Enhanced recovery after surgery for liver transplantation: a review of recent literature

PURPOSE OF REVIEW

This review was created to highlight important articles from the past year related to the evolving field of enhanced recovery after surgery (ERAS) in liver transplantation that are relevant to the transplant anesthesiologist.

RECENT FINDINGS

The International Liver Transplantation Society (ILTS) recently completed a landmark project, the ERAS4OLT.org project, which culminated in 80 recommendations for ERAS in liver transplantation. These recommendations encompass management for deceased donor recipients, living donor recipients and living donors. This review highlights selected articles relevant to the perioperative management of deceased donor liver transplant recipients.

SUMMARY

Though, there are now published internationally agreed upon recommendations for ERAS topics specific to liver transplantation, there is an obvious need for further investigation into this area to provide high quality evidence to support these recommendations. It is reasonable to utilize these recommendations in ERAS protocols for individual institutions; however, more evidence is needed in several areas to confirm the effects of these protocols on short-term outcomes.

Pain management for liver transplant recipients

PURPOSE OF REVIEW

Liver transplant recipients pose several pain management challenges. Altered hepatic drug metabolism and clearance in end-stage liver disease patients complicates the use of certain medications, while existing coagulopathy and thrombocytopenia can limit the use of regional anesthetic techniques. Largely due to a high prevalence of substance use disorders, these patients have increased vulnerability to opioid misuse in the perioperative period, which can make acute postoperative pain difficult to control and potentiates prolonged and painful recovery, increasing the risk of developing chronic postsurgical pain. We present current evidence-based literature that reviews optimal pain management strategies for this challenging patient demographic.

RECENT FINDINGS

Multiple studies have shown that thoracic epidurals provide superior pain control in open hepatic resections. Recent data suggests thoracic epidurals may be safely considered in select liver transplant recipients with normal preoperative coagulation status; however, this evidence is limited, and further studies are needed. When the risks of coagulopathy prohibit epidural placement, truncal blocks such as transversus abdominis plane blocks or quadratus lumborum blocks and abdominal wound catheters can serve as alternative regional modalities. Specialized teams should manage pain using a multimodal approach.

SUMMARY

Thoracic epidural analgesia may be an option for liver transplant recipients with normal coagulation profiles prior to surgery; however, additional studies are warranted. Other regional techniques are also available. Emphasis should be placed on optimizing multimodal pain medication management. Nonpharmacological interventions should also be considered.

Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation

Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.

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.

Perioperative management of living donor liver transplantation: Part 2 - Donors

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.

Perioperative management of adult living donor liver transplantation: Part 1 - recipients

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.

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.

Transitioning to Virtual Meetings: Experiences From the Society for Education in Anesthesia Virtual Fall 2020 Meeting

The COVID-19 pandemic has forced organizers of traditional in-person continuing medical education conferences to transition to a virtual format. There are both advantages and disadvantages to this change in format. When planning a virtual meeting, several factors require consideration, including costs, virtual platforms, sponsorship, networking, and meeting logistics. This manuscript describes the authors' experiences of transforming the Society of Education in Anesthesia 2020 Fall Meeting into a virtual conference and explores the lessons learned and future impacts of this new medium.

Opioid-Free Epidural-Free Anesthesia for Open Hepatectomy: A Case Report

Opioid-free perioperative approaches hold promise to reduce opioid use after surgery and their associated side effects. Here, we report the perioperative analgesic plan of a patient who requested opioid-free care for an open partial hepatectomy. Opioid-free anesthesia care for abdominal surgery is usually dependent on epidural analgesia. However, as in this case, placing an epidural is not always an option due to contraindications such as infection, coagulopathy, or patient refusal. Our multimodal management plan provided an alternative opioid-free, epidural-free perioperative strategy that may prove useful for other patients undergoing similar surgeries.

