Outcomes following formation of a dedicated pediatric liver transplant anesthesia team

Abstract

Background: Given the complex nature of liver transplant surgery, adult centers typically use a dedicated liver transplant anesthesia team, which has improved patient outcomes.Aims: Our goal was to determine whether a dedicated pediatric liver transplant anesthesia team was associated with improved patient outcomes. Methods: This retrospective cohort study analyzed patients who underwent liver transplantation from April 2013 to September 2020 at St. Louis Children's Hospital. The general group (April 2013-December 2016) was compared with the liver group (January 2017-September 2020). Outcomes measured included cases per anesthesiologist, early extubation, ventilator days, fluid and blood administration, postoperative events, and intensive care unit and hospital length of stay (LOS).Results: Patients in both groups had similar demographics. The average number of cases/anesthesiologist/year was 2.9 times higher in the liver group (mean (SD) general 0.7 (0.5), liver 2.0 (0.6), and difference in mean [95% CI] 1.3 [0.8, 1.8]). The rate of extubation in the operating room was higher for patients in the liver group (general 56%, liver 80%, and difference in proportion [95% CI] 24.7 [7.0, 42.4]), while the number of ventilator days was lower (mean (SD) general 2.1 (4.4), liver 1.1 (3.6), and difference in proportion [95%CI] −0.9 [−2.6, 0.7]). Colloid administration was higher in the liver group (mean (SD) general 23.9 (14.5) ml/kg, liver 48.4 (37.7) ml/kg, and difference in mean [95% CI] 24. 6 [12.7, 36.4]), while fresh frozen plasma administration was lower in the liver group (mean (SD) general 15.3 (23.9) ml/kg, liver 6.2 (14) ml/kg, and difference in mean [95% CI] −9.0 [−16.8, −1.3]). There were no significant differences between the groups in postoperative events including blood product transfusions, vasopressor use, and thromboses, or in the intensive care unit and hospital LOS. Conclusions:The liver group was associated with increased early extubations, decreased ventilator days, and decreased fresh frozen plasma use.

Educational Review: Error traps in anesthesia for pediatric liver transplantation

“…Pediatric liver transplantation requires a multidisciplinary team to care for complex patients safely and successfully during this highly specialized and challenging procedure 5 . A dedicated team that included anesthesiologists specializing in the perioperative care of liver transplantation was associated with improved patient outcomes at both adult and pediatric transplant centers 6,7 . The insights gained by a designated anesthesia team led to improved patient blood management (PBM) and decreased ventilator days from increased early extubation.…”

“… 5 A dedicated team that included anesthesiologists specializing in the perioperative care of liver transplantation was associated with improved patient outcomes at both adult and pediatric transplant centers. 6 , 7 The insights gained by a designated anesthesia team led to improved patient blood management (PBM) and decreased ventilator days from increased early extubation. The importance of having a consistent team of surgeons, nurses, and anesthesiologists cannot be underestimated.…”

Outcomes in pediatric liver transplant recipients receiving bilateral continuous erector spinae plane blocks

“…As initially reported in a series of two cases in 2019, our institution established an analgesia protocol for pediatric liver transplantation which includes continuous ESP blockade 20 . Protocol development occurred as part of an initiative to form a dedicated pediatric transplant anesthesia team with standard care procedures 21 . This study aimed to evaluate several outcomes in extubated liver transplant patients, including postoperative pain scores, opioid consumption, return of bowel function, and length of stay.…”

“…20 Protocol development occurred as part of an initiative to form a dedicated pediatric transplant anesthesia team with standard care procedures. 21 This study aimed to evaluate several outcomes in extubated liver transplant patients, including postoperative pain scores, opioid consumption, return of bowel function, and length of stay. We hypothesized that patients who received an ESP block would demonstrate improved functional recovery compared to patients who did not, as evidenced by reduced opioid requirements, earlier first bowel movement, and shorter duration of stay in the ICU and the hospital.…”

Use of an ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum to improve paediatric anaesthesia care

“…We previously created and evaluated a simulation-based mastery learning (SBML) curriculum to teach USGIV skills to paediatric anesthesiologists. 16 SBML is an intense form of competency-based learning, in which learners use deliberate practice on a simulator and are expected to reach a high skills standard (minimum passing standard [MPS]) 17 on a simulated assessment before training completion. 18 Those who are unable to meet the MPS participate in further deliberate practice until they can be reassessed and reach the standard.…”