Optimal anesthetic conduct regarding immediate and short‐term outcomes after liver transplantation – Systematic review of the literature and expert panel recommendations

Chadha, Ritu; Patel, Dhupal; Bhangui, Pooja; Blasi, Annabel; Xia, Victor W.; Parotto, Matteo; Wray, Christopher; Findlay, James Y.; Spiro, Michael; Raptis, Dimitri Aristotle

doi:10.1111/ctr.14613

Cited by 11 publications

(7 citation statements)

References 54 publications

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“…Therefore, the overall QoE was limited on the best vasoactive drug to use during liver transplantation, similar to many other intraoperative interventions in this population. 21,74,75 In other populations, higher-quality data are available to help clinicians decide what vasoactive drugs they should use. In different types of shock, norepinephrine was reported as less harmful than dopamine.…”

Section: Discussionmentioning

confidence: 99%

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Intraoperative Vasoactive Medications and Perioperative Outcomes in Liver Transplantation: A Systematic Review and Network Meta-analyses

et al. 2023

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We conducted a systematic review and network meta-analyses evaluating the effects of different intraoperative vasoactive drugs on acute kidney injury (AKI) and other perioperative outcomes in adult liver transplant recipients. We searched multiple electronic databases using words from the “liver transplantation” and “vasoactive drug” domains. We included all randomized controlled trials conducted in adult liver transplant recipients comparing 2 different intravenous vasoactive drugs or 1 against a standard of care that reported AKI, intraoperative blood loss, or any other postoperative outcome. We conducted 4 frequentist network meta-analyses using random effect models, based on the interventions’ mechanism of action, and evaluated the quality of evidence (QoE) using Grading of Recommendations, Assessment, Development, and Evaluations recommendations. We included 9 randomized controlled trials comparing different vasopressor drugs (vasoconstrictor or inotrope), 3 comparing a somatostatin infusion (or its analogues) to a standard of care, 11 comparing different vasodilator infusions together or against a standard of care, and 2 comparing vasoconstrictor boluses at graft reperfusion. Intravenous clonidine was associated with shorter duration of mechanical ventilation, intensive care unit, and hospital length of stay (very low QoE), and some vasodilators were associated with lower creatinine level 24 h after surgery (low to very low QoE). Phenylephrine and terlipressin were associated with less intraoperative blood loss when compared with norepinephrine (low and moderate QoE). None of the vasoactive drugs improve any other postoperative outcomes, including AKI. There is still important equipoise regarding the best vasoactive drug to use in liver transplantation for most outcomes. Further studies are required to better inform clinical practice.

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Section: Discussionmentioning

confidence: 99%

“…Therefore, the overall QoE was limited on the best vasoactive drug to use during liver transplantation, similar to many other intraoperative interventions in this population. 21,74,75…”

Section: Discussionmentioning

confidence: 99%

Intraoperative Vasoactive Medications and Perioperative Outcomes in Liver Transplantation: A Systematic Review and Network Meta-analyses

et al. 2023

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“…Furthermore, the impact of peri-reperfusion excess oxygen exposure in deceased donor OLT recipients has not been examined. A 2022 expert panel of liver transplant clinicians recommended a restrictive oxygen strategy targeting a PaO 2 of 70-120 mmHg during OLT, citing evidence from non-OLT surgeries such as abdominal surgery [25]. These abdominal surgery studies demonstrate an increased risk of mortality, cancer, atelectasis, and elevated cardiac injury markers with higher perioperative oxygen concentrations [25][26][27][28][29].…”

Section: Effect Of Hyperoxemia On Eadmentioning

confidence: 99%

OXIDATIVE study: A pilot prospective observational cohort study protocol examining the influence of peri-reperfusion hyperoxemia and immune dysregulation on early allograft dysfunction after orthotopic liver transplantation

Wilson,

Woodbury,

Williams

et al. 2024

PLoS ONE

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Early allograft dysfunction (EAD) is a functional hepatic insufficiency within a week of orthotopic liver transplantation (OLT) and is associated with morbidity and mortality. The etiology of EAD is multifactorial and largely driven by ischemia reperfusion injury (IRI), a phenomenon characterized by oxygen scarcity followed by paradoxical oxidative stress and inflammation. With the expanded use of marginal allografts more susceptible to IRI, the incidence of EAD may be increasing. This necessitates an in-depth understanding of the innate molecular mechanisms underlying EAD and interventions to mitigate its impact. Our central hypothesis is peri-reperfusion hyperoxemia and immune dysregulation exacerbate IRI and increase the risk of EAD. We will perform a pilot prospective single-center observational cohort study of 40 patients. The aims are to determine (1) the association between peri-reperfusion hyperoxemia and EAD and (2) whether peri-reperfusion perturbed cytokine, protein, and hypoxia inducible factor-1 alpha (HIF-1α) levels correlate with EAD after OLT. Inclusion criteria include age ≥ 18 years, liver failure, and donation after brain or circulatory death. Exclusion criteria include living donor donation, repeat OLT within a week of transplantation, multiple organ transplantation, and pregnancy. Partial pressure of arterial oxygen (PaO2) as the study measure allows for the examination of oxygen exposure within the confines of existing variability in anesthesiologist-administered fraction of inspired oxygen (FiO2) and the inclusion of patients with intrapulmonary shunting. The Olthoff et al. definition of EAD is the primary outcome. Secondary outcomes include postoperative acute kidney injury, pulmonary and biliary complications, surgical wound dehiscence and infection, and mortality. The goal of this study protocol is to identify EAD contributors that could be targeted to attenuate its impact and improve OLT outcomes. If validated, peri-reperfusion hyperoxemia and immune perturbations could be targeted via FiO2 titration to a goal PaO2 and/or administration of an immunomodulatory agent by the anesthesiologist intraoperatively.

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“…Chadha et al performed a systematic review of 14 studies to evaluate whether intraoperative anesthetic management affects short-term outcomes after liver transplantation [14]. The authors recommend the use of volatile anesthetics (VA) instead of total intravenous anesthesia (TIVA) along with minimum alveolar concentration (MAC) rather than EEG based monitoring for depth of anesthetic monitoring but highlight that both are weak recommendations with very low evidence.…”

Section: Anesthetic Managementmentioning

confidence: 99%

“…Optimal anesthetic conduct regarding immediate and short-term outcomes after liver transplantation --Systemic review of the literature and expert panel recommendations (Chadha et al [14])…”

Section: Grade Of Recommendationmentioning

confidence: 99%

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

Crouch,

Stewart,

Hendrickse

2023

Current Opinion in Organ Transplantation

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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.

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Optimal anesthetic conduct regarding immediate and short‐term outcomes after liver transplantation – Systematic review of the literature and expert panel recommendations

Cited by 11 publications

References 54 publications

Intraoperative Vasoactive Medications and Perioperative Outcomes in Liver Transplantation: A Systematic Review and Network Meta-analyses

Intraoperative Vasoactive Medications and Perioperative Outcomes in Liver Transplantation: A Systematic Review and Network Meta-analyses

OXIDATIVE study: A pilot prospective observational cohort study protocol examining the influence of peri-reperfusion hyperoxemia and immune dysregulation on early allograft dysfunction after orthotopic liver transplantation

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

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