Integrating a Cadaver Review Session into the Existing Regional Anesthesia Training for Anesthesiology Residents: An Initial Experience

The Department of Anesthesiology's Acute Pain Service (APS) places ultrasound-guided peripheral nerve blocks (PNBs) to manage acute peri-operative pain. PNB success is dependent on detailed anatomical knowledge which residents may not have formally reviewed since medical school. This study describes the integration of a cadaver review session (CRS) that reintroduces PNB-related anatomy into the existing APS rotation. During each CRS, an anatomist reviewed the major nerve and surrounding structures, while an APS attending integrated the anatomy with PNB techniques. During the pilot, 1st- and 3rd-year clinical anesthesia (CA) residents (9 CA1s, 7 CA3s) completed pre- and post-session surveys and rated the CRS's perceived value and impact on self-confidence with anatomical knowledge. Following the pilot, an additional 17 CA1s and 9 CA3s participated in the CRS and completed post-session surveys. Descriptive statistics were used to summarize responses and unpaired t tests were used to compare pre- and post-session responses and responses between cohorts. All participants were overwhelmingly positive about the CRS and its value to the APS rotation, with 98% agreeing they recommend the CRS and found it accessible. Residents believed participation would improve board exam (average = 4.83 ± 0.66) and clinical performance (average = 4.86 ± 0.65), and self-reported increases in confidence with anatomical knowledge. Residents in the pilot group reported significantly greater confidence (p < 0.01) in their perceived anatomical knowledge after the CRS. The CRS positively impacted resident confidence in their anatomical knowledge and perceived ability to identify anatomical structures. Residents reported the CRS was a highly valued addition to regional anesthesia training.

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.

Unexpected Complication of Hydroxocobalamin Administration for Refractory Vasoplegia in Orthotopic Liver Transplant: A Case Report

A 40-year-old male with alcoholic cirrhosis and end-stage renal disease presented for simultaneous liver and kidney transplantation. Hemodialysis was utilized intraoperatively during liver transplantation. During the procedure, the patient developed refractory hypotension and ultimately received hydroxocobalamin for vasoplegia. Shortly after administration, the hemodialysis machine ceased working after a "blood leak" alarm developed. Without the ability to continue intraoperative dialysis, the kidney transplantation portion of his surgery was postponed. The patient was transferred to the intensive care unit, where he underwent continuous renal replacement therapy overnight, and his kidney transplant proceeded the following morning.

Case Report of a Massive Retropharyngeal Goiter Resulting in Laryngeal Compression

This is a rare presentation of a morbidly obese male with a massive retropharyngeal goiter causing laryngeal compressive symptoms and unique airway management challenges. Flexible laryngoscopy revealed a retropharyngeal mass circumferentially compressing the oropharynx and supraglottis and preventing the visualization of the glottis. Awake tracheostomy was performed before total thyroidectomy. Airway compression from a goiter typically results from substernal extension, which usually does not cause difficulty with endotracheal intubation. Extensive retropharyngeal extension can cause supraglottic obstruction of the airway. In these cases, optimal management consists of a closely coordinated approach between anesthesia and surgery teams to establish a surgical airway.

Hepatopulmonary syndrome and portopulmonary hypertension

The incidence of pulmonary vascular disorders is significantly increased in patients with liver disease. Intrapulmonary shunting with hypoxemia in patients with liver disease is diagnosed as hepatopulmonary syndrome (HPS), whereas precapillary pulmonary vessel obliteration is identified as portopulmonary hypertension (PPHTN). Because the symptoms of liver disease can mimic those of pulmonary vascular disease, all patients with hepatic failure should be screened for these two diseases. Pulse oximetry effectively screens for hypoxemia associated with HPS, whereas an elevated right ventricular systolic pressure estimated by echocardiography identifies patients at risk of having PPHTN. Liver transplantation is the only effective medical therapy for HPS. However, those who have a resting arterial oxygenation less than 50 mm Hg or a shunt measured by scintigraphic perfusion greater than 20% have an unacceptably high mortality rate following surgery. Compared with HPS, there are more therapeutic options that can bridge patients with PPHTN to transplantation. Drugs used to manage idiopathic pulmonary hypertension have shown promise in the treatment of PPHTN. Prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors have improved transplant survival. Despite treatment, however, perioperative mortality for patients with PPHTN remains high. Even with successful transplantation, HPS and PPHTN can persist or develop de novo. Long-term follow-up and surveillance of liver transplant recipients is thus indicated to identify HPS and PPHTN following surgery.