Intensive Care Unit Enhanced Recovery Pathway for Patients Undergoing Orthotopic Liver Transplants Recipients: A Prospective, Observational Study

Autologous liver transplantation for unresectable hepatobiliary malignancies in enhanced recovery after surgery model

Ex vivo liver resection combined with autologous liver transplantation offers the opportunity to treat otherwise unresectable hepatobiliary malignancies and has been applied in clinic. The implementation of enhanced recovery after surgery (ERAS) program improves the outcome of surgical procedures. This is a retrospective single-center study including 11 cases of patients with liver cancer that underwent autologous liver transplantation and received ERAS: cholangiocarcinoma of the hilar region (n = 5), intrahepatic cholangiocarcinoma (n = 3), gallbladder cancer (n = 1), liver metastasis from colorectal cancer (n = 1), and liver metastasis from gastrointestinal mesenchymal tumor (n = 1). There were no deaths within 30 days and major complications occurred in two patients, and four patients were readmitted upon the first month after the surgery. Median hospital stay was 20 days (range 13-44) and median open diet was Day 4 (range 2-9) after surgery and median early post-operative activity was Day 5 (range 2-9) after surgery. In conclusion, autologous liver transplantation is feasible in the treatment of otherwise unresectable hepatobiliary malignancies, and our study showed favorable results with autologous liver transplantation in ERAS modality. ERAS modality provides a good option for some patients whose tumors cannot be resected in situ and offers a chance for rapid recovery.

The influence of delirium on mortality and length of ICU stay and analysis of risk factors for delirium after liver transplantation

Objective

To analyze the incidence, timing, risk factors and prognosis of delirium after liver transplantation (LT).

Methods

The clinical data of 321 patients undergoing LT in the Third Xiangya Hospital of Central South University from January 2018 to December 2022 were collected to investigate the incidence, onset, and risk factors for post-LT delirium and the impact of delirium on LT recipients' prognosis by statistical analysis.

Results

The incidence of post-LT delirium was 19.3% (62/321), and the median interval between LT and onset of delirium was 20.1 h. Univariate analysis showed that pre-LT variables (Model for End Stage Liver Disease (MELD) score, hospital stay, hepatic encephalopathy, infection, white blood cell (WBC) count, lymphocyte count, abnormal potassium, lactulose use), intraoperative variables (red blood cell transfusion, remimazolam use, dexmedetomidine use) and post-LT variables (hypernatraemia, acute rejection, reoperation, basiliximab use, tacrolimus concentration) were associated with post-LT delirium. Multivariate logistic regression analysis revealed that MELD score at LT ≥22 [OR = 3.400, 95% CI:1.468-7.876, p = 0.004], pre-LT hepatic encephalopathy [OR = 3.224, 95% CI:1.664-6.244, p = 0.001], infection within 2 months prior to LT [OR = 2.238, 95% CI:1.151-4.351, p = 0.018], acute rejection [OR = 2.974, 95% CI:1.322-6.690, p = 0.008], and reoperation [OR = 11.919, 95% CI:2.938-48.350, p = 0.001] were independent risk factors for post-LT delirium. Post-LT delirium was reduced in LT recipients exposing to intraoperative remimazolam [OR = 0.287, 95% CI: 0.113-0.733, p = 0.009] or ≥ 25 μg of intraoperative dexmedetomidine [OR = 0.441, 95% CI 0.225-0.867, p = 0.018]. As for clinical outcomes, patients with delirium had a higher percentage of staying at the (ICU) ≥7 d after LT than those without delirium [OR = 2.559, 95% CI 1.418-4.617, p = 0.002].

Conclusion

The incidence of delirium was high and the onset of delirium was early after LT. Risk factors for post-LT delirium included high MELD score at LT, pre-LT hepatic encephalopathy and infections, acute rejection and reoperation. Intraoperative use of remimazolam or dexmedetomidine reduced post-LT delirium. Delirium had a negative impact on the length of ICU stay.

Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant

BACKGROUND

Immediate postoperative extubation (IPE) can reduce perioperative complications and length of stay (LOS), however it is performed variably after liver transplant across institutions and has historically excluded high-risk recipients from consideration. In late 2012, we planned and implemented a single academic institution structured quality improvement (QI) initiative to standardize perioperative care of liver transplant recipients without exceptions. We hypothesized that such an approach would lead to a sustained increase in IPE after primary (PAC) and delayed abdominal closure (DAC).

METHODS

We retrospectively studied 591 patients from 2013 to 2018 who underwent liver transplant after initiative implementation. We evaluated trends in incidence of IPE versus delayed extubation (DE), and reintubation, LOS, and mortality.

RESULTS

Overall, 476/591 (80.5%) recipients underwent PAC (278 IPE, 198 DE) and 115/591 (19.5%) experienced DAC (39 IPE, 76 DE). When comparing data from 2013 to data from 2018, the incidence of IPE increased from 9/67 (13.4%) to 78/90 (86.7%) after PAC and from 1/12 (8.3%) to 16/23 (69.6%) after DAC. For the same years, the incidence of IPE after PAC for recipients with MELD scores ≥30 increased from 0/19 (0%) to 12/17 (70.6%), for recipients who underwent simultaneous liver-kidney transplant increased from 1/8 (12.5%) to 4/5 (80.0%), and for recipients who received massive transfusion (>10 units of packed red blood cells) increased from 0/17 (0%) to 10/13 (76.9%). Reintubation for respiratory considerations <48 h after IPE occurred in 3/278 (1.1%) after PAC and 1/39 (2.6%) after DAC. IPE was associated with decreased intensive care unit (HR of discharge: 1.92; 95% CI: 1.58, 2.33; P < 0.001) and hospital LOS (HR of discharge: 1.45; 95% CI: 1.20, 1.76; P < 0.001) but demonstrated no association with mortality.

CONCLUSION

A structured QI initiative led to sustained high rates of IPE and reduced LOS in all liver transplant recipients, including those classified as high risk.

A brief history of liver transplantation and transplant anesthesia

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.

Warning and Nursing Experience of Anesthesia Depth Monitoring for Patients with General Anesthesia Delayed to Leave Anesthesia Recovery Room and Delirium

Affected by the residues of narcotic drugs, patients under general anesthesia are vulnerable to emergence of agitation, delirium, hemodynamic changes, and other adverse events in the recovery period of anesthesia. Therefore, it is necessary to strengthen the observation and care of these patients. Depth of anesthesia monitoring (DAM) has always been a concern for anesthesiologists, but there are few reports related to it. This study compared the early warning value of DAM for patients under general anesthesia with delayed exit from the anesthesia recovery unit (PACU) and delirium and summarized the related nursing experience. The results showed that DAM could reduce the incidence of complications in patients under general anesthesia, reduce the incidence of delirium, shorten the time of postoperative anesthesia recovery and PACU observation time, reduce the workload of nursing staff, and improve nursing satisfaction. DAM plays an important role in improving the quality and efficiency of care in PACU.

Textbook outcome among patients undergoing enhanced recovery after liver transplantation stratified by risk. A single-center retrospective observational cohort study

BACKGROUND & AIMS

Liver transplantation (LT) is one of the most complex surgical procedures. Enhanced recovery after surgery (ERAS) aims to reduce the risk of postoperative complications. When patients achieve all desirable outcomes after a procedure, they are considered to have experienced a textbook outcome (TO).

METHODS

Two cohorts of patients undergoing low (n = 101) or medium risk (n = 15) LT were identified. The remaining patients (n = 65) were grouped separately. The ERAS protocol included pre-, intra-, and post-operative steps. TO was defined as the absence of complications, prolonged length of hospital stays, readmission and mortality during the first 90 days.

