The Success of a Simulation-Based Transesophageal Echocardiography Course for Liver Transplant Anesthesiologists.

INTRODUCTION: Transesophageal echocardiography (TEE) is increasingly used for intraoperative management during orthotopic liver transplantation. Proficient TEE use requires skill and knowledge to accurately assess the hemodynamic status and guide clinical management. Currently there are no TEE educational tracks specifically focused on perioperative liver transplant management and barriers to obtaining basic certification exist. METHODS: A 4-hour simulation-based learning (SBL) course was provided to improve liver transplant anesthesiologist TEE knowledge and skill. Learners received training and education using a TEE simulator in small groups focusing on basic image acquisition, relevant anatomy, hemodynamic calculations, and pathology germane to the liver transplant period. Knowledge assessment and survey responses were assessed at the beginning and completion of the course. Learners completed TEE examinations with simulated pathology during high-fidelity simulations following the course. RESULTS: Seventeen anesthesiologists completed the course. The median baseline knowledge assessment score was 55.0% (37-70). The median postcourse knowledge assessment score improved to 95.0% (94-100) (P < .001). All anesthesiologists were able to identify TEE pathology during high-fidelity simulation. Survey responses yielded significant median score improvement in all areas assessed using a 5-point Likert scale. CONCLUSIONS: A small group, simulation TEE course delivered over 4 hours can increase knowledge and skill in TEE use for liver transplant anesthesiologists.

The perioperative management of simultaneous bilateral nephrectomy with renal transplantation: a case series.

PURPOSE: Bilateral nephrectomy is performed at times with renal transplantation. Though surgical indications and timing of these two procedures have been described, there are no large case series describing the anesthetic management of these cases. We sought to describe our experience. METHODS: We performed a historical cohort study on 54 consecutive cases of simultaneous bilateral nephrectomy with renal transplantation at a single, tertiary-care medical centre. Descriptive statistics were used. RESULTS: The most common etiology of kidney disease involved was autosomal dominant polycystic kidney disease at 52/54 (96%) cases. All patients received grafts from living donors. An arterial line was placed in 44 (81%) and a central venous catheter in 16 (30%) subjects. At least one vasopressor infusion was used in 44 (81%) cases and 37 (69%) patients required admission to the intensive care unit (ICU). Of this subset, 30 (81%) were admitted for ongoing vasopressor support and six (16%) for hemodynamic monitoring. All patients were extubated in the operating room upon completion of the procedure. Median [interquartile range (IQR)] ICU length of stay (LOS) was 0.9 [0.7-1.4] days and total hospital LOS was 4.4 [4.3-5.4] days. There were no cases of mortality at 30 days or of postoperative dialysis. CONCLUSIONS: Adult patients undergoing simultaneous bilateral nephrectomy with renal transplantation often developed perioperative hypotension requiring vasopressor infusions and postoperative transfer to the ICU. This is possibly due to a temporary loss of the renin-angiotensin system. Despite this, patients most commonly were transferred to the floor on postoperative day 1 and had successful outcomes with no mortality at 30 days.

RéSUMé: OBJECTIF: La néphrectomie bilatérale est parfois réalisée en même temps qu'une transplantation rénale. Bien que les indications chirurgicales et le moment de ces deux interventions aient été décrits, il n'existe aucune grande série de cas décrivant la prise en charge anesthésique de ces procédures. Notre objectif était de décrire notre expérience. MéTHODE: Nous avons réalisé une étude de cohorte historique sur 54 cas consécutifs de néphrectomie bilatérale avec transplantation rénale simultanée dans un seul centre médical de soins tertiaires. Des statistiques descriptives ont été utilisées. RéSULTATS: La maladie polykystique des reins autosomique dominante constituait l'étiologie de la maladie rénale la plus fréquente, représentant 52/54 (96 %) des cas. Tous les patients ont reçu des greffes de donneurs vivants. Une ligne artérielle a été installée chez 44 (81 %) patients et un cathéter veineux central chez 16 (30 %) patients. Au moins une perfusion de vasopresseurs a été utilisée chez 44 (81 %) patients, et 37 (69 %) patients ont dû être admis à l'unité de soins intensifs (USI). De ce sous-ensemble, 30 (81 %) patients ont été admis pour recevoir un soutien continu de vasopresseurs et six (16 %) pour un monitorage hémodynamique. Tous les patients ont été extubés en salle d'opération à la fin de l'intervention. La durée médiane [écart interquartile (ÉIQ)] de séjour aux soins intensifs était de 0,9 [0,7 à 1,4] jour, et la durée totale de séjour à l'hôpital était de 4,4 [4,3 à 5,4] jours. Il n'y a eu aucun cas de mortalité à 30 jours ou de dialyse postopératoire. CONCLUSION: Les patients adultes subissant une néphrectomie bilatérale et une transplantation rénale simultanées ont souvent souffert d'hypotension périopératoire exigeant des perfusions de vasopresseurs et un transfert postopératoire aux soins intensifs. Ceci est probablement dû à une perte temporaire du système rénine-angiotensine. Malgré cela, les patients étaient en général transférés à l'étage au jour postopératoire 1 et ont eu des devenirs favorables sans mortalité à 30 jours.

