Xiao F, Liu F, Wang Y, Liu C. Enhanced recovery after surgery protocols in patients undergoing liver transplantation: A retrospective comparative cohort study. Int J Surg 2020; 78:108-112. [PMID: 32304897 DOI: 10.1016/j.ijsu.2020.03.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Qianqian Xu
- Department of Organ Transplantation, Qilu Hospital of Shandong University, NO. 107 Wenhuaxi Road, Jinan, 250012, China
| | - Min Zhu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Zhu Li
- Department of Organ Transplantation, Liaocheng People's Hospital, NO. 67 Dongchangxi Road, Liaocheng, 252000, China
| | - Jiankang Zhu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Fei Xiao
- Department of Organ Transplantation, Liaocheng People's Hospital, NO. 67 Dongchangxi Road, Liaocheng, 252000, China
| | - Fengyue Liu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Yadong Wang
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Chongzhong Liu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China.
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22
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Lebovitz EE, Nguyen AVT, Sakai T. Economic considerations in abdominal transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:15-23. [DOI: 10.1016/j.bpa.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/08/2020] [Indexed: 12/16/2022]
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23
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Mandell MS, Huang J, Zhao J. Enhanced recovery after surgery and practical application to liver transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:119-127. [PMID: 32334782 DOI: 10.1016/j.bpa.2020.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado, CO, USA
| | - Jiapeng Huang
- Department of Anesthesiology, University of Louisville, Louisville, KY, USA
| | - Jing Zhao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China.
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Chadha RM, Croome KP, Aniskevich S, Pai SL, Nguyen J, Burns J, Perry D, Taner CB. Intraoperative Events in Liver Transplantation Using Donation After Circulatory Death Donors. Liver Transpl 2019; 25:1833-1840. [PMID: 31539458 DOI: 10.1002/lt.25643] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/18/2019] [Indexed: 02/07/2023]
Abstract
Liver grafts from donation after circulatory death (DCD) are a source of organs to decrease wait-list mortality. While there have been lower rates of graft loss, there are concerns of an increased incidence of intraoperative events in recipients of DCD grafts. We aim to look at the incidence of intraoperative events between recipients of livers from DCD and donation after brain death (DBD) donors. We collected data for 235 DCD liver recipients between 2006 and 2017. We performed a 1:1 propensity match between these patients and patients with DBD donors. Variables included recipient age, liver disease etiology, biological Model for End-Stage Liver Disease (MELD) score, allocation MELD score, diagnosis of hepatocellular carcinoma, and year of transplantation. DCD and DBD groups had no significant differences in incidence of postreperfusion syndrome (P = 0.75), arrhythmia requiring cardiopulmonary resuscitation (P = 0.66), and treatments for hyperkalemia (P = 0.84). In the DCD group, there was a significant increase in amount of total intraoperative and postreperfusion blood products (with exception of postreperfusion packed red blood cells) utilized (P < 0.05 for all products), significant differences in postreperfusion thromboelastography parameters, as well as inotropes and vasopressors used (P < 0.05 for all infusions). There was no difference in patient (P = 0.49) and graft survival (P = 0.10) at 1, 3, and 5 years. In conclusion, DCD grafts compared with a cohort of DBD grafts have a similar low incidence of major intraoperative events, but increased incidence of transient vasopressor/inotropic usage and increased blood transfusion requirements. This does not result in differences in longterm outcomes. While centers should continue to look at DCD liver donors, they should be cognizant regarding intraoperative care to prevent adverse outcomes.
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Affiliation(s)
- Ryan M Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL
| | | | - Stephen Aniskevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Justin Nguyen
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Justin Burns
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Dana Perry
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
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Croome KP, Lee DD, Croome S, Nakhleh RE, Abader Sedki Senada P, Livingston D, Yataco M, Taner CB. Does Donor Allograft Microsteatosis Matter? Comparison of Outcomes in Liver Transplantation With a Propensity-Matched Cohort. Liver Transpl 2019; 25:1533-1540. [PMID: 31187923 DOI: 10.1002/lt.25583] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/03/2019] [Indexed: 01/04/2023]
Abstract
It has been suggested that microsteatosis does not negatively impact graft survival following liver transplantation (LT). The present study represents the largest series on donor livers with significant microsteatosis and investigates the impact of microsteatosis on perioperative factors such as postreperfusion syndrome (PRS), early allograft dysfunction (EAD), and postoperative renal dysfunction. Clinical outcomes of all patients undergoing LT with donor livers with isolated microsteatosis (≥30%; n = 239) between 2000 and 2017 were compared with a propensity score-matched cohort of patients undergoing LT with donor livers with no steatosis (n = 239). Patients in the microsteatosis group had a higher rate of PRS (33.1% versus 24.2%; P = 0.03), EAD (38.2% versus 23.0%; P < 0.001), and continuous renal replacement therapy (CRRT) requirement following LT (10.9% versus 3.6%; P = 0.002) than the no steatosis group. No difference in patient (P = 0.33) or graft survival (P = 0.18) was observed between the 2 groups. On multivariate regression, livers with microsteatosis had an increased risk of graft loss with retransplant recipients (hazard ratio [HR], 1.59; P < 0.001), increasing Model for End-Stage Liver Disease (MELD) score (HR, 1.13; P = 0.01), and organs from donation after circulatory death donors (HR, 1.46; P = 0.003). In conclusion, recipients of donor livers with significant microsteatosis are at an increased risk of PRS, EAD, and postoperative renal dysfunction requiring CRRT. Livers with significant microsteatosis should be avoided in retransplant recipients and in recipients with high biological MELD scores. Once appropriately selected recipients of these livers are able to overcome the initial perioperative implications of using these donor livers, longterm patient and graft survival is similar to recipients receiving grafts with no steatosis.