RESULTS

One third of patients who underwent ERAS after LT experienced a TO. On multivariable analysis, age (OR, 1.05 [95% CI, 1.01-1.09]; P = .02), and having hepatocellular carcinoma (OR, 2.83 [95% CI, 1.37-6.03]; P = .005) were individually associated with a greater probability of achieving a TO. Belonging to the cohorts of medium risk or outside the selection criteria was associated with a lower probability of achieving a TO (OR, 0.46 [96% CI, 0.22-0.93]; P = .03). Patients less likely to experience TO required more hospital resources. Patients who achieved TO were more likely to remain free of chronic kidney disease (achieved TO, 83.8% [82.7-85.6]; failed TO, 67.9% [66.9-70.2]; P < .05). Tacrolimus dose and trough levels were similar.

CONCLUSIONS

A novel finding of our study is that short and medium-term kidney function is better preserved in patients who experience a TO. Better kidney function of patients who achieve TO is not due to lower tacrolimus dosage.

Predicting Early Extubation After Liver Transplantation: External Validation and Improved Generalizability of a Proposed Fast-track Score

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.

Enhanced recovery after surgery programs improve short-term outcomes after liver transplantation - A systematic review and meta-analysis

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.

Association Between Fast-Track Extubation After Orthotopic Liver Transplant, Postoperative Vasopressor Requirement, and Acute Kidney Injury

OBJECTIVES

Acute kidney injury is a significant cause of morbidity after orthotopic liver transplant. Early extubation after liver transplant may have a beneficial effect on postoperative renal function. This may be the result of reduction in vasopressor-mediated vasoconstriction used to counteract the hypotension associated with sedative use and the effects of positive-pressure ventilation. Previous studies explored advantages of early extubation after liver transplant but focused on resource usage rather than clinical benefit. This study was designed to determine the association between fast-track extubation and reduction in postoperative vasopressor requirement and whether this had any association with acute kidney injury incidence or renal replacement therapy requirement.

MATERIALS AND METHODS

Data were collected from 144 orthotopic liver transplants. A propensity-matched case-control analysis was conducted on a subgroup of 33 patients who were fast-track extubated and with 33 propensity score-matched control patients who were not. The primary outcome was median days of postoperative vasopressor use, and secondary outcomes included incidence of acute kidney injury, renal replacement therapy requirement, and critical care admission duration.

RESULTS

The fast-track extubation group had a shorter postoperative vasopressor requirement (0 vs 2 days; P < .01) and a reduced need for renal replacement therapy (3% vs 21.2%; P = .05). Median critical care admission duration (3 vs 4 days; P = .03) and hospital admission duration (14 vs 19 days; P = .04) were shorter in the fast-track extubation group.

CONCLUSIONS

This is the first study to reveal a significant association between fast-track extubation and reduced postoperative vasopressor requirement. Additionally, this was associated with a trend toward reduced renal replacement requirement after liver transplant. It suggests that early extubation may not just be a resource benefit to an institution but may convey a clinical benefit to patients through a reduction in organ failure and requirement for organ support.

Outcomes and resource use for liver transplantation in the United States: Insights from the 2009-2017 National Inpatient Sample

INTRODUCTION

Liver transplantation (LT) is a life-saving treatment for end-stage liver disease patients that requires significant resources. We used national data to evaluate LT outcomes and factors associated with hospital resource use.

METHODS

Using the National Inpatient Sample, we identified all patients undergoing LT from 2009 to 2017 and defined high-resource use (HRU) as having costs ≥ 90th percentile. Hierarchical regression models were used to assess factors associated with length of stay (LOS) and HRU.

RESULTS

Over the study period, approximately 53,000 patients underwent LT, increasing from 5,582 in 2009 to 7,095 in 2017 (nptrend < 0.001). Morbidity and mortality were 42.2% and 3.9%, respectively, with a median post-LT LOS of 10 days. Hospitalization costs increased from $106,866 to $145,868 (nptrend < 0.001). Acute kidney injury (β:4.7 days, P < .001) and end-stage renal disease (ESRD) with dialysis (β:4.3 days, P < .001) were associated with greater LOS while the Northeast region (AOR:5.2, P < .001), ESRD with dialysis (AOR:3.4, P < .001), heart failure (AOR:2.5, P < .001), and fulminant liver disease (AOR:1.8, P = .01) were associated with HRU.

