Justification for routine intensive care after liver transplantation

Ramsay, Michael A. E.

doi:10.1002/lt.23745

Cited by 10 publications

(3 citation statements)

References 18 publications

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“…Further review of the available literature [ 4 , 12 ] confirms that early extubation after liver transplantation is feasible, safe, and cost-effective, and it has been increasingly accepted as a better option over conventional postoperative ventilation due to its physiological (graft blood flow improvement, lesser complications from mechanical ventilation, improvement of patient comfort, etc) and economical (better utilization of resources, cost containment, etc) advantages. Fast tracking has also been shown to allow an altogether bypassing of the ICU after liver transplantation, providing a 1:1 nursing to patient ratio and close monitoring are in place for the initial 24 hours [ 13 ], although some concerns have been raised regarding ICU avoidance [ 14 ]. As stated previously, our protocol called for mandatory ICU admission.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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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

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Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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“…These changes led opponents of fast-tracking to theorize that patients were now too ill to be extubated and bypass the ICU. 20 Opponents held this viewpoint despite evidence demonstrating that few patient or surgical characteristics could predict failure of early extubation. 21 Rather, the only reliable predictors identified during this time period were higher grades of hepatic encephalopathy and more blood use.…”

Section: Severity Of Illness and Early Extubation: How Government Allmentioning

confidence: 99%

Rapid Recovery of Liver Transplantation Recipients by Implementation of Fast-Track Care Steps: What Is Holding Us Back?

Biancofiore

Tomescu

Mandell

2018

Semin Cardiothorac Vasc Anesth

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A body of scientific studies has shown that early extubation is safe and cost-effective in a large number of liver transplant (LT) recipients including pediatric patients. However, fast-track practices are not universally accepted, and debate still lingers about whether these interventions are safe and serve the patients' best interest. In this article, we focus on reasons why physicians still have a persistent, although diminishing, reluctance to adopt fast-track protocols. We stress the importance of collection/analysis of perioperative data, adoption of a consensus-based standardized protocol for perioperative care, and formation of LT anesthesia focused teams and leadership. We conclude that the practice of early extubation and fast-tracking after LT surgery could help improve anesthesia performance, safety, and cost-effectiveness.

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“…Comprehensive understanding of SOT physiology and pathophysiology, and advancements in medicine - antibiosis, immunosuppression, diagnostic-therapeutic modalities in critical care - have effectively reduced the mortality among critically ill OLT recipients below the overall mortality rate for all ICU admissions (10.6% versus 15%) [21]. Effective critical care supports a transplant program’s ability to consider high-risk donors and high-risk recipients, which expectantly would enhance the overall survival of the population of patients with ESOF [1,26]. This is where assurance of skillful, experienced, transplant-specific and critical care competent peri-operative management is essential to be able to:…”

Section: Volume Expansion Quality Improvement and Resource Utilizationmentioning

confidence: 99%

Transplant Critical Care: Is There A Need for Sub-specialized Units? — A Perspective

Sakpal

Agarwal

Saucedo-Crespo

et al. 2018

The Journal of Critical Care Medicine

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The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.

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Justification for routine intensive care after liver transplantation

Cited by 10 publications

References 18 publications

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

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

Rapid Recovery of Liver Transplantation Recipients by Implementation of Fast-Track Care Steps: What Is Holding Us Back?

Transplant Critical Care: Is There A Need for Sub-specialized Units? — A Perspective

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