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Affiliation(s)
| | - David D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Raouf E Nakhleh
- Department of Pathology, Mayo Clinic Florida, Jacksonville, FL
| | | | | | - Maria Yataco
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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Croome KP, Lee DD, Croome S, Chadha R, Livingston D, Abader P, Keaveny AP, Taner CB. The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis. Am J Transplant 2019; 19:2550-2559. [PMID: 30821923 DOI: 10.1111/ajt.15330] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/24/2019] [Accepted: 02/19/2019] [Indexed: 01/25/2023]
Abstract
The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%-60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%-29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long-term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.
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Affiliation(s)
| | - David D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Ryan Chadha
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - David Livingston
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Peter Abader
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
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Loh CPA, Croome KP, Burcin Taner C, Keaveny AP. Bias-corrected estimates of reduction of post-surgery length of stay and corresponding cost savings through the widespread national implementation of fast-tracking after liver transplantation: a quasi-experimental study. J Med Econ 2019; 22:684-690. [PMID: 30841773 DOI: 10.1080/13696998.2019.1592179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Fast-tracking is an approach adopted by Mayo Clinic in Florida's (MCF) liver transplant (LT) program, which consists of early tracheal extubation and transfer of patients to surgical ward, eliminating a stay in the intensive care unit in select patients. Since adopting this approach in 2002, MCF has successfully fast-tracked 54.3% of patients undergoing LT. Objectives: This study evaluated the reduction in post-operative length of stay (LOS) that resulted from the fast-tracking protocol and assessed the potential cost saving in the case of nationwide implementation. Methods: A propensity score for fast-tracking was generated based on MCF liver transplant databases during 2011-2013. Various propensity score matching algorithms were used to form control groups from the United Network of Organ Sharing Standard Analysis and Research (STAR) file that had comparable demographic characteristics and health status to the treatment group identified in MCF. Multiple regression and matching estimators were employed for evaluation of the post-surgery LOS. The algorithm generated from the analysis was also applied to the STAR data to determine the proportion of patients in the US who could potentially be candidates for fast-tracking, and the potential savings. Results: The effect of the fast-tracking on the post-transplant LOS was estimated at approximately from 2.5 (p-value = 0.001) to 3.2 (p-value < 0.001) days based on various matching algorithms. The cost saving from a nationwide implementation of fast-tracking of liver transplant patients was estimated to be at least $78 million during the 2-year period. Conclusion: The fast-track program was found to be effective in reducing post-transplant LOS, although the reduction appeared to be less than previously reported. Nationwide implementation of fast-tracking could result in substantial cost savings without compromising the patient outcome.
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Affiliation(s)
- Chung-Ping A Loh
- a Department of Economics and Geography, Coggin College of Business , University of North Florida , Jacksonville , FL , USA
| | | | - C Burcin Taner
- b Department of Transplant , Mayo Clinic Florida , Jacksonville , FL , USA
| | - Andrew P Keaveny
- b Department of Transplant , Mayo Clinic Florida , Jacksonville , FL , USA
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Cerullo M, Gani F, Chen SY, Canner JK, Dillhoff M, Cloyd J, Pawlik TM. Routine intensive care unit admission among patients undergoing major pancreatic surgery for cancer: No effect on failure to rescue. Surgery 2019; 165:741-746. [DOI: 10.1016/j.surg.2018.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/29/2018] [Accepted: 11/13/2018] [Indexed: 12/13/2022]
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29
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Kramer DJ, Siegal EM, Frogge SJ, Chadha MS. Perioperative Management of the Liver Transplant Recipient. Crit Care Clin 2019; 35:95-105. [PMID: 30447783 DOI: 10.1016/j.ccc.2018.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Perioperative management of the liver transplant recipient is a team effort that requires close collaboration between intensivist, surgeon, anesthesiologist, hepatologist, nephrologist, other specialists, and hospital staff before and after surgery. Transplant viability must be reassessed regularly and particularly with each donor organ. Regular discussions with patient and family facilitate realistic determinations of goals based on patient aspirations and clinical realities. Early attention to hemodynamics with optimal resuscitation and judicious vasopressor support, respiratory care designed to minimize iatrogenic injury, and early renal support is key. Preoperative and postoperative nutritional support and physical rehabilitation should remain a focus.
