Fast‐Track Liver Transplantation: Six‐year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol

Abstract

Introduction Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results. Patients and methods Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. Results A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. Conclusion Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care

Outcomes following formation of a dedicated pediatric liver transplant anesthesia team

“…We highlight this result because historically, most patients remained intubated after liver transplantation due to concerns of bleeding, large volume fluid administration and shifts, and hemodynamic instability, all potentially contributing to respiratory failure after this major surgery. However, during the past 20 years, extubation rates have increased in both the adult and pediatric liver transplant populations 6–11 . Recently, several pediatric groups have shared their data regarding early extubation after liver transplantation with excellent outcomes, including extubation rates of 67%, 12 58%, 13 48%, 14 and 54% 15 .…”

“…In reviewing the demographic data for the general and liver a Data presented using chi-square test; however, given low frequency of events, Fishers' exact test also performed with p = .12. and pediatric liver transplant populations. [6][7][8][9][10][11] Recently, several pediatric groups have shared their data regarding early extubation after liver transplantation with excellent outcomes, including extubation rates of 67%, 12 58%, 13 48%, 14 and 54%. 15 Here, we report the highest immediate extubation rate of 80% for patients cared for by our liver team in 2017-2020, an increase from our rate of 56% for patients cared for by the general team in 2013-2016, with no patients in either group requiring reintubation.…”

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

“…103 The primary goal of this ERAS protocol is early extubation. Early extubation after LT is possible using standard criteria 102 in the operating room. It is safe 104 and known to improve survival, 105 with an added cost-savings benefit 106 and a marked reduction in the need for mechanical ventilation.…”

“…Enhanced Recovery After Surgery (ERAS) protocols have revolutionized surgical care in various surgical specialties and led to reduced surgical stress, in‐hospital stay length, and morbidity. Recently, the successful application of ERAS programs for LT recipients has been reported 102 . The ideal LT ERAS protocol includes general anesthesia with short‐acting agents (induction with propofol, rocuronium and fentanyl; maintenance with sevoflurane, remifentanil, and rocuronium) to reduce the postoperative sedative effect; a goal‐directed fluid therapy with balanced saline solution (Plasma‐Lyte‐A/Ionolyte) to avoid excessive fluid administration and maintain a relative hypovolemia; a restrictive PRBC transfusion policy (for hemoglobin < 7 g/dl or central venous oxygen saturation < 70%); routine preoperative whole blood hemo‐extraction, in which units are reinfused during the biliary reconstruction; routine use of a cell‐saver; maintaining a MAP of 65 mm Hg with preload optimization guided by both a pulse index continuous cardiac output monitor and administration of pressors, including norepinephrine, phenylephrine, and/or terlipressin; VET‐guided coagulation management; and the use of sugammadex as the primary reversal agent of choice, as sugammadex is associated with a lower incidence of major pulmonary complications 103 …”

Fifty liver transplants: a single centre experience of haemodynamic management in liver transplantation for cirrhosis [part 2]

“…Adoption of such a protocol is associated with early extubation, early mobilization, reduction of postoperative ventilation, postoperative complications, length of intensive care and hospital stay and cost. Adoption of the protocol has been linked to a rapid pace of recovery even in the sicker, high MELD patients [32][33][34].…”