Anesthesia for liver transplantation in US academic centers: institutional structure and perioperative care

Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE

BACKGROUND

Anesthesiologists frequently use intraoperative transesophageal echocardiography (TEE) to aid in the diagnosis and management of hemodynamic problems during liver transplantation (LT). Although the use of TEE in US centers continues to increase, data regarding international use are lacking.

METHODS

This prospective, global, survey-based study evaluates international experience with TEE for LT. Responses from 252 LT (105 US and 147 non-US) centers representing 1789 anesthesiologists were analyzed.

RESULTS

Routine use of TEE in the United States has increased in the last 5 y (from 37% to 47%), but only 21% of non-US LT anesthesiologists use TEE routinely. Lack of training (44% US versus 70% non-US) and equipment (9% non-US, versus 34% US) were cited as obstacles. Most survey participants preferred not to perform a complete cardiac examination but rather use only 6 of 11 basic views. Although non-US LT anesthesiologists more frequently had additional clinical training than their US counterparts, they had less TEE experience (13% versus 44%) and less frequently, TEE certification (22% versus 35%). Most LT anesthesiologists agreed that TEE certification is essential for proficiency. Of all respondents, 89% agreed or strongly agreed that TEE provides valuable information needed for immediate clinical decision-making, and >86% agreed or strongly agreed that that information could not be derived from other sources.

CONCLUSIONS

The use of TEE for LT surgery in the US LT centers is currently higher compared with non-US LT centers. This may become a standard monitoring modality during LT in the near future.

International Liver Transplantation Society/Society for Advancement of Transplant Anesthesia Consensus Statement on Essential Attributes of a Liver Transplant Anesthesiologist

BACKGROUND

We sought to establish consensus on the essential skills, knowledge, and attributes that a liver transplant (LT) anesthesiologist should possess in a bid to help guide the further training process.

METHODS

Consensus was achieved via a modified Delphi methodology, surveying 15 identified international experts in the fields of LT anesthesia and critical care.

RESULTS

Key competencies were identified in preoperative management and optimization of a potential LT recipient; intraoperative management, including hemodynamic monitoring; coagulation and potential crisis management; and postoperative intensive and enhanced recovery care.

CONCLUSIONS

This article provides an essential guide to competency-based training of an LT anesthesiologist.

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 comparison of pediatric liver transplant anesthesia practices with new organ procurement and transplant network pediatric policy requirements: A report from the society for the advancement of transplant anesthesia and the society for pediatric anesthesia

INTRODUCTION

Organ Procurement and Transplant Network (OPTN) pediatric policies on knowledge and skill requirements for key personnel failed to address the Director of Anesthesia for Pediatric Liver Transplantation. A Joint Committee representing the Society for the Advancement of Transplant Anesthesia and Society for Pediatric Anesthesia (SPA) surveyed all pediatric anesthesia liver transplant practices to determine if practices were aligned with policies and what changes would be needed for compliance.

METHODS

A survey of the Director or equivalent at each program collected data about specialized knowledge and skill sets. Questions focused on (1) skill and knowledge of the Director and team, (2) requirements for appointment, (3) experience in pediatrics, and (4) characteristics of the program including the availability of pediatric resources.

RESULTS

Response rate was 73% (n = 63). Most responding programs had a Director (67%) with certification, selection committee, and continuing education credits outlined in existing policies. Team members met similar requirements. Alternate pathways for acquiring knowledge and skill sets were identified between programs.

CONCLUSIONS

Pediatric liver transplant anesthesiologists use knowledge and skill pathways that align with the new pediatric policies. We suggest that collaborative work with oversight agencies is needed to resolve high case volume requirements originally designed for adult programs.

SUMMARY

Most pediatric liver transplant anesthesiologists in the US have specialized knowledge and skills for expert care consistent with current oversight policies. Differences in pathways to acquire knowledge and skill sets were still aligned with the new policies for pediatric transplant surgeons and bylaws for the Director of Transplant Anesthesia. We conclude that minimal changes in case volume requirements to the existing Pediatric Transplant Anesthesiology Directorship criteria that authenticates the pediatric anesthesia Director's position would improve the safety of care without limiting access to transplantation.

Outcomes following formation of a dedicated pediatric liver transplant anesthesia team

BACKGROUND

Given the complex nature of liver transplant surgery, adult centers typically use a dedicated liver transplant anesthesia team, which has improved patient outcomes.

AIMS

Our goal was to determine whether a dedicated pediatric liver transplant anesthesia team was associated with improved patient outcomes.