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Affiliation(s)
- David J Kramer
- Aurora Critical Care Service, Advocate Aurora Health Care, 2901 W Kinnickinnic River Parkway, Suite 305, Milwaukee, WI 53215, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health in Madison, 750 Highland Avenue, Madison, WI 53726, USA.
| | - Eric M Siegal
- Aurora Critical Care Service, Advocate Aurora Health Care, 2901 W Kinnickinnic River Parkway, Suite 305, Milwaukee, WI 53215, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health in Madison, 750 Highland Avenue, Madison, WI 53726, USA
| | - Sarah J Frogge
- Aurora Critical Care Service, Advocate Aurora Health Care, 2901 W Kinnickinnic River Parkway, Suite 305, Milwaukee, WI 53215, USA
| | - Manpreet S Chadha
- Aurora Critical Care Service, Advocate Aurora Health Care, 2901 W Kinnickinnic River Parkway, Suite 305, Milwaukee, WI 53215, USA; Aurora Abdominal Transplant and Hepatobiliary Program, 2801 W Kinnickinnic River Parkway, Suite 580, Milwaukee, WI 53215, USA
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30
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Pita A, Nguyen B, Rios D, Maalouf N, Lo M, Genyk Y, Sher L, Cobb JP. Variability in intensive care unit length of stay after liver transplant: Determinants and potential opportunities for improvement. J Crit Care 2019; 50:296-302. [PMID: 30677626 DOI: 10.1016/j.jcrc.2019.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/27/2018] [Accepted: 01/08/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Recovery after liver transplant (LT) requires extensive resources, including prolonged intensive care unit stays. The objective of this study was to use an assessment tool to determine if LT recipients remain in ICU beyond designated indications. METHODS Records from 100 consecutive LTs performed in a single institution were retrospectively reviewed. An admission, discharge, and triage screening (ADT) tool was utilized to assess the indications for each ICU day. Data collected included demographics; pre-, intra-, and post-operative course; and complications. Days not meeting ADT criteria were considered additional ICU days. RESULTS 100 patients: mean age 55 years (range 24-78 years) and mean MELD score 30 (range 6-47). Three recipients who died within one week were excluded. Forty-eight (49.5%) patients had a total of 75 additional days on initial ICU stay. Univariate analysis revealed no significant differences between patients with and without additional days. 12/97 (12.4%) patients returned to ICU including 5/48 and 7/49 with and without additional days. CONCLUSION Nearly half of the LT recipients remained in ICU an average of 1.6 additional days. Monitoring of organ function appeared to be the most common reason. Opportunities to improve resource utilization could include transfer to an intermediate/progressive care ("step-down") unit.
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Affiliation(s)
- Alejandro Pita
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.
| | - Brian Nguyen
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Daisy Rios
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Nicolas Maalouf
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mary Lo
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Yuri Genyk
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Linda Sher
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - J Perren Cobb
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Son YG, Lee H, Oh SY, Jung CW, Ryu HG. Risk Factors for Intensive Care Unit Readmission After Liver Transplantation: A Retrospective Cohort Study. Ann Transplant 2018; 23:767-774. [PMID: 30385737 PMCID: PMC6248006 DOI: 10.12659/aot.911589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Most liver transplant patients require Intensive Care Unit (ICU) care in the immediate postoperative period and some patients require readmission to the ICU before discharge from the hospital. A retrospective cohort study was conducted to identify risk factors for ICU readmission after liver transplantation. Material/Methods Adult patients who underwent living donor or deceased donor liver transplantation at Seoul National University Hospital between 2004 and 2015 were included. A retrospective review of baseline and perioperative factors that may be associated with ICU readmission was performed. Patients requiring ICU readmission during the hospitalization for LT (readmission group) were compared with patients who did not need ICU readmission (control group). A multivariable logistic regression analysis was performed to identify factors associated with ICU readmission after LT. Results Of the 1181 patients, 68 patients (5.8%) were readmitted to the ICU during the postoperative period after liver transplantation. Common causes of ICU readmission included postoperative bleeding, pulmonary complications, and sepsis. Multivariate analysis revealed that old age (OR 1.030 95%CI 1.002–1.059, p=0.035), pre-transplant chronic kidney disease (CKD) (OR 4.912 95%CI 2.556–9.439, p<0.001), intraoperative red blood cell (RBC) transfusion (OR 1.029 95%CI 1.008–1.050, p=0.007), new-onset atrial fibrillation in the ICU (OR 2.807 95%CI 1.087–7.249, p=0.033), and transplantation between 2011 and 2015 (vs. 2004–2010) were risk factors for ICU readmission after LT. Conclusions Old age, pre-transplant CKD, more intraoperative RBC transfusion, new-onset atrial fibrillation during ICU stay, and transplant period were identified as risk factors for ICU readmission.
