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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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2
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Pandit JJ, Irwin MG. Airway management in critical illness: practice implications of new Difficult Airway Society guidelines. Anaesthesia 2018; 73:544-548. [PMID: 29577242 DOI: 10.1111/anae.14270] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong and Queen Mary Hospital, Hong Kong, HKSAR
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Avoiding ICU Admission by Using a Fast-Track Protocol Is Safe in Selected Adult-to-Adult Live Donor Liver Transplant Recipients. Transplant Direct 2017; 3:e213. [PMID: 29026876 PMCID: PMC5627744 DOI: 10.1097/txd.0000000000000730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/18/2017] [Indexed: 01/27/2023] Open
Abstract
Background We evaluated patient characteristics of live donor liver transplant (LDLT) recipients undergoing a fast-track protocol without intensive care unit (ICU) admission versus LDLT patients receiving posttransplant ICU care. Methods Of the 153 LDLT recipients, 46 patients were included in our fast-track protocol without ICU admission. Both, fast-tracked patients and ICU-admitted patients were compared regarding donor and patient characteristics, perioperative characteristics, and postoperative outcomes and complications. In a subgroup analysis, we compared fast-tracked patients with patients who were admitted in the ICU for less than 24 hours. Results Fast-tracked versus ICU patients had a lower model for end-stage liver disease score (13 ± 4 vs 18 ± 7; P < 0.0001), lower preoperative bilirubin levels (51 ± 50 μmol/L vs 119.4 ± 137.3 μmol/L; P < 0.001), required fewer units of packed red blood cells (1.7 ± 1.78 vs 4.4 ± 4; P < 0.0001), and less fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 5; P < 0.0001) during transplantation. Regarding postoperative outcomes, fast-tracked patients presented fewer bacterial infections within 30 days (6.5% [3] vs 29% [28]; P = 0.002), no episodes of pneumonia (0% vs 11.3% [11]; P = 0.02), and less biliary complications within the first year (6% [3] vs 26% [25]; P = 0.001). Also, fast-tracked patients had a shorter posttransplant hospital stay (10.8 ± 5 vs 21.3 ± 29; P = 0.002). In the subgroup analysis, fast-tracked vs ICU patients admitted for less than 24 hours had lower requirements of packed red blood cells (1.7 ± 1.78 vs 3.9 ± 4; P = 0.001) and fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 4.5; P = 0.0001). Conclusions Fast-track of selected patients after LDLT is safe and feasible. An objective score to perioperatively select LDLT recipients amenable to fast track is yet to be determined.
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4
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Postoperative Care of the Liver Transplant Recipient. ANESTHESIA AND PERIOPERATIVE CARE FOR ORGAN TRANSPLANTATION 2017. [PMCID: PMC7120127 DOI: 10.1007/978-1-4939-6377-5_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Aydınlı B, Karadeniz Ü, Demir A, Güçlü ÇY, Kazancı D, Koçulu R, Haytural C, Özgök A, Bostancı EB, Zorlu A. Postperfusion Syndrome in Cadaveric Liver Transplantations: A Retrospective Study. Turk J Anaesthesiol Reanim 2016; 44:128-33. [PMID: 27366575 DOI: 10.5152/tjar.2016.32657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 10/23/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the factors that affects the postperfusion syndrome in cadaveric liver transplantations and the effect of the postperfusion syndrome on discharge from the hospital. METHODS Patients who underwent cadaveric liver transplantations between 2007 and 2013 were scanned retrospectively. Intraoperative anaesthesia records, intensive care unit follow-up forms and discharge reports were examined from patient files. Overall, 43 patients having complete data were included in the study. The postperfusion syndrome is defined as asystoli or a decrease in mean arterial pressure of more than 30%, which occurred in the first 5 min of reperfusion and continued for 1 min. Patients were divided into two groups: those who had the postperfusion syndrome and those who did not. RESULTS The number of patients who had the postperfusion syndrome was 25 of 43 (58.1%). The MELD score of patients without the postperfusion syndrome was calculated as 16.9±3.2 and that of patients with the postperfusion syndrome was 19.7±3.6. A statistically significant relationship was detected between the postperfusion syndrome occurrence and a high MELD score (p=0.013). The diastolic blood pressure just before reperfusion was statistically lower in the group with the postperfusion syndrome than in the other group (p=0.023, 50±8 vs. 58±11). According to the logistic regression analysis, the MELD score and the decrease in diastolic blood pressure before reperfusion were defined as independent predictive factors. CONCLUSION According to the study, the ratio for having the postperfusion syndrome was found to be 58.1%. The independent predictor factors affecting the postperfusion syndrome were detected as the MELD score and the decrease in diastolic blood pressure before reperfusion. The postperfusion syndrome during orthotropic liver transplantation is an important issue for anaesthesiologists. The awareness of the related factors with the postperfusion syndrome may help in the development of various preventive strategies.