METHODS

This retrospective cohort study analyzed patients who underwent liver transplantation from April 2013 to September 2020 at St. Louis Children's Hospital. The general group (April 2013-December 2016) was compared with the liver group (January 2017-September 2020). Outcomes measured included cases per anesthesiologist, early extubation, ventilator days, fluid and blood administration, postoperative events, and intensive care unit and hospital length of stay (LOS).

RESULTS

Patients in both groups had similar demographics. The average number of cases/anesthesiologist/year was 2.9 times higher in the liver group (mean (SD) general 0.7 (0.5), liver 2.0 (0.6), and difference in mean [95% CI] 1.3 [0.8, 1.8]). The rate of extubation in the operating room was higher for patients in the liver group (general 56%, liver 80%, and difference in proportion [95% CI] 24.7 [7.0, 42.4]), while the number of ventilator days was lower (mean (SD) general 2.1 (4.4), liver 1.1 (3.6), and difference in proportion [95%CI] -0.9 [-2.6, 0.7]). Colloid administration was higher in the liver group (mean (SD) general 23.9 (14.5) ml/kg, liver 48.4 (37.7) ml/kg, and difference in mean [95% CI] 24.6 [12.7, 36.4]), while fresh frozen plasma administration was lower in the liver group (mean (SD) general 15.3 (23.9) ml/kg, liver 6.2 (14) ml/kg, and difference in mean [95% CI] -9.0 [-16.8, -1.3]). There were no significant differences between the groups in postoperative events including blood product transfusions, vasopressor use, and thromboses, or in the intensive care unit and hospital LOS.

CONCLUSIONS

The liver group was associated with increased early extubations, decreased ventilator days, and decreased fresh frozen plasma use.

Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia

INTRODUCTION

Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors.

METHODS

Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%).

RESULTS

Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys.

CONCLUSION

The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.

Perioperative Viscoelastic Assay Use for Monitoring Coagulation Among US Liver Transplantation Centers

BACKGROUND

Viscoelastic assay has been used in liver transplantation since 1985 and shown to be beneficial in detecting coagulopathy and to guide transfusion. The objective of this study was to review and evaluate the current uses of viscoelastic assay among US liver transplantation programs.

METHODS

Anesthesia program directors at all 137 liver transplantation centers in the United States were contacted via email and asked to complete a 21-item survey. The primary outcome measure was the percentage of viscoelastic assay used in the perioperative management of liver transplantation. Secondary outcome measures were institutional demographics, physician training level, and device demographics.

RESULTS

Sixty-one of 137 (46%) centers responded. Liver transplantations were performed in the university setting at 48 of the 61 centers (77%), with a modal value of 11 to 50 liver transplantations a year and 74% in adult patients only. Most of the institutions (n = 57, 92%) had access to either rotational thromboelastometry or thrombelastography during liver transplantation. Most centers (n = 54; 87%) also used viscoelastic monitoring routinely (>60% of the time), including 42 (67.7%) that always used viscoelastic assay intraoperatively during liver transplantation. Thirty-five centers (59%) used it preoperatively, and 51 (84%) used it postoperatively. Most viscoelastic assay users (68%) learned how to use it through self-education and 10.5% learned during their fellowship or from a superuser or colleagues.

CONCLUSION

Currently, viscoelastic monitoring is widely available and routinely used in most US liver transplantation centers regardless of university or private practice setting, but training in it is limited. Only 21.1% of respondents reported that they received any type of official training in viscoelastic assay interpretation.

Pediatric liver transplantation in Australia and New Zealand: The case for a collaborative anesthetic database

BACKGROUND

Liver transplantation is conducted with strict oversight of organizational structure and clinical practice. However, specific regulations pertaining to the delivery of anesthetic services are lacking and consideration of departmental structure and mechanisms for quality control must occur at a local level. Busy centers collect and process sufficient data to guide this process but those with low case loads may not generate enough data for useful analysis. In Australia and New Zealand, pediatric liver transplants are performed at only four locations. As these operations are not equally distributed geographically or temporally there are periods of low activity at some centers. As anesthesia affects patient outcome, quality assurance activities are important in this setting.

AIMS

Provide a global overview of the structure and function of liver transplantation networks. Identify issues related to provision of pediatric anesthetic services with specific reference to Australasia. Examine anesthetic data from a single pediatric center to illustrate benefits and limitations of such activity.

METHODS

Pediatric liver transplant centers from Australia and New Zealand were surveyed to determine the organizational and logistical issues related to a liver transplant service. An audit of 15 years of liver transplants from a single center was conducted for benchmarking purposes and to identify changes in anesthetic practice over time.

RESULTS

Pediatric liver transplants performed in Queensland from January 2005 to December 2019 were reviewed. Changes in transfusion practice reflected international trends. Morbidity and mortality were comparable to international data. Important complications such as hepatic artery and portal vein thrombosis were uncommon and did not generate enough data for further analysis.

