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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: 22] [Impact Index Per Article: 7.3] [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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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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Transplant Critical Care: Is there a Need for Sub-specialized Units? - A Perspective. ACTA ACUST UNITED AC 2018; 4:83-89. [PMID: 30582000 PMCID: PMC6294987 DOI: 10.2478/jccm-2018-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/15/2018] [Indexed: 01/27/2023]
Abstract
The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.
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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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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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Biancofiore G, Bindi M, Ghinolfi D, Lai Q, Bisa M, Esposito M, Meacci L, Mozzo R, Spelta A, Filipponi F. Octogenarian donors in liver transplantation grant an equivalent perioperative course to ideal young donors. Dig Liver Dis 2017; 49:676-682. [PMID: 28179097 DOI: 10.1016/j.dld.2017.01.149] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Use of grafts from very old donors for liver transplantation is controversial. AIM To compare the perioperative course of patients receiving liver grafts from young ideal vs octogenarian donors. METHODS Analysis of the perioperative course of patients receiving liver grafts from young, ideal (18-39 years) vs octogenarian (≥80years) deceased donors between 2001 and 2014. RESULTS 346 patients were studied: 179 (51.7%) received grafts aged 18-39 years whereas 167 (48.3%) received a graft from a donor aged ≥80years. Intra-operative cardiovascular (p=0.2), coagulopathy (p=0.5) and respiratory (p=1.0) complications and incidence of reperfusion syndrome (p=0.3) were similar. Patients receiving a young graft required more fresh frozen plasma units (p≤0.03) but did not differ for the need of packed red cells (p=0.2) and platelet (p=0.3) transfusions. Median ICU stay was identical (p=0.4). Patients receiving octogenarian vs young grafts did not differ in terms of death or re-transplant (p=1.0) during the ICU stay. Similar cardiovascular, respiratory, renal, infectious and neurological postoperative complication rates were observed in the two groups. CONCLUSIONS Octogenarian donors in liver transplantation grant an equivalent perioperative course to ideal young donors.
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Affiliation(s)
- Gianni Biancofiore
- Anaesthesia and Critical Care for General and Transplantation Surgery, Azienda Ospedaliera-Universitaria Pisana, Italy.
| | - Maria Bindi
- Anaesthesia and Critical Care for General and Transplantation Surgery, Azienda Ospedaliera-Universitaria Pisana, Italy
| | - Davide Ghinolfi
- Hepatobiliary and Liver Transplant Surgery, University School of Medicine, Pisa, Italy
| | - Quirino Lai
- Hepatobiliary and Liver Transplant Surgery, University School of Medicine, Pisa, Italy
| | - Massimo Bisa
- Anaesthesia and Critical Care for General and Transplantation Surgery, Azienda Ospedaliera-Universitaria Pisana, Italy
| | - Massimo Esposito
- Anaesthesia and Critical Care for General and Transplantation Surgery, Azienda Ospedaliera-Universitaria Pisana, Italy
| | - Luca Meacci
- Anaesthesia and Critical Care for General and Transplantation Surgery, Azienda Ospedaliera-Universitaria Pisana, Italy
| | - Roberto Mozzo
- Anaesthesia and Critical Care for General and Transplantation Surgery, Azienda Ospedaliera-Universitaria Pisana, Italy
| | - Alicia Spelta
- Anaesthesia and Critical Care for General and Transplantation Surgery, Azienda Ospedaliera-Universitaria Pisana, Italy
| | - Franco Filipponi
- Hepatobiliary and Liver Transplant Surgery, University School of Medicine, Pisa, Italy
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