CONCLUSION

The cost of LT has increased over time. Renal dysfunction, regional practice patterns, and patient acuity were associated with greater resource use. Transplanting patients before health deterioration may help contain costs, mitigate resource use, and improve LT outcomes.

Enhanced recovery after low- and medium-risk liver transplantation. A single-center prospective observational cohort study

BACKGROUND & AIMS

Few studies have fully applied an enhanced recovery after surgery (ERAS) protocol to liver transplantation (LT). Our aim was to assess the effects of a comprehensive ERAS protocol in our cohort of low- and medium-risk LT patients.

METHODS

The ERAS protocol included pre-, intra-, and post-operative steps. During the five-year study period, 181 LT were performed in our institution. Two cohorts were identified: low risk patients (n = 101) had a laboratory model for end-stage liver disease (MELD) score of 20 points or less at the time of LT, received a liver from a donor after brain death, and had a balance of risk score of 9 points or less; medium-risk patients (n = 15) had identical characteristics except for a higher MELD score (21-30 points). In addition, we analyzed the remaining patients (n = 65) who were transplanted over the same study period separately using the ERAS protocol.

RESULTS

The low-risk cohort showed a low need for packed red blood cells transfusion (median: 0 units) and renal replacement therapy (1%), as well as a short length of stay both in the intensive care unit (13 h) and in the hospital (4 days); morbidity during one-year follow-up, and probability of surviving to one year (89.30%) and five years (76.99%) were in line with well-established reference data. Similar findings were observed in the medium-risk cohort.

CONCLUSIONS

This single-center prospective observational cohort study provides evidence that ERAS is feasible and safe for low- and medium-risk LT.

Restrictive fluid management strategies and outcomes in liver transplantation: a systematic review

PURPOSE

Restrictive fluid management strategies have been proposed to reduce complications in liver transplant recipients. We conducted a systematic review to evaluate the effects of restrictive perioperative fluid management strategies, compared with liberal ones, on postoperative outcomes in adult liver transplant recipients. Our primary outcome was acute kidney injury (AKI). Our secondary outcomes were bleeding, mortality, and other postoperative complications.

SOURCE

We searched major databases (CINAHL, EMB Reviews, EMBASE, MEDLINE, and the grey literature) from their inception to 10 July 2018 for randomized-controlled trials (RCTs) and observational studies comparing two fluid management strategies (or observational studies reporting two outcomes with available data on fluid volume received) in adult liver transplant recipients. Study selection, data abstraction, and risk of bias assessment were performed by at least two investigators. Data from RCTs were pooled using risk ratios (RR) and mean differences (MD) with random-effect models.

PRINCIPAL FINDINGS

We found seven RCTs and 29 observational studies. Based on RCTs, fluid management strategies did not have any effect on AKI, mortality, or any other postoperative complications. Intraoperative RCTs suggested that a restrictive fluid management strategy reduced pulmonary complications (RR, 0.69; 95% confidence interval [CI], 0.47 to 0.99; n = 283; I² = 27%), duration of mechanical ventilation (MD, -13.04 hr; 95% CI, -22.2 to -3.88; n = 130; I² = 0%) and blood loss (MD, -1.14 L; 95% CI, -1.72 to -0.57; n = 151; I² = 0%).

CONCLUSION

Based on low or very low levels of evidence, we did not find any association between restrictive fluid management strategies and AKI, but we observed possible protective effects of intraoperative restrictive fluid management strategies on other outcomes.

TRIAL REGISTRATION

PROSPERO (CRD42017054970); registered 18 May, 2017.

Critical Care Management of Living Donor Liver Transplants

This article represents a review of the postoperative management of donors and recipients after living donor liver transplant, including monitoring, liberation from mechanical ventilation, nutritional support, and pain control. Vascular complications, such as biliary and sepsis, and bleeding are also discussed. Finally, commonly used immunosuppression and antimicrobial prophylaxes are reviewed.