CONCLUSIONS

Combining the anesthetic liver transplant data from all sites in a single registry would expand data collection and generate broadly applicable findings. We propose the establishment of an Australasian pediatric anesthetic liver transplant database.

Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.

Enhanced recovery after surgery and practical application to liver transplantation

There is a growing support for the use of protocols that incorporate multiple steps aimed at reducing the time patients require to regain health. A recurring limitation is the variable outcomes of these protocols with more or less success at the sites at which they are instituted. This review examines the essential building blocks needed to launch a successful ERAS protocol. It addresses why there are differences in outcome measures between centers such as the length of stay and the cost of care even if the protocols and patient populations are similar.

Use, Training, and Opinions About Effectiveness of Transesophageal Echocardiography in Adult Liver Transplantation Among Anesthesiologists in the United States

Study Objective. Describe transesophageal echocardiography (TEE) use, preparatory training and opinions about clinical importance, and future training pathways in a sample of liver transplant anesthesiologists. Design. Online survey questionnaire. Setting. Liver Transplant Centers in the United States. Participants. Director of Liver Transplant Anesthesia or designated alternate respondent. Results. A total of 79 Directors or alternates from 111 (71%) centers were identified. There were 56 responses (71%) representing 433 transplant anesthesiologists who cared for 63.3% of liver transplant cases performed in 2015. Basic TEE certification was reported more frequently (64%) than advanced (53.6%). At least one team member used TEE in over 90% of responding centers. Most respondents (83.9%) agreed TEE provided unique and valuable clinical information but were equally divided about future training pathways (on the job learning vs basic TEE certification). Conclusion. TEE use in liver transplantation is growing with a substantial increase in basic TEE certified users. Transplant anesthesiologists support basic certification but an equal number believe there should be more applied training at the site of care.

Society for the Advancement of Transplant Anesthesia: Liver Transplant Anesthesia Fellowship—White Paper Advocating Measurable Proficiency in Transplant Specialties Training

The anesthesia community has openly debated if the care of transplant patients was generalist or specialist care ever since the publication of an opinion paper in 1999 recommended subspecialty training in the field of liver transplantation anesthesia. In the past decade, liver transplant anesthesia has become more complex with a sicker patient population and evolving evidence-based practices. Transplant training is currently not required for accreditation or certification in anesthesiology, and not all anesthesia residency programs are associated with transplant centers. Yet there is evidence that patient outcome is affected by the experience of the anesthesiologist with liver transplants as part of a multidisciplinary care team. Requests for a formal review of the inequities in training opportunities and requirements led the Society for the Advancement for Transplant Anesthesia (SATA) to begin the task of developing post-graduate fellowship training recommendations. In this article, members of the SATA Working Group on Transplant Anesthesia Education present their reasoning for specialized education and conclusions about which pathways can better prepare trainees to care for complex transplant patients.

Risk Factors Associated with Reoperation for Bleeding following Liver Transplantation

Introduction. This study's objective was to identify risk factors associated with reoperation for bleeding following liver transplantation (LTx). Methods. A retrospective study was performed at a single institution between 2001 and 2012. Operative reports were used to identify patients who underwent reoperation for bleeding within 2 weeks following LTx (operations for nonbleeding etiologies were excluded). Results. Reoperation for bleeding was observed in 101/928 (10.8%) of LTx patients. The following characteristics were associated with reoperation on multivariable analysis: recipient MELD score (OR 1.06/MELD unit, 95% CI 1.03, 1.09), number of platelets transfused (OR 0.73/platelet unit, 95% CI 0.58, 0.91), and aminocaproic acid utilization (OR 0.46, 95% CI 0.27, 0.80). LTx patients who underwent reoperation for bleeding had a longer ICU stay (5 days ± 7 versus 2 days ± 3, P < 0.001) and hospitalization (18 days ± 9 versus 10 days ± 18, P < 0.001). The risk of death increased in patients who underwent reoperation for bleeding (HR 1.89, 95% CI 1.26, 2.85). Conclusion. Reoperation for bleeding following LTx was associated with increased resource utilization and recipient mortality. A lower threshold for intraoperative platelet transfusion and antifibrinolytics, especially in patients with high lab-MELD score, may decrease the incidence of reoperation for bleeding following LTx.

Intraoperative fluid and pharmacologic management and the anesthesiologist's supervisory role for nontraditional technologies during liver transplantation: a survey of US academic centers

BACKGROUND

Volume resuscitation and use of vasoactive medications during liver transplantation has not been systematically assessed. Furthermore, the anesthesiologist's role for intraoperative oversight of technologies such as renal replacement therapy and procedures such as venovenous bypass is poorly defined, and it is unclear if the center's annual transplant frequency affects these practices.

