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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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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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Mian MUM, Kennedy C, Fogarty T, Naeem B, Lam F, Coss-Bu J, Arikan AA, Nguyen T, Bashir D, Virk M, Harpavat S, Raynor T, Rana AA, Goss J, Leung D, Desai MS. The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single-center experience. Pediatr Transplant 2022; 26:e14140. [PMID: 34523781 DOI: 10.1111/petr.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/07/2021] [Accepted: 09/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Children with end-stage liver disease and multi-organ failure, previously considered as poor surgical candidates, can now benefit from liver transplantation (LT). They often need prolonged mechanical ventilation (MV) post-LT and may need tracheostomy to advance care. Data on tracheostomy after pediatric LT are lacking. METHOD Retrospective chart review of children who required tracheostomy in the peri-LT period in a large, freestanding quaternary children's hospital from 2014 to 2019. RESULTS Out of 205 total orthotopic LTs performed in 200 children, 18 (9%) required tracheostomy in the peri-transplant period: 4 (2%) pre-LT and 14 (7%) post-LT. Among those 14 needing tracheostomy post-LT, median age was 9 months [IQR = 7, 14] at LT and 10 months [9, 17] at tracheostomy. Nine (64%) were infants and 12 (85%) were cirrhotic at the time of LT. Seven (50%) were intubated before LT. Median MV days prior to LT was 23 [7, 36]. Eight (57%) patients received perioperative continuous renal replacement therapy (CRRT). The median MV days from LT to tracheostomy was 46 [33, 56]; total MV days from initial intubation to tracheostomy was 57 [37, 66]. Four (28%) children died, of which 3 (21%) died within 1 year of transplant. Total ICU and hospital length of stay were 92 days [I72, 126] and 177 days [115, 212] respectively. Among survivors, 3/10 (30%) required MV at home and 8/10 (80%) were successfully decannulated at 400 median days [283, 584]. CONCLUSION Tracheostomy though rare after LT remains a feasible option to support and rehabilitate critically ill children who need prolonged MV in the peri-LT period.
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Affiliation(s)
- Muhammad Umair M Mian
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Curtis Kennedy
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Thomas Fogarty
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Buria Naeem
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fong Lam
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jorge Coss-Bu
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ayse A Arikan
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Trung Nguyen
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dalia Bashir
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Manpreet Virk
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sanjiv Harpavat
- Department of Pediatrics, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Tiffany Raynor
- Department of Surgery, Division of Pediatric Otolaryngology, Baylor College of Medicine, Houston, TX, USA
| | - Abbas A Rana
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX, USA
| | - John Goss
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Leung
- Department of Pediatrics, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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Ünlükaplan A, Torgay A, Pirat A, Arslan G, Haberal M. Predictors of Immediate Tracheal Extubation in the Operating Room After Pediatric Liver Transplantation. EXP CLIN TRANSPLANT 2020. [PMID: 32370697 DOI: 10.6002/ect.2019.0312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Pediatric orthotopic liver transplant recipients frequently need mechanical ventilation during the immediate posttransplant period. However, intensive care unit beds are costly and scarce; therefore, anticipating which patients will require postoperative mechanical ventilation support is important. In addition, immediate postoperative extubation may reduce the incidence of postoperative respiratory complications and improve patient outcomes after orthotopic liver transplant. Here, we aimed to determine the predictors of need for mechanical ventilation after orthotopic liver transplant in pediatric patients. MATERIALS AND METHODS We retrospectively analyzed the records of 57 pediatric patients who underwent orthotopic liver transplant (performed by the same team at Baskent University Hospital from April 1996 to August 2009). Patients were divided into 2 groups according to whether they required postoperative mechanical ventilation or not. Collected data included demographic features; comorbidities; cause of liver failure; perioperative laboratory values; intraoperative hemodynamic parameters; use and volume of crystalloids, colloids, and blood products; albumin levels; portal vein clamping time, requirement of inotropes/vasopressors; and anesthesia duration. RESULTS Mean age and body weight of patients were 25.0 ± 23.1 months and 10.8 ± 5.3 kg, respectively. Of 57 patients, 26 (46%) needed postoperative mechanical ventilation. Compared with those who did not require postoperative mechanical ventilation, patients who required mechanical ventilation had growth failure (P = .03), higher mean intraoperative lactate level (P = .03), and higher mean intraoperative fresh frozen plasma/erythrocyte suspension (P = .049) and intraoperative vasopressor (P = .022) requirements. Multivariate logistic regression analysis revealed that growth failure (odds ratio = 37; P = .03) and higher intraoperative lactate level (odds ratio = 1.5; P = .03) were predictors of the need for mechanical ventilation. CONCLUSIONS About 46% of our pediatric orthotopic liver transplant recipients required mechanical ventilation postoperatively. Growth failure and higher intraoperative lactate levels were associated with need for postoperative mechanical ventilation.