When Is a Critically Ill Cirrhotic Patient Too Sick to Transplant? Development of Consensus Criteria by a Multidisciplinary Panel of 35 International Experts.

BACKGROUND: Critically ill cirrhotic patients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility. METHODS: Thirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement. RESULTS: The panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or <72 hours of appropriate antimicrobial therapy in case of ongoing sepsis were considered reasons to delay LT. A simple assessment of the number of organs failing was considered the most appropriate way to decide whether LT should be delayed or denied, with respiratory, circulatory and metabolic failures having the most influence in this decision. The thresholds of severity of organ failures contraindicating LT for which a consensus was achieved were a Pao2/FiO2 ratio<150 mm Hg, a norepinephrine dose >1 µg/kg per minute and a serum lactate level >9 mmol/L. CONCLUSIONS: Our expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented.

Outcomes of Liver Transplantation in Treated Portopulmonary Hypertension Patients With a Mean Pulmonary Arterial Pressure ≥35 mm Hg.

Portopulmonary hypertension (POPH), pulmonary arterial hypertension (PAH) that develops in the setting of portal hypertension, affects 5%-6% of patients with liver disease and is associated with significant morbidity and mortality. A mean pulmonary arterial pressure (mPAP) threshold of 35 mm Hg is used to stratify perioperative risk and liver transplant eligibility in treated POPH patients but does not take into account the specific factors that contribute to the pressure elevation. METHODS: In this case series, we describe the characteristics and posttransplant outcomes of patients with treated POPH and an mPAP ≥35 mm Hg and pulmonary vascular resistance (PVR) <250 dynes-s-cm-5 at or just before liver transplantation (LT). We also describe the effect of PAH therapy on pulmonary hemodynamics in patients with POPH. RESULTS: Sixteen patients were included. All patients were on PAH therapy at the time of LT. PAH therapy resulted in a decrease of mPAP (median 18.4%; interquartile range [IQR] 8.9%-27.0%) with a reduction in PVR (median 50.5%; IQR, 45.4%-70.7%), and an increase in both cardiac output (CO) (median 28.1%; IQR 5.7%-63.8%) and PAWP (median 50.0%; IQR 16.7%-108.3%) before LT. One year posttransplant survival was 69% (11/16); however, only 1 death was attributed to POPH. At 1-year posttransplant, 63.6% (7/11) of patients were weaned off all PAH therapy with clinical and echocardiographic resolution of POPH. CONCLUSIONS: In treated POPH patients with an mPAP ≥35 mm Hg and PVR < 250 dynes-s-cm-5 before LT, 1-year posttransplant survival was 69% and the majority of patients were able to discontinue PAH therapy.

Anesthetic considerations for combined heart--liver transplantation in patients with Fontan-associated liver disease.

PURPOSE OF REVIEW: The success of the Fontan procedure has led to increased survival of patients born with certain congenital heart disease to the point that new sequlae, as a result of Fontan circulation, are being discovered. Included among these is Fontan-associated liver disease (FALD). The purpose of this review is to present available literature on the perioperative management of the combined heart--liver transplantation (CHLT) in patients with FALD. RECENT FINDINGS: The perioperative management of a combined heart-liver transplant in a patient with Fontan circulation is complex. The patient is at risk for hemodynamic disturbances, significant blood loss, coagulopathies, and metabolic derangements. The maintenance of an appropriate transpulmonary pressure gradient is paramount to success. Postoperative management should be accomplished by a multidisciplinary care team. Limited series have demonstrated good outcomes in patients who have undergone CHLT. SUMMARY: The perioperative management of CHLT in patients with FALD is complex and available literature is limited. Future studies are needed to further assess proper perioperative management of patients with FALD who undergo CHLT.

Association of Perioperative Variables and the Acute Respiratory Distress Syndrome in Liver Transplant Recipients.