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Affiliation(s)
- Bahar Aydınlı
- Clinic of Anaesthesia, Mersin State Hospital, Mersin, Turkey
| | - Ümit Karadeniz
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Aslı Demir
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Çiğdem Yıldırım Güçlü
- Department of Anaesthesiology and Reanimation, Ankara University School of Medicine, Ankara, Turkey
| | - Dilek Kazancı
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Rabia Koçulu
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Candan Haytural
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ayşegül Özgök
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Erdal Birol Bostancı
- Clinic of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ali Zorlu
- Department of Cardiology, Cumhuriyet University School of Medicine, Sivas, Turkey
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6
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Fernandez TMA, Gardiner PJ. Critical Care of the Liver Transplant Recipient. CURRENT ANESTHESIOLOGY REPORTS 2015; 5:419-428. [PMID: 32288651 PMCID: PMC7101679 DOI: 10.1007/s40140-015-0133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patient survival following orthotopic liver transplantation has greatly increased following improvements in surgical technique, anesthetic care, and immunosuppression. The critical care of the liver transplant recipient has paralleled these improvements, largely thanks to input from multidisciplinary teams and institution-specific protocols guiding management and care. This article provides an overview of the approach to critical care of the postoperative adult liver transplant recipient outlining common issues faced by the intensivist. Approaches to extubation and hemodynamic assessment are described. The provision of appropriate immunosuppression, infection prophylaxis, and nutrition is addressed. To aid prompt diagnosis and treatment, intensivists must be aware of postoperative complications of bleeding, primary nonfunction, delayed graft function, vascular thromboses, biliary complications, rejection, and organ dysfunction.
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Affiliation(s)
- Thomas M. A. Fernandez
- Department of Anesthesia and Perioperative Care, Auckland City Hospital, 2 Park Road, Grafton, Auckland, 1023 New Zealand
| | - Paul J. Gardiner
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
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Bulatao IG, Heckman MG, Rawal B, Aniskevich S, Shine TS, Keaveny AP, Perry DK, Canabal J, Willingham DL, Taner CB. Avoiding stay in the intensive care unit after liver transplantation: a score to assign location of care. Am J Transplant 2014; 14:2088-96. [PMID: 25088768 DOI: 10.1111/ajt.12796] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/03/2014] [Accepted: 04/23/2014] [Indexed: 01/25/2023]
Abstract
Select liver transplantation (LT) recipients in our program are transferred from operating room to postanesthesia care unit for recovery and extubation with transfer to the ward, completely eliminating an intensive care unit (ICU) stay. Developing a reliable method to determine patients suitable for fast-tracking would be of practical benefit to centers considering this practice. The aim of this study was to create a fast-tracking probability score that could be used to predict successful assignment of care location after LT. Recipient, donor and operative characteristics were assessed for independent association with successful fast-tracking to create a probability score. Of the 1296 LT recipients who met inclusion criteria, 704 (54.3%) were successfully fast-tracked and 592 (45.7%) were directly admitted to the ICU after LT. Based on nine readily available variables at the time of LT, we created a scoring system that classified patients according to the likelihood of being successfully fast-tracked to the surgical ward, with an area under the curve (AUC) of 0.790 (95% CI: 0.765-0.816). This score was validated in an independent group of 372 LT with similar AUC. We describe a score that can be used to predict successful fast-tracking immediately after LT using readily available clinical variables.
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Affiliation(s)
- I G Bulatao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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Kleine M, Vondran FWR, Johanning K, Timrott K, Bektas H, Lehner F, Klempnauer J, Schrem H. Respiratory risk score for the prediction of 3-month mortality and prolonged ventilation after liver transplantation. Liver Transpl 2013; 19:862-71. [PMID: 23696476 DOI: 10.1002/lt.23673] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 04/28/2013] [Indexed: 02/07/2023]
Abstract
Survival of critically ill patients is significantly affected by prolonged ventilation. The goal of this study was the development of a respiratory risk score (RRS) for the prediction of 3-month mortality and prolonged ventilation after liver transplantation (LT). Two hundred fifty-four consecutive LT patients from a single center were retrospectively randomized into a training group for model design and a validation group. A receiver operating characteristic (ROC) curve analysis was used to test sensitivity and specificity. The accuracy of the predictions was assessed with the Brier score, and the model calibration was assessed with the Hosmer-Lemeshow test. Cutoff values were determined with the best Youden index. The RRS was calculated in the first 24 hours as follows: (laboratory Model for End-Stage Liver Disease score > 30 = 2.36 points) + (fresh frozen plasma > 13.5 U = 2.70 points) + (partial pressure of arterial oxygen/fraction of inspired oxygen ratio < 200 mm Hg = 2.23 points) + (packed red blood cells > 10.5 U = 3.50 points) + (preoperative mechanical ventilation = 3.87 points) + (preoperative dialysis = 2.83 points) + (donor steatosis hepatis > 40% = 2.95 points). The RSS demonstrated high predictive accuracy, good model calibration, and c statistics > 0.7 in the training and validation groups. The RSS was able to predict 3-month mortality [cutoff = 6.64, area under the (ROC) curve (AUROC) = 0.794] and prolonged ventilation (cutoff = 3.69, AUROC = 0.798) with sensitivities of 69% and 81%, specificities of 83% and 73%, and overall model correctness of 76% and 77%, respectively. In conclusion, this study provides the first prognostic model for the prediction of 3-month mortality and prolonged ventilation after LT with high sensitivity and specificity and good model accuracy. The application of the RRS to an external cohort would be desirable for its further validation and introduction as a clinical tool for intensive care resource planning and prognostic decision making.