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Affiliation(s)
- Aytekin Ünlükaplan
- From the Department of Anesthesiology, Acibadem Maslak Hospital, Istanbul, Turkey
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5
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Segurança do paciente no intraoperatório do transplante hepático: revisão integrativa. ACTA PAUL ENFERM 2020. [DOI: 10.37689/acta-ape/2020ar0187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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6
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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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Li J, Wang C, Chen N, Song J, Sun Y, Yao Q, Yan L, Yang J. Immediate postoperative tracheal extubation in a liver transplant recipient with encephalopathy and the Mayo end-stage liver disease score of 41: A CARE-compliant case report revealed meaningful challenge in recovery after surgery (ERAS) for liver transplantation. Medicine (Baltimore) 2017; 96:e8467. [PMID: 29381921 PMCID: PMC5708920 DOI: 10.1097/md.0000000000008467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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
RATIONALE Immediate postoperative tracheal extubation (IPTE) is one of the most important subject in recovery after surgery (ERAS) for liver transplantation. However, the criteria for IPTE is not uniform at present. PATIENT CONCERNS We reported a successful IPTE in a liver transplant recipient with encephalopathy and a high Mayo end-stage liver disease (MELD) score of 41, which beyond the so-called criteria reported in the literature. The patient was 48-year-old man, admitted in September 2016 for end-stage liver cirrhosis secondary to hepatitis B. DIAGNOSES End-stage liver cirrhosis secondary to hepatitis B with encephalopathy and a high MELD score of 41. INTERVENTIONS He was involved in our ERAS project and was extubated at the end of the liver transplantation in the operating room. OUTCOMES As a result, the patient was not reintubated and had an excellent postoperative recovery, staying in intensive care unit (ICU) for just 2 days and discharged home on day 10. LESSONS We believed IPTE in liver transplant recipients with severe liver dysfunction is a meaningful challenge in ERAS for liver transplantation. Our case and literature review suggest 3 things: IPTE in liver transplantation is generally feasible and safe; the encephalopathy or high MELD score should not be the only limiting factor; and a more systematic predicting system for IPTE in liver transplantation should be addressed in future studies.
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Affiliation(s)
- Jianbo Li
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University
| | - Chengdi Wang
- Department of Respiratory and Critical Care Medicine, West China Medical School/West China Hospital
| | - Nan Chen
- West China School of Medicine/West China Hospital, Sichuan University
| | - Jiulin Song
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University
| | - Yan Sun
- West China School of Medicine/West China Hospital, Sichuan University
| | - Qin Yao
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, P.R. China
| | - Lunan Yan
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University
| | - Jiayin Yang
- Department of Liver Surgery and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University
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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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9
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Abstract
Anesthesia for liver transplantation pertains to a continuum of critical care of patients with end-stage liver disease. Hence, anesthesiologists, armed with a comprehensive understanding of pathophysiology and physiologic effects of liver transplantation on recipients, are expected to maintain homeostasis of all organ function. Specifically, patients with fulminant hepatic failure develop significant changes in cerebral function, and cerebral perfusion is maintained by monitoring cerebral blood flow and cerebral metabolic rate of oxygen, and intracranial pressure. Hyperdynamic circulation is challenged by the postreperfusion syndrome, which may lead to cardiovascular collapse. The goal of circulatory support is to maintain tissue perfusion via optimal preload, contractility, and heart rate using the guidance of right-heart catheterization and transesophageal echocardiography. Portopulmonary hypertension and hepatopulmonary syndrome have high morbidity and mortality, and they should be properly evaluated preoperatively. Major bleeding is a common occurrence, and euvolemia is maintained using a rapid infusion device. Pre-existing coagulopathy is compounded by dilution, fibrinolysis, heparin effect, and excessive activation. It is treated using selective component or pharmacologic therapy based on the viscoelastic properties of whole blood. Hypocalcemia and hyperkalemia from massive transfusion, lack of hepatic function, and the postreperfusion syndrome should be aggressively treated. Close communication between all parties involved in liver transplantation is also equally valuable in achieving a successful outcome.