BACKGROUND: The assessment of perioperative risk factors for the development of acute respiratory distress syndrome (ARDS) has been described in various surgical populations. However, there are only limited data among patients undergoing liver transplantation (LT), particularly regarding the influence of intraoperative ventilation parameters. We sought to identify the perioperative risk factors associated with the development of ARDS in LT recipients. METHODS: This is a single-center, retrospective cohort study of adult patients who underwent LT at a tertiary academic medical center between January 1, 2006, and January 31, 2016. Postoperative ARDS was identified using the Berlin definition. Multivariable logistic regression analysis was used to identify perioperative risk factors for ARDS. RESULTS: Of 817 eligible patients who underwent an LT during the study period, 20 (2.45%) developed postoperative ARDS. In the preoperative model, ongoing dialysis (odds ratio, 6.41; P < 0.01) was identified as an independent risk factor of ARDS post-LT. A higher mean peak inspiratory pressure per increase of 1 cm H2O (odds ratio, 1.31; P < 0.01) was the only independent risk factor in the intraoperative model. Patients who developed ARDS postoperatively had significantly greater intensive care unit and hospital stay compared to non-ARDS patients (P < 0.001). There were no significant differences in the 30-day (P = 0.16) and 1-year (P = 0.51) mortality between the groups. CONCLUSIONS: Dialysis at the time of transplant and elevated intraoperative mean peak inspiratory pressure were associated with the development of ARDS. ARDS post LT was associated with increased intensive care unit and hospital length of stay, but not increased mortality.

Influence of Intraoperative Transesophageal Echocardiography and Pulmonary Artery Catheter Monitoring on Outcomes in Liver Transplantation.

Anesthetic management of orthotopic liver transplantation (OLT) can be challenging. Management involves responding to sudden hemodynamic shifts, addressing instability, and performing ongoing volume assessment. To best prepare for these perturbations, various monitors are used intraoperatively. We sought to explore the impact of transesophageal echocardiography (TEE) and pulmonary artery catheter (PAC) use on outcomes of patients undergoing OLT. METHODS: We retrospectively reviewed records of patients who underwent OLT at a single institution and included all who were monitored intraoperatively with TEE alone, PAC alone, or both methods concurrently (TEE + PAC). We determined whether these groups had differences in length of hospitalization (primary outcome), 30-day mortality rate, and other outcomes. RESULTS: Three hundred eighteen liver transplant operations were included in the study. Patients in the TEE + PAC group had the shortest median length of hospitalization (TEE + PAC, 8.6 days; TEE, 10.3; PAC, 9.1; P = 0.04). The TEE + PAC group also had the lowest 30-day mortality rate (TEE + PAC, n = 1 [1.3%]; TEE, n = 5 [12.8%]; PAC, n = 7 [3.5%]; P = 0.009). However, the TEE + PAC group also had the highest rate of a new postoperative need for dialysis (TEE + PAC, n = 8 [10.3%]; TEE, n = 2 [5.1%]; PAC, n = 1 [0.5%]; P < 0.001). CONCLUSIONS: Compared with either TEE alone or PAC alone, intraoperative monitoring with TEE + PAC during OLT was associated with the shortest length of hospitalization and lowest 30-day mortality rate. Transplant anesthesiologists should be aware of the potential benefit on patient mortality and hospital length of stay with concurrent intraoperative TEE + PAC monitoring and the increased need for new postoperative dialysis.

Redefining Cirrhotic Cardiomyopathy for the Modern Era.

Cirrhotic cardiomyopathy (CCM) is cardiac dysfunction in patients with end-stage liver disease in the absence of prior heart disease. First defined in 2005 during the World Congress of Gastroenterology, CCM criteria consisted of echocardiographic parameters to identify subclinical cardiac dysfunction in the absence of overt structural abnormalities. Significant advancements in cardiovascular imaging over the past 14 years, including the integration of myocardial deformation imaging into routine clinical practice to identify subclinical cardiovascular dysfunction, have rendered the 2005 CCM criteria obsolete. Therefore, new criteria based on contemporary cardiovascular imaging parameters are needed. In this guidance document, assembled by a group of multidisciplinary experts in the field, new core criteria based on contemporary cardiovascular imaging parameters are proposed for the assessment of CCM. This document provides a critical assessment of the diagnosis of CCM and ongoing assessment aimed at improving clinical outcomes, particularly surrounding liver transplantation. Key points and practice-based recommendations for the diagnosis of CCM are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.

Acute Benefits After Liposomal Bupivacaine Abdominal Wall Blockade for Living Liver Donation: A Retrospective Review.

OBJECTIVE: To investigate whether the