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Affiliation(s)
- Moritz Kleine
- Department of General, Visceral, and Transplant Surgery, Hannover, Germany.
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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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Taner CB, Willingham DL, Bulatao IG, Shine TS, Peiris P, Torp KD, Canabal J, Nguyen JH, Kramer DJ. Is a mandatory intensive care unit stay needed after liver transplantation? Feasibility of fast-tracking to the surgical ward after liver transplantation. Liver Transpl 2012; 18:361-9. [PMID: 22140001 DOI: 10.1002/lt.22459] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The continuation of hemodynamic, respiratory, and metabolic support for a variable period after liver transplantation (LT) in the intensive care unit (ICU) is considered routine by many transplant programs. However, some LT recipients may be liberated from mechanical ventilation shortly after the discontinuation of anesthesia. These patients might be appropriately discharged from the postanesthesia care unit (PACU) to the surgical ward and bypass the ICU entirely. In 2002, our program started a fast-tracking program: select LT recipients are transferred from the operating room to the PACU for recovery and tracheal extubation with a subsequent transfer to the ward, and the ICU stay is completely eliminated. Between January 1, 2003 and December 31, 2007, 1045 patients underwent LT at our transplant program; 175 patients were excluded from the study. Five hundred twenty-three of the remaining 870 patients (60.10%) were fast-tracked to the surgical ward, and 347 (39.90%) were admitted to the ICU after LT. The failure rate after fast-tracking to the surgical ward was 1.90%. The groups were significantly different with respect to the recipient age, the raw Model for End-Stage Liver Disease (MELD) score at the time of LT, the recipient body mass index (BMI), the retransplantation status, the operative time, the warm ischemia time, and the intraoperative transfusion requirements. A multivariate logistic regression analysis revealed that the raw MELD score at the time of LT, the operative time, the intraoperative transfusion requirements, the recipient age, the recipient BMI, and the absence of hepatocellular cancer/cholangiocarcinoma were significant predictors of ICU admission. In conclusion, we are reporting the largest single-center experience demonstrating the feasibility of bypassing an ICU stay after LT.
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Affiliation(s)
- C Burcin Taner
- Department of Transplantation, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Aneja S, Raina R. Immediate postoperative extubation after liver transplantation at our centre: A report of two cases. Indian J Anaesth 2011; 55:392-4. [PMID: 22013259 PMCID: PMC3190517 DOI: 10.4103/0019-5049.84861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Liver transplantation is a dynamic field undergoing continuous changes in management. Prolonged postoperative mechanical ventilation has been a norm but now there is a trend towards early extubation. We developed a protocol for early extubation based on bispectral index monitoring. This protocol was applied in two cases with satisfactory outcome.
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Affiliation(s)
- Sanjeev Aneja
- Department of Anesthesia and Intensive Care, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
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Liu LL, Niemann CU. Intraoperative management of liver transplant patients. Transplant Rev (Orlando) 2011; 25:124-9. [PMID: 21514137 DOI: 10.1016/j.trre.2010.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 10/25/2010] [Indexed: 12/13/2022]
Abstract
Liver transplantation for end-stage liver disease results in excellent outcomes. Patient and graft outcome is closely monitored on a national level, and 1-year survival is between 80% and 95%. Liver transplantation relies on a multidisciplinary approach, with close involvement of anesthesiologists and intensivists. However, intraoperative care of these patients remains inconsistent and is highly institution dependent. This brief-review article will focus on controversial topics of intraoperative care. Existing evidence on intraoperative monitoring, intraoperative fluid and transfusion management, electrolyte and glucose management, postoperative patient disposition, and, lastly, anesthesia team management will be reviewed.
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Affiliation(s)
- Linda L Liu
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
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Abstract
PURPOSE OF REVIEW The present review describes new trends and ongoing controversies in the anesthetic care of liver transplant recipients. RECENT FINDINGS Recent studies have improved our knowledge of conditions increasing perioperative risk, such as portopulmonary hypertension and renal failure. Improved surgical and anesthetic management has reduced intraoperative blood loss, as more studies identify an independent association between blood transfusion and poor outcome. New concepts in the coagulopathy of liver failure are emerging, with clear implications for clinical practice, including greater awareness of the risks of intraoperative thromboembolism. Less invasive intraoperative hemodynamic monitoring has been advocated, as has wider use of transoesophageal echocardiography. Early extubation is becoming more routinized. SUMMARY Anesthetic management still varies widely between liver transplant centers with little data to indicate best practice. Future research should focus on fluid replacement, prevention and treatment of coagulopathy, care of the acutely ill patient and the safety and benefits of early extubation.
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