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Garg K, Jain AK, Nimje GR, Kajal K. Perioperative care in acute liver failure: An anaesthesiologist perspective in the operating theatre. Indian J Gastroenterol 2024; 43:387-396. [PMID: 38753226 DOI: 10.1007/s12664-024-01575-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/15/2024] [Indexed: 05/28/2024]
Abstract
Acute liver failure (ALF) is a life-threatening condition characterized by rapid liver function deterioration, necessitating a multidisciplinary approach for optimal perioperative care. This comprehensive review focuses on the critical role of the anaesthesiologist throughout the preoperative, intraoperative, and postoperative phases, addressing the unique challenges posed by ALF. The article begins with an exploration of ALF, underlining the urgency of timely referral to specialized hepatology centres. Liver transplantation emerges as a life-saving intervention, and the complex decision-making process is discussed, emphasizing the need for a multidisciplinary team to assess transplantation candidacy based on established prognostic criteria. In the preoperative phase, the review stresses the importance of early engagement with tertiary liver centres for timely referrals and identifies patients suitable for transplantation. Safe transport protocols are detailed, highlighting the meticulous planning required for the secure transfer of ALF patients between healthcare facilities. The intraoperative management section delves into the anaesthesiologist's key concerns, including neurological status, sepsis, acute kidney injury, body mass index, and preoperative fasting. Hemodynamic stability, fluid management, and coagulation balance during surgery are emphasized, with insights into anaesthesia techniques, vascular access, monitoring, and hemodynamic management tailored to the challenges posed by ALF patients. The postoperative care is thoroughly examined covering neurological, hemodynamic, metabolic, renal, and nutritional aspects. Management of ALF involves multidisciplinary team, including nephrology for continuous renal replacement therapy, transfusion medicine for plasma exchange, critical care for overall patient care, nutritionists for ensuring adequate nutrition, and hepatologists as the primary guides. In conclusion, the review recognizes the anaesthesiologist as a linchpin in the perioperative care of ALF patients. The integration of safe transport protocols and multidisciplinary approach is deemed crucial for navigating complexities of ALF, contributing to improved patient outcomes. This article serves as an invaluable resource for gastroenterologist and intensivists, enhancing their understanding of the anaesthesiologist's indispensable role in the holistic care of ALF patients in an ever-evolving healthcare landscape.
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Affiliation(s)
- Kashish Garg
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Satellite Centre, Sangrur, Punjab, India
| | - Anand Kumar Jain
- Department of Organ Transplant Anaesthesia and Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Ganesh Ramaji Nimje
- Department of Organ Transplant Anaesthesia and Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Kamal Kajal
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Caballero M, Sabate A, Perez L, Vidal J, Reverter E, Gutierrez R, Crespo G, Penafiel J, Blasi A. Factors associated with mechanical ventilation longer than 24 h after liver transplantation in patients at risk for bleeding. BMC Anesthesiol 2023; 23:356. [PMID: 37919695 PMCID: PMC10621188 DOI: 10.1186/s12871-023-02321-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND This risk analysis aimed to explore all modifiable factors associated with prolonged mechanical ventilation (lasting > 24 h) after liver transplantation, based on prospectively collected data from a clinical trial. METHODS We evaluated 306 candidates. Ninety-three patients were excluded for low risk for transfusion (preoperative haemoglobin > 130 g.l-1), and 31 patients were excluded for anticoagulation therapy, bleeding disorders, familial polyneuropathy, or emergency status. Risk factors were initially identified with a log-binomial regression model. Relative risk was then calculated and adjusted for age, sex, and disease severity (Model for End-Stage Liver Disease [MELD] score). RESULTS Early tracheal extubation was performed in 149 patients (84.7%), and 27 patients (15.3%) required prolonged mechanical ventilation. Reoperations were required for 6.04% of the early extubated patients and 44% of patients who underwent prolonged ventilation (p = 0.001). A MELD score > 23 was the main risk factor for prolonged ventilation. Once modifiable risk factors were adjusted for MELD score, sex, and age, three factors were significantly associated with prolonged ventilation: tranexamic acid (p = 0.007) and red blood cell (p = 0.001) infusion and the occurrence of postreperfusion syndrome (p = 0.004). The median (IQR) ICU stay was 3 (2-4) days in the early extubation group vs. 5 (3-10) days in the prolonged ventilation group (p = 0.001). The median hospital stay was also significantly shorter after early extubation, at 14 (10-24) days, vs. 25 (14-55) days in the prolonged ventilation group (p = 0.001). Eight patients in the early-extubation group (5.52%) were readmitted to the ICU, nearly all for reoperations, with no between-group differences in ICU readmissions (prolonged ventilation group, 3.7%). CONCLUSION We conclude that bleeding and postreperfusion syndrome are the main modifiable factors associated with prolonged mechanical ventilation and length of ICU stay, suggesting that trials should explore vasopressor support strategies and other interventions prior to graft reperfusion that might prevent potential fibrinolysis. TRIAL REGISTRATION European Clinical Trials Database (EudraCT 2018-002510-13,) and on ClinicalTrials.gov (NCT01539057).
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Affiliation(s)
- Marta Caballero
- Department of Anaesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Antoni Sabate
- Department of Anaesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Barcelona, Spain.
| | - Lourdes Perez
- Department of Anaesthesiology, University Hospital of Bellvitge, University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Julia Vidal
- Department of Anaesthesiology, Clinic Hospital, University of Barcelona Health Campus, IDIBAPS, Barcelona, Spain
| | - Enric Reverter
- Department of Hepatology, Hospital Clínic, Barcelona, IDIBAPS, Spain
| | - Rosa Gutierrez
- Department of Anaesthesiology, University Hospital of Cruces, Bilbao, Spain
| | - Gonzalo Crespo
- Department of Hepatology, Liver Transplant Unit, Hospital Clínic, Barcelona; University of Barcelona; IDIBAPS; CIBERehd, Barcelona, Spain
| | - Judith Penafiel
- Biostatistics Unit (UBiDi), University of Barcelona Health Campus, IDIBELL, Barcelona, Spain
| | - Annabel Blasi
- Department of Anaesthesiology, Clinic Hospital, University of Barcelona Health Campus, IDIBAPS, Barcelona, Spain
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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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Quandahl R, Vanneman MW, Wilke TJ, Kassel CA. 2022 Clinical Updates in Liver Transplantation. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00116-7. [PMID: 36964080 DOI: 10.1053/j.jvca.2023.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Affiliation(s)
- Rachel Quandahl
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Trevor J Wilke
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Cale A Kassel
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
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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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Milne B. Role of Early Extubation After Orthotopic Liver Transplant. EXP CLIN TRANSPLANT 2021; 20:108-111. [PMID: 34775935 DOI: 10.6002/ect.2021.0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Benjamin Milne
- From the Department of Anaesthesia, King's College Hospital, London, United Kingdom
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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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