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10
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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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Fullington NM, Cauley RP, Potanos KM, O'Melia L, Zurakowski D, Bae Kim H, Seefelder C, Vakili K. Immediate extubation after pediatric liver transplantation: a single-center experience. Liver Transpl 2015; 21:57-62. [PMID: 25368908 DOI: 10.1002/lt.24036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 09/08/2014] [Accepted: 09/14/2014] [Indexed: 02/07/2023]
Abstract
The care of pediatric liver transplant recipients has traditionally included postoperative mechanical ventilation. In 2005, we started extubating children undergoing liver transplantation in the operating room according to standard criteria for extubation used for general surgery cases. We reviewed our single-center experience to determine our rates of immediate extubation and practice since that time. The records of 84 children who underwent liver transplantation from 2005 to 2011 were retrospectively reviewed. The immediate extubation rate increased from 33% during 2005-2008 to 67% during 2009-2011. Immediate extubation did not result in an increased reintubation rate in comparison with delayed extubation in the intensive care unit (ICU). Patients undergoing immediate extubation had a trend toward a shorter mean ICU stay as well as a significantly decreased overall hospital length of stay. Our findings suggest that there is a learning curve for instituting immediate extubation in the operating room after liver transplantation and that the majority of pediatric liver recipients can safely undergo immediate extubation.
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12
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Lee S, Sa GJ, Kim SY, Park CS. Intraoperative predictors of early tracheal extubation after living-donor liver transplantation. Korean J Anesthesiol 2014; 67:103-9. [PMID: 25237446 PMCID: PMC4166381 DOI: 10.4097/kjae.2014.67.2.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/19/2014] [Accepted: 02/07/2014] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Prolonged mechanical ventilation after liver transplantation has been associated with deleterious clinical outcomes, so early tracheal extubation posttransplant is now increasing. However, there is no universal clinical criterion for predicting early extubation in living-donor liver transplantation (LDLT). We investigated specific predictors of early extubation after LDLT. METHODS Perioperative data of adult patients undergoing LDLT were reviewed. "Early" extubation was defined as tracheal extubation in the operating room or intensive care unit (ICU) within 1 h posttransplant, and we divided patients into early extubation (EX) and non-EX groups. Potentially significant (P < 0.10) perioperative variables from univariate analyses were entered into multivariate logistic regression analyses. Individual cut-offs of the predictors were calculated by area under the receiver operating characteristic curve (AUC) analysis. RESULTS Of 107 patients, 66 (61.7%) were extubated early after LDLT. Patients in the EX group showed shorter stays in the hospital and ICU and lower incidences of reoperation, infection, and vascular thrombosis. Preoperatively, model for end-stage liver disease score, lung disease, hepatic encephalopathy, ascites, and intraoperatively, surgical time, transfusion of packed red blood cell (PRBC), urine output, vasopressors, and last measured serum lactate were associated with early extubation (P < 0.05). After multivariate analysis, only PRBC transfusion of ≤ 7.0 units and last serum lactate of ≤ 8.2 mmol/L were selected as predictors of early extubation after LDLT (AUC 0.865). CONCLUSIONS Intraoperative serum lactate and blood transfusion were predictors of posttransplant early extubation. Aggressive efforts to ameliorate intraoperative circulatory issues would facilitate successful early extubation after LDLT.