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Affiliation(s)
- Young Gon Son
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, South Korea.,Department of Anesthesiology, Seoul Sebarun Hospital, Seoul, South Korea
| | - Hannah Lee
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Chul-Woo Jung
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho Geol Ryu
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, South Korea
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Li J, Wang C, Jiang Y, Song J, Zhang L, Chen N, Zhang R, Yang L, Yao Q, Jiang L, Yang J, Zhu T, Yang Y, Li W, Yan L, Yang J. Immediate versus conventional postoperative tracheal extubation for enhanced recovery after liver transplantation: IPTE versus CTE for enhanced recovery after liver transplantation. Medicine (Baltimore) 2018; 97:e13082. [PMID: 30407308 PMCID: PMC6250540 DOI: 10.1097/md.0000000000013082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION To systematically compare immediate postoperative tracheal extubation (IPTE) with conventional tracheal extubation (CTE) and to determine whether IPTE can achieve an enhanced recovery for adult patients underwent liver transplantation (LT) without additional risks. We designed a systematic review and meta-analysis. METHODS The RCTs, cohorts, case-controls, or case series that explored outcomes of IPTE after LT for adults were involved in our study. The Newcastle-Ottawa scale was used to assess the risk of bias. RESULTS A total of 15 studies (n = 4144) were included, consisting of 10 studies (retrospective cohorts; n = 3387) for quantitative synthesis and 5 studies (1 prospective cohort, and 4 case series; n = 757) for qualitative synthesis. The pooled estimates suggested IPTE could reduce time to discharge from ICU stay (TDICU) (mean difference [MD] -2.12 days, 95% confidence interval [CI] -3.04 to -1.19 days), time to discharge from the hospital (TDH) (MD -6.43 days, 95% CI -9.53 to -3.33 days), re-intubation rate (RI) (odds ratio [OR] 0.29, 95% CI 0.22-0.39), morbidity rate (MR) (OR 0.15, 95% CI 0.08-0.30) and graft dysfunction rate (GD) (IPTE vs CTE: 0.3% vs 3.8%, P < .01), and had comparable ICU survival rate (ICUS) (OR 6.67 95% CI 1.34-33.35) when compared with CTE after LT. CONCLUSIONS IPTE can achieve an enhanced recovery for adult patients underwent LT without additional re-intubation, morbidity, and mortality risks. However, further work needs to be done to establish the extent definitively through carefully designed and conducted RCTs.
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Affiliation(s)
- Jianbo Li
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital
| | - Chengdi Wang
- Department of Respiratory and Critical Care Medicine, West China Medical School/West China Hospital
| | | | - Jiulin Song
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital
| | | | | | - Rui Zhang
- Department of Respiratory and Critical Care Medicine, West China Medical School/West China Hospital
| | - Lan Yang
- Department of Respiratory and Critical Care Medicine, West China Medical School/West China Hospital
| | - Qin Yao
- Department of Anesthesiology, West China Hospital
| | - Li Jiang
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital
| | - Jian Yang
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital
| | - Tao Zhu
- West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yang Yang
- West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, West China Medical School/West China Hospital
| | - Lunan Yan
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital
| | - Jiayin Yang
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital
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Niazi SK, Schneekloth TD, Vasquez AR, Keaveny AP, Davis S, Picco M, Heckman MG, Diehl NN, Jowsey-Gregoire SG, Rummans TA, Burcin Taner C. Impact of psychiatric comorbidities on outcomes of elderly liver transplant recipients. J Psychosom Res 2018; 111:27-35. [PMID: 29935751 DOI: 10.1016/j.jpsychores.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study evaluated the impact of psychiatric comorbidities in liver transplant (LT) recipients aged ≥65 years (elderly) on length of hospital-stay (LOS), death, and a composite outcome of graft loss or death. METHODS This retrospective study assessed impact of psychiatric comorbidities in 122 elderly LT recipients and a matched group of 122 LT recipients aged <65 years (younger). Associations were assessed using adjusted multivariable regression models. RESULTS Among elderly, median age at LT was 68 years, most were males (62%), white (85%) and 61.7% had a history of any psychiatric diagnosis. Among younger, median age was 55, most were males (67.2%), white (77.5%) and 61.5% had any psychiatric diagnosis. Median LOS was 8 days for both groups. Among elderly, after a median follow-up of 5 years, 25.4% died and 29.5% experienced graft loss or death. History of adjustment disorder, history of depression, past psychiatric medication use, and pain prior to LT were associated with an increased risk of death or the composite graft loss or death. Perioperative use of SSRIs and lack of sleeping medication use were associated with longer LOS. Among aged <65, after median follow-up of 4.7 years, 21 patients (17%) died and 25 (20%) experienced graft loss or death; history of depression, perioperative SSRIs or sleeping medications use was associated with increased mortality and graft-loss or death. CONCLUSION Six out of 10 patients among both elderly and younger cohorts had pre-LT psychiatric comorbidities, some of which adversely affected outcomes after LT.