METHODS

We conducted a database analysis of the Liver Transplant Anesthesia Consortium survey 202 that addresses these questions. Data from US academic liver transplant anesthesia programs meeting inclusion criteria were included. Results were categorized by their annual transplant volume.

RESULTS

A representative sample of 66% of all eligible centers contributed to the results. Normal saline among crystalloids and albumin among colloids were the most frequently chosen maintenance and non-blood product volume expansion fluids, with little variation by center size. A large variety of vasoactive agents is routinely utilized across programs, with vasopressors as a cornerstone of hemodynamic support. Large programs seem to use less of these agents compared with lower volume centers.

CONCLUSION

Anesthesiologists are increasingly involved in oversight and management of intraoperative renal replacement therapies, venovenous bypass and cell saver devices with rising transplant frequency. This new insight may be indicative of skill sets needed by members of liver transplantation anesthesia teams and should be considered in curriculum design for hepatobiliary transplant anesthesia fellowships.

United States practice patterns in the use of transesophageal echocardiography during adult liver transplantation

OBJECTIVE

To characterize contemporary practice patterns in the use of transesophageal echocardiography during adult liver transplantation and to identify factors preventing more frequent use.

DESIGN

Online questionnaire.

SETTING

Liver transplantation centers in the United States performing 12 or more adult liver transplants in 2011.

PARTICIPANTS

One representative from each qualifying center: The transplant anesthesiology director, a transplant anesthesiologist personally known to the authors, or the department of anesthesiology chair.

INTERVENTIONS

Three e-mail attempts were made to solicit participation in the study between June and August 2012.

MEASUREMENTS AND MAIN RESULTS

Of the 97 institutions identified, an anesthesiologist from each of 79 (81.4%) centers completed the questionnaire; 38.0% of centers reported routine use and 57.0% for special circumstances or rescue situations, yielding an overall use rate of 94.9%. This distribution was consistent regardless of operative volume, practice size, or academic affiliation. The sole factor predictive of routine transesophageal echocardiography use was an overlap between an institution's cardiac and transplant anesthesiology teams. In practices not routinely employing the technology, the most compelling reason was a sense that it was not necessary. Although 69.9% of transplant anesthesiologists reportedly were proficient in echocardiography, inadequate anesthesiologist training was also a strongly cited hindrance.

CONCLUSIONS

Transesophageal echocardiography during adult liver transplantation in the United States has become widely prevalent, with notable growth in its use as a routine diagnostic and monitoring modality. Almost all institutions now use the technology at least occasionally, with the participation of cardiac anesthesiologists being predictive of a center's routine use.

Meeting report of the 19th Annual International Congress of the International Liver Transplantation Society (Sydney Convention and Exhibition Centre, Sydney, Australia, June 12-15, 2013)

The International Liver Transplantation Society held its annual meeting from June 12 to 15 in Sydney, Australia. More than 800 registrants attended the congress, which opened with a conference celebrating 50 years of liver transplantation (LT). The program included series of featured symposia, focused topic sessions, and oral and poster presentations. This report is by no means all-inclusive and focuses on specific abstracts on key topics in LT. Similarly to previous reports, this one presents data in the context of the published literature and highlights the current direction of LT.

Advances in transplantation 1940-2014

The history of medicine is that what was inconceivable yesterday and barely achievable today often becomes routine tomorrow. Liver transplantation began with almost no resources at the same time as the tentative first steps were taken to land a man on the moon. Because human lives would be at stake, both objectives had a sacramental element from the outset: a solemnly binding commitment to perfection. The gift of an organ is really a gift of life, and something as valuable as a life-saving organ is more important to a suffering patient than wealth or power. The concept of a team approach to the care of the transplant patient is an important factor in the development of a successful program. This has resulted in recipient survival rates reaching 90% at one year.

Director of anesthesiology for liver transplantation: existing practices and recommendations by the United Network for Organ Sharing

A new Organ Procurement and Transplantation Network/United Network for Organ Sharing bylaw recommends that all centers appoint a director of liver transplant anesthesia with a uniform set of criteria. We obtained survey data from the Liver Transplant Anesthesia Consortium so that we could compare existing criteria for a director in the United States with the current recommendations. The data set included responses from adult academic liver transplant programs before the new bylaw. The respondent rates were within statistical limits to exclude sampling bias. All centers had a director of liver transplant anesthesia. The criteria varied between institutions, and the data suggest that the availability of resources influenced the choice of criteria. The information suggests that the criteria used in the new bylaw reflect existing practices. The bylaw plays an important role in supporting emerging leadership roles in liver transplant anesthesia and brings greater uniformity to the directorship position.