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Affiliation(s)
- Serin Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Gye Jeol Sa
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Stephanie Youna Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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13
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Graziadei I. [Intensive care treatment before and after liver transplantation]. Med Klin Intensivmed Notfmed 2014; 109:411-7. [PMID: 25142222 DOI: 10.1007/s00063-014-0364-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 06/21/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Liver transplantation (LT) has become an established therapeutic option for patients with acute and chronic liver failure. Overall survival has dramatically increased over the last decades, mainly due to improved surgical techniques, the introduction of new immunosuppressive and anti-infective drugs but also due to continuous progress in the pre- and post-operative intensive care management of these patients. AIM This article aims to give a short overview of the main aspects regarding pre- and post-LT critical care issues. RESULTS Intensive care treatment plays a major role in the management of patients with acute and acute-on-chronic liver failure in order to enable a life-saving LT for these patients. Severe infections/sepsis mostly accompanied by multi-organ failure represent the major challenges for intensive care specialists. The immediate postoperative care takes place in the intensive care unit (ICU) in almost all patients. The expected ICU stay has been significantly shortened over the years to an average of about 1-2 days. Infections as well as acute kidney injury are the main complications in the first post-operative weeks being responsible for prolonged ICU stays. Immunologic and surgical complications are additional important issues in the post-LT intensive care setting. CONCLUSION The intensive care management pre and post LT is an important, multidisciplinary challenge in the successful treatment of patients with acute and chronic liver failure.
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Affiliation(s)
- I Graziadei
- Abteilung für Innere Medizin, Landeskrankenhaus Hall i.T., Milserstr. 10, 6060, Hall, Österreich,
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14
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Ramsay M. Justification for routine intensive care after liver transplantation. Liver Transpl 2013; 19 Suppl 2:S1-5. [PMID: 24038741 DOI: 10.1002/lt.23745] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/27/2013] [Indexed: 01/12/2023]
Affiliation(s)
- Michael Ramsay
- Department of Anesthesiology, Baylor University Medical Center, Dallas, TX
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15
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Wu J, Rastogi V, Zheng SS. Clinical practice of early extubation after liver transplantation. Hepatobiliary Pancreat Dis Int 2012; 11:577-85. [PMID: 23232628 DOI: 10.1016/s1499-3872(12)60228-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anesthetic practices such as early tracheal extubation facilitate postoperative recovery. Early extubation after liver transplantation has been adopted by some centers in the recent two decades. No universal clinical guidelines are used and questions remain. This review aimed to address the current status of early extubation after liver transplantation. DATA SOURCES A literature search of MEDLINE and ISI Web of Knowledge databases was performed using terms such as liver transplantation, early extubation, immediate tracheal extubation, fast tracking or fast track anesthesia and postoperative tracheal extubation. Additional papers were identified by a manual search of the references in the key articles. RESULTS Review of the available literature provided an insight into the definition, evolution, advantages and risks of early extubation, and anesthetic techniques that prompt early extubation in liver transplant patients. Early extubation has proved to be feasible and safe in these patients, but the outcomes are still uncertain. CONCLUSIONS Early extubation after liver transplantation is feasible, safe and cost-effective in the majority of patients and has been increasingly accepted as an option for conventional postoperative ventilation. Comprehensive and individualized evaluation of the patient's condition before extubation by an experienced anesthesiologist is the cornerstone of success. Understanding of its effect on the outcome remains incomplete. In the future, additional trials are required to establish universal early extubation guidelines and to determine its benefits for patients and practitioners.