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Affiliation(s)
- Shehzad K Niazi
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, United States; Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States.
| | - Terry D Schneekloth
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Adriana R Vasquez
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, United States; Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
| | - Andrew P Keaveny
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
| | - Susan Davis
- Mayo Clinic, Jacksonville, FL, United States
| | | | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, United States
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, United States
| | - Sheila G Jowsey-Gregoire
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States
| | - Teresa A Rummans
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, United States; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States
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Niewińsk G, Raszeja-Wyszomirska J, Główczyńska R, Figiel W, Zając K, Kornasiewicz O, Zieniewicz K, Grąt M. Risk Factors of Prolonged ICU Stay in Liver Transplant Recipients in a Single-Center Experience. Transplant Proc 2018; 50:2014-2017. [PMID: 30177100 DOI: 10.1016/j.transproceed.2018.02.143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prolonged initial intensive care unit (ICU) stay after liver transplantation (LT) is associated with prolonged total hospitalization, increased hospital mortality, and impaired patient and graft survival. Recent data suggested that model for end-stage liver disease (MELD) score at the time of LT and the length of surgery were the two independent risk factors for an ICU stay longer than 3 days after LT. We further identified factors influencing prolonged ICU stay in single-center liver graft recipients. PATIENTS AND METHODS One hundred fifty consecutive LT recipients (M/F 94/56, median age 55 (range, 39-60), 36% with viral hepatitis, were prospectively enrolled into the study. Associations between clinical factors and prolonged ICU stay were evaluated using logistic regression models. Receiver operating characteristic curves were analyzed to determine the appropriate cutoffs for continuous variables. Threshold for significance was P ≤ .05. RESULTS Highly prolonged (≥8 days) and moderately prolonged (≥6 days) postoperative ICU stay was noted in 19 (12.7%) and 59 (39.3%) patients, respectively. Serum bilirubin (P = .001) and creatinine concentrations (P = .011), international normalized ratio (P = .004), and sodium-MELD (P < .001) were all significantly associated with postoperative intensive care unit stay over or equal to 75th percentile (6 days). Sodium-MELD was significantly associated with postoperative care unit stay greater or equal to the 90th percentile (8 days; P = .018). CONCLUSIONS Sodium-MELD might be a novel risk factor of prolonged ICU stay in this single-center experience.
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Affiliation(s)
- G Niewińsk
- II Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - J Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.
| | - R Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - W Figiel
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - K Zając
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - O Kornasiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - K Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - M Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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Biancofiore G, Tomescu DR, Mandell MS. Rapid Recovery of Liver Transplantation Recipients by Implementation of Fast-Track Care Steps: What Is Holding Us Back? Semin Cardiothorac Vasc Anesth 2018; 22:191-196. [PMID: 29488444 DOI: 10.1177/1089253218761124] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Bhangui P, Bhangui P, Gupta N, Jolly AS, Bhalotra S, Sharma N, Soin AS, Vohra V. Fast tracking in adult living donor liver transplantation: A case series of 15 patients. Indian J Anaesth 2018; 62:127-130. [PMID: 29491518 PMCID: PMC5827479 DOI: 10.4103/ija.ija_566_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and Aims: Fast tracking (FT) for more efficacious use of resources may be difficult after living donor liver transplantation (LDLT) due to a partial liver graft, complex vascular anastomoses and longer operating time. Our study was aimed at reporting our experience with FT (on table extubation) in LDLT recipients. A secondary objective of our study was to look at defining a subgroup of patients who could be prospectively planned for FT. Methods: We studied the demographics and outcomes of 15 LDLT recipients extubated immediately in the operating suite based on an uneventful intraoperative course, haemodynamic stability after graft reperfusion and improvement of metabolic parameters post-implantation and vascular anastomoses. Results: Twelve recipients were males, and mean age, body mass index (BMI) and Model for End Stage Liver Disease (MELD) score were 43 ± 12 years, 23 ± 3 kg/m2 and 15.5 ± 6, respectively, most were Child–Turcotte–Pugh Class B. Diabetes and hypothyroidism were present in 1 and 2 patients, respectively. Post-extubation, none required immediate re-intubation and one patient needed non-invasive ventilation for 2 h. Conclusion: Fast tracked recipients were young, with a low BMI, low MELD scores, minimal comorbidities and good immediate graft function post-reperfusion.