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Affiliation(s)
- Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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Rando K, Niemann CU, Taura P, Klinck J. Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to medium-income countries. Liver Transpl 2011; 17:1247-78. [PMID: 21837742 DOI: 10.1002/lt.22405] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) is a highly effective treatment, it has been considered too costly for publicly funded health systems in many countries with low to medium average incomes. However, with economic growth and improving results, some governments are reconsidering this position. Cost-effectiveness data for LT are limited, especially in perioperative care, and the techniques and costs vary widely between centers without overt differences in outcomes. Anesthesiologists working in new programs find it difficult to determine which modalities are essential, which are needed only in exceptional circumstances, and which may be omitted without effects on outcomes. We investigated key elements of preoperative evaluations, intraoperative management, and early postoperative care that might significantly affect costs in order to develop a best-value approach for new programs in resource-limited health systems. We identified all modalities of care commonly used in anesthesia and perioperative care for adult LT along with their costs. Those considered to be universally accepted as minimum requirements for safe care were excluded from the analysis, and so were those considered to be safe and low-cost, even when evidence of efficacy was lacking. The remaining items were, therefore, those with uncertain or context-restricted value and significant costs. A systematic review of the published evidence, practice surveys, and institutional guidelines was performed, and the evidence was graded and summarized. With respect to costs and benefits, each modality was then cited as strongly recommended, recommended or optional, or no recommendation was made because of insufficient evidence. Sixteen modalities, which included preoperative cardiovascular imaging, venovenous bypass, pulmonary artery catheterization, high-flow fluid warming devices, drug therapies for hemostasis, albumin, cell salvage, anesthetic drugs, personnel (staffing) requirements, and early extubation, were assessed. Only high-flow fluid warming was strongly recommended. The recommended modalities included preoperative echocardiography, cell salvage, tranexamic acid and early extubation. Six others were rated optional, and there was insufficient evidence for 5 modalities. We conclude that some costly techniques and treatments can be omitted without adverse effects on outcomes.
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Affiliation(s)
- Karina Rando
- Department of Hepatic Diseases, Military Hospital, Montevideo, Uruguay
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17
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Anesthesia care for liver transplantation. Transplant Rev (Orlando) 2011; 25:36-43. [PMID: 21126662 DOI: 10.1016/j.trre.2010.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 10/04/2010] [Indexed: 12/13/2022]
Abstract
Intraoperative transfusion practices for liver transplantation have evolved dramatically since the first transplants of the 1960s. It is important for today's clinicians to be current in their understanding of how transplant patients should be managed with regard to their coagulation profile, volume status, and general hemodynamic state. The anesthesia team is presented with the unique task of manipulating this tenuous balance in a rapid and precise manner when managing patients undergoing liver transplantation. Although significant progress has been made in reducing blood product administration, it is still common to encounter large volume blood loss in these cases. Increasingly, clinicians are challenged to justify transfusion practices with a stronger evidentiary base. The current state of the literature for transfusion guidelines and blood product management in this particular patient subset will be discussed, as well as a variety of means (both pharmacologic and otherwise) used to reduce the need for transfusion. The aim was to review the latest evidence on these topics, as well as to highlight areas that need further clarification regarding their role in the optimal care of these patients.
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Mandell MS, Tsou MY. The development of perioperative practices for liver transplantation: advances and current trends. J Chin Med Assoc 2008; 71:435-41. [PMID: 18818135 DOI: 10.1016/s1726-4901(08)70145-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Transplantation is a young medical specialty that has grown rapidly over the past 50 years. Anesthesiologists, surgeons and hepatologists are all essential partners in the process of determining patient outcome. Each specialty has made landmark improvements in patient outcome. However, there is still variability in practice patterns in each of the 3 major specialties. This review will use a historic perspective to explore the unique forces that shaped specific transplant practices and those that gave rise to differences in perioperative practices. Anesthesiologists and surgeons have made significant improvements in the management of blood loss, and coagulation monitoring and intervention. This has improved operative survival and early patient outcome. Perioperative survival has improved despite a worldwide shortage of donor organs and a trend to transplant sicker patients. A smaller pool of donor organs is required to meet the needs of an expanding waiting list. The innovations to reduce deaths on the transplant wait list are reviewed along with their impact on overall patient outcome. The evolving organ shortage is the pinnacle point in shaping future transplant practices. Currently, institutional-specific practices may be reinforced by the informal "tutorship" that is used to train physicians and by the resources available at each site of practice. However, there is evidence that specific intraoperative practices such as the use of a low central venous pressure, selection of vasopressors and certain surgical techniques can modify patient outcome. Further investigation is needed to determine whether the good or the bad associated with each practice prevails and in what unique circumstance.
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Affiliation(s)
- Merceds Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Aurora, Colorado, USA
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21
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Affiliation(s)
- Randolph H Steadman
- Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1778, USA.
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22
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO, USA.
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23
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Zeyneloglu P, Pirat A, Guner M, Torgay A, Karakayali H, Arslan G. Predictors of Immediate Tracheal Extubation in the Operating Room After Liver Transplantation. Transplant Proc 2007; 39:1187-9. [PMID: 17524928 DOI: 10.1016/j.transproceed.2007.02.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Immediate postoperative extubation may reduce the incidence of postoperative respiratory complications after orthotopic liver transplantation (OLT). We evaluated the predictors of immediate tracheal extubation in the operating room (OR) in our patients by retrospectively reviewing data from all patients who underwent OLT between January 2004 and June 2006. The patients were divided into two groups according to whether they had undergone extubation in the OR (group 1 n=52) or in the intensive care unit (ICU; group 2 n=48). When compared with the patients in group 2, those in group 1 had lower mean preoperative serum creatinine levels (0.9 +/- 1 vs 0.6 +/- 0.3 mg/dL, P=.04) and intraoperative transfusion requirements (packed red blood cells, 35.5 +/- 29.8 vs 25.6 +/- 19.0 mL/kg; P=.05, and fresh frozen plasma, 33.1 +/- 15.6 vs 25.7 +/- 14.3 mL/kg; P=.01). The incidence of intraoperative hypotension and emergent OLT was significantly greater in group 2 than group 1 (33.3% vs 13.5%, P=.01 and 45.8% vs 21.2%, respectively, P=.009). On logistic regression analysis, only emergent OLT (P=.009, odds ratio = 3.5) and intraoperative hypotension (P=.018, odds ratio = 3.7) were significantly associated with a lower probability of immediate postoperative extubation in the OR. Our results suggested that hemodynamic stability and elective OLT were predictors of successful immediate tracheal extubation in the OR.
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Affiliation(s)
- P Zeyneloglu
- Department of Anesthesiology, Baskent University Faculty of Medicine, Ankara, Turkey.
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Salizzoni M, Cerutti E, Romagnoli R, Lupo F, Franchello A, Zamboni F, Gennari F, Strignano P, Ricchiuti A, Brunati A, Schellino MM, Ottobrelli A, Marzano A, Lavezzo B, David E, Rizzetto M. The first one thousand liver transplants in Turin: a single-center experience in Italy. Transpl Int 2006; 18:1328-35. [PMID: 16297051 DOI: 10.1111/j.1432-2277.2005.00215.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The first Italian liver transplant center to reach the goal of 1000 procedures was Turin. The paper reports this single-center experience, highlighting the main changes that have occurred over time. From 1990 to 2002, 1000 consecutive liver transplants were performed in 910 patients, mainly cirrhotics. Surgical technique was based on the preservation of the retrohepatic vena cava of the recipient. The veno-venous bypass was used in 30 cases only and abandoned since 1997. Operating time, warm ischemia time and length of hospital stay significantly decreased over the years, while operating room extubation became routine. Immunosuppression pivoted on cyclosporine A. Management of retransplantations, marginal grafts, and of HCV-positive, HBV-positive and hepatocellular carcinoma recipients were optimized. Median follow-up of the patients was 41 months. Overall survival rates at 1, 5 and 10 years were 87%, 78% and 72% respectively. Survival rates obtained in the second half of the cases (1999-2002 period) were significantly better than those obtained in the first half (1990-1998 period) (90% vs. 83% at 1 year and 81% vs. 76% at 5 years respectively). Increasing experience in liver transplant surgery and postoperative care allowed standardization of the procedure and expansion of the activity, with parallel improvement of the results.
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Affiliation(s)
- Mauro Salizzoni
- Liver Transplantation Center, San Giovanni Battista Hospital, Turin, Italy.
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Affiliation(s)
- Mike Lindop
- Department of Anesthesia, Addenbrookes Hospital, Cambridge, UK.
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