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Affiliation(s)
- Pooja Bhangui
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Nikunj Gupta
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Annu Sarin Jolly
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Seema Bhalotra
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Nishant Sharma
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - A S Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Vijay Vohra
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
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Chadha RM, Crouch C, Zerillo J, Pretto EA, Planinsic R, Kim S, Nicolau-Raducu R, Adelmann D, Elia E, Wray CL, Srinivas C, Mandell MS. Society for the Advancement of Transplant Anesthesia: Liver Transplant Anesthesia Fellowship—White Paper Advocating Measurable Proficiency in Transplant Specialties Training. Semin Cardiothorac Vasc Anesth 2017; 21:352-356. [DOI: 10.1177/1089253217737043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The anesthesia community has openly debated if the care of transplant patients was generalist or specialist care ever since the publication of an opinion paper in 1999 recommended subspecialty training in the field of liver transplantation anesthesia. In the past decade, liver transplant anesthesia has become more complex with a sicker patient population and evolving evidence-based practices. Transplant training is currently not required for accreditation or certification in anesthesiology, and not all anesthesia residency programs are associated with transplant centers. Yet there is evidence that patient outcome is affected by the experience of the anesthesiologist with liver transplants as part of a multidisciplinary care team. Requests for a formal review of the inequities in training opportunities and requirements led the Society for the Advancement for Transplant Anesthesia (SATA) to begin the task of developing post-graduate fellowship training recommendations. In this article, members of the SATA Working Group on Transplant Anesthesia Education present their reasoning for specialized education and conclusions about which pathways can better prepare trainees to care for complex transplant patients.
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Affiliation(s)
| | - Cara Crouch
- University of Colorado Hospital, Aurora, CO, USA
| | - Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Sang Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Elia Elia
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Adapting the Surgical Apgar Score for Perioperative Outcome Prediction in Liver Transplantation: A Retrospective Study. Transplant Direct 2017; 3:e221. [PMID: 29184910 PMCID: PMC5682766 DOI: 10.1097/txd.0000000000000739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/27/2017] [Indexed: 02/07/2023] Open
Abstract
Background The surgical Apgar score (SAS) is a 10-point scale using the lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL) during surgery to predict postoperative outcomes. The SAS has not yet been validated in liver transplantation patients, because typical blood loss usually exceeds the highest EBL category. Our primary aim was to develop a modified SAS for liver transplant (SAS-LT) by replacing the EBL parameter with volume of red cells transfused. We hypothesized that the SAS-LT would predict death or severe complication within 30 days of transplant with similar accuracy to current scoring systems. Methods A retrospective cohort of consecutive liver transplantations from July 2007 to November 2013 was used to develop the SAS-LT. The predictive ability of SAS-LT for early postoperative outcomes was compared with Model for End-stage Liver Disease, Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation III scores using multivariable logistic regression and receiver operating characteristic analysis. Results Of 628 transplants, death or serious perioperative morbidity occurred in 105 (16.7%). The SAS-LT (receiver operating characteristic area under the curve [AUC], 0.57) had similar predictive ability to Acute Physiology and Chronic Health Evaluation III, model for end-stage liver disease, and Sequential Organ Failure Assessment scores (0.57, 0.56, and 0.61, respectively). Seventy-nine (12.6%) patients were discharged from the ICU in 24 hours or less. These patients’ SAS-LT scores were significantly higher than those with a longer stay (7.0 vs 6.2, P < 0.01). The AUC on multivariable modeling remained predictive of early ICU discharge (AUC, 0.67). Conclusions The SAS-LT utilized simple intraoperative metrics to predict early morbidity and mortality after liver transplant with similar accuracy to other scoring systems at an earlier postoperative time point.
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Taner CB, Keaveny AP. Innovative care models after liver transplant. Clin Liver Dis (Hoboken) 2017; 10:68-71. [PMID: 30992763 PMCID: PMC6467115 DOI: 10.1002/cld.656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/18/2017] [Indexed: 02/04/2023] Open
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Avoiding ICU Admission by Using a Fast-Track Protocol Is Safe in Selected Adult-to-Adult Live Donor Liver Transplant Recipients. Transplant Direct 2017; 3:e213. [PMID: 29026876 PMCID: PMC5627744 DOI: 10.1097/txd.0000000000000730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/18/2017] [Indexed: 01/27/2023] Open
Abstract
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.
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Rao JH, Zhang F, Lu H, Dai XZ, Zhang CY, Qian XF, Wang XH, Lu L. Effects of multimodal fast-track surgery on liver transplantation outcomes. Hepatobiliary Pancreat Dis Int 2017; 16:364-369. [PMID: 28823365 DOI: 10.1016/s1499-3872(17)60020-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 11/30/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fast-track surgery and enhanced recovery after surgery have been applied to many surgical procedures; however, data on fast-track surgery and enhanced recovery after surgery following liver transplantation is limited. This study aimed to conduct a prospective study to determine the effects of fast-track surgery on prognosis after liver transplantation. METHODS This was a prospective, single-blinded, randomized study. One hundred twenty-eight patients undergoing liver transplantation were selected for the fast-track (FT group, n=54) or conventional process (NFT group, n=74). The primary endpoints were intensive care unit (ICU) stay and hospital stay. The secondary endpoints were as follows: operative time, anhepatic phase time, intraoperative blood loss, intraoperative blood transfusion volume, postoperative complications, readmission rate, and postoperative mortality. RESULTS There was no significant difference in preoperative demographics between the two groups. The median ICU stay was 2 days (range 1-7 days) in the FT group and 5 days (range 3-12 days) in the NFT group (P<0.01). Furthermore, the hospital stay was also significantly reduced in the FT group (P<0.01). The operative time, anhepatic phase time, intraoperative blood loss, and intraoperative blood transfusion volume were decreased in the FT group compared with the NFT group (P<0.05). Based on Spearman correlation analysis, the ICU stay and hospital stay may be positively correlated with operative time, anhepatic phase time and intraoperative blood loss. There were no differences in the incidence of postoperative complications, readmissions, and postoperative mortality between the two groups. CONCLUSION Fast-track procedures effectively reduce the ICU stay and hospital stay without adversely affecting prognosis. This study demonstrated that fast-track protocols are safe and feasible in liver transplantation.
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Affiliation(s)
- Jian-Hua Rao
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Feng Zhang
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Hao Lu
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Xin-Zheng Dai
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Chuan-Yong Zhang
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Xiao-Feng Qian
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Xue-Hao Wang
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Ling Lu
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China.
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Abstract
With the evolution of surgical and anesthetic techniques, liver transplantation has become "routine," allowing for modifications of practice to decrease perioperative complications and costs. There is debate over the necessity for intensive care unit admission for patients with satisfactory preoperative status and a smooth intraoperative course. Postoperative care is made easier when the liver graft performs optimally. Assessment of graft function, vigilance for complications after the major surgical insult, and optimization of multiple systems affected by liver disease are essential aspects of postoperative care. The intensivist plays a vital role in an integrated multidisciplinary transplant team.
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Affiliation(s)
- Mark T Keegan
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Charlton 1145, 200 1st Street Southwest, Rochester, MN 55905, USA.
| | - David J Kramer
- Aurora Critical Care Service, 2901 W Kinnickinnic River Parkway, Milwaukee, WI 53215, USA; University of Wisconsin, School of Medicine and Public Health, 750, Highland Avenue, Madison, WI 53705, USA
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Stratigopoulou P, Paul A, Hoyer DP, Kykalos S, Saner FH, Sotiropoulos GC. High MELD score and extended operating time predict prolonged initial ICU stay after liver transplantation and influence the outcome. PLoS One 2017; 12:e0174173. [PMID: 28319169 PMCID: PMC5358862 DOI: 10.1371/journal.pone.0174173] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 03/03/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of the present study is to determine the incidence of a prolonged (>3 days) initial ICU-stay after liver transplantation (LT) and to identify risk factors for it. PATIENTS AND METHODS We retrospectively analyzed data of adult recipients who underwent deceased donor first-LT at the University Hospital Essen between 11/2003 and 07/2012 and showed a primary graft function. RESULTS Of the 374 recipients, 225 (60.16%) had prolonged ICU-stay. On univariate analysis, donor INR, high doses of vasopressors, "rescue-offer" grafts, being hospitalized at transplant, high urgency cases, labMELD, alcoholic cirrhosis, being on renal dialysis and length of surgery were associated with prolonged ICU-stay. After multivariate analysis, only the labMELD and the operation's length were independently correlated with prolonged ICU-stay. Cut-off values for these variables were 19 and 293.5 min, respectively. Hospital stay was longer for patients with a prolonged initial ICU-stay (p<0.001). Survival rates differed significantly between the two groups at 3 months, 1-year and 5-years after LT (p<0.001). CONCLUSIONS LabMELD and duration of LT were identified as independent predictors for prolonged ICU-stay after LT. Identification of recipients in need of longer ICU-stay could contribute to a more evidenced-based and cost-effective use of ICU facilities in transplant centers.
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Affiliation(s)
- Panagiota Stratigopoulou
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Dieter P. Hoyer
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Stylianos Kykalos
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
- * E-mail:
| | - Fuat H. Saner
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Georgios C. Sotiropoulos
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
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Yataco M, Cowell A, David W, Keaveny AP, Taner CB, Patel T. Predictors and impacts of hospital readmissions following liver transplantation. Ann Hepatol 2017; 15:356-62. [PMID: 27049489 DOI: 10.5604/16652681.1198805] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
While liver transplantation is the definitive therapy for end stage liver disease, it remains a major procedure, with many potential complications. Hospital readmissions after the initial hospitalization for liver transplantation can be associated with adverse outcomes, increased cost, and resource utilization. Our aim was to define the incidence and reasons for hospital readmission after liver transplant and the impact of readmissions on patient outcomes. We retrospectively analyzed 30- and 90-day readmission rates and indications in patients who underwent liver transplant at a large-volume transplant center over a 3-year period. Four hundred seventy-nine adult patients underwent their first liver transplant during the study period. The 30-day readmission rate was 29.6%. Recipient and donor age, etiology of liver disease, biological Model for End-Stage Liver Disease score, and cold ischemia time were similar between patients who were readmitted within 30 days and those who were not readmitted. Readmissions occurred in 25% of patients who were hospitalized prior to liver transplant compared to 30% who were admitted for liver transplant. The most common indications for readmission were infection, severe abdominal pain, and biliary complications. Early discharge from hospital (fewer than 7 days after liver transplant), was not associated with readmission; however, a prolonged hospital stay after liver transplant was associated with an increased risk of readmission (p = 0.04). In conclusion, patients who undergo liver transplant have a high rate of readmission. In our cohort, readmissions were unrelated to pre-existing recipient or donor factors, but were associated with a longer hospital stay after liver transplant.
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Affiliation(s)
- Maria Yataco
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Alissa Cowell
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Waseem David
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Tushar Patel
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
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Eilers H. Advances in anesthesia and critical care. Liver Transpl 2016; 22:20-24. [PMID: 27595667 DOI: 10.1002/lt.24632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/01/2016] [Accepted: 09/01/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Helge Eilers
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.
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Piñero F, Fauda M, Quiros R, Mendizabal M, González-Campaña A, Czerwonko D, Barreiro M, Montal S, Silberman E, Coronel M, Cacheiro F, Raffa P, Andriani O, Silva M, Podestá LG. Predicting early discharge from hospital after liver transplantation (ERDALT) at a single center: a new model. Ann Hepatol 2016; 14:845-55. [PMID: 26436356 DOI: 10.5604/16652681.1171770] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Federico Piñero
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Martín Fauda
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Rodolfo Quiros
- Internal Medicine, Infectious Diseases and Statistics. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Ariel González-Campaña
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Demian Czerwonko
- Intensive Care Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Mariano Barreiro
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Silvina Montal
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Ezequiel Silberman
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Matías Coronel
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Fernando Cacheiro
- Department of Anesthesiology. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Pía Raffa
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Oscar Andriani
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Marcelo Silva
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Luis G Podestá
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
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Factors Affecting Breathing Capacity and Early Tracheal Extubation After Liver Transplantation. Transplant Proc 2016; 48:1692-6. [DOI: 10.1016/j.transproceed.2016.01.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/21/2016] [Indexed: 12/13/2022]
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48
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Wadei HM, Lee DD, Croome KP, Mai ML, Golan E, Brotman R, Keaveny AP, Taner CB. Early Allograft Dysfunction After Liver Transplantation Is Associated With Short- and Long-Term Kidney Function Impairment. Am J Transplant 2016; 16:850-9. [PMID: 26663518 DOI: 10.1111/ajt.13527] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/03/2015] [Accepted: 09/06/2015] [Indexed: 01/25/2023]
Abstract
Early allograft dysfunction (EAD) after liver transplantation (LT) is related to ischemia-reperfusion injury and may lead to a systemic inflammatory response and extrahepatic organ dysfunction. We evaluated the effect of EAD on new-onset acute kidney injury (AKI) requiring renal replacement therapy within the first month and end-stage renal disease (ESRD) within the first year post-LT in 1325 primary LT recipients. EAD developed in 358 (27%) of recipients. Seventy-one (5.6%) recipients developed AKI and 38 (2.9%) developed ESRD. Compared with those without EAD, recipients with EAD had a higher risk of AKI and ESRD (4% vs. 9% and 2% vs. 6%, respectively, p < 0.001 for both). Multivariate logistic regression analysis showed an independent relationship between EAD and AKI as well as ESRD (odds ratio 3.5, 95% confidence interval 1.9-6.4, and odds ratio 3.1, 95% confidence interval 11.9-91.2, respectively). Patients who experienced both EAD and AKI had inferior 1-, 3-, 5-, and 10-year patient and graft survival compared with those with either EAD or AKI alone, while those who had neither AKI nor EAD had the best outcomes (p < 0.001). Post-LT EAD is a risk factor for both AKI and ESRD and should be considered a target for future intervention to reduce post-LT short- and long-term renal dysfunction.
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Affiliation(s)
- H M Wadei
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - D D Lee
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - K P Croome
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - M L Mai
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - E Golan
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - R Brotman
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - A P Keaveny
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - C B Taner
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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Milan Z. Analgesia after liver transplantation. World J Hepatol 2015; 7:2331-5. [PMID: 26413222 PMCID: PMC4577640 DOI: 10.4254/wjh.v7.i21.2331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/26/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023] Open
Abstract
This article addresses postoperative analgesia in patients with end-stage liver disease who have undergone liver transplantation (LT). Postoperative analgesia determines how patients perceive LT. Although important, this topic is underrepresented in the current literature. With an increased frequency of fast tracking in LT, efficient intra- and postoperative analgesia are undergoing changes. We herein review the current literature, compare the benefits and disadvantages of the therapeutic options, and make recommendations based on the current literature and clinical experience.
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Affiliation(s)
- Zoka Milan
- Zoka Milan, King's College Hospital, SE5 9RS London, United Kingdom
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Diaz G. Potential catalysts in postoperative management/critical care. Liver Transpl 2014; 20 Suppl 2:S16-8. [PMID: 25212664 DOI: 10.1002/lt.23993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/08/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Geraldine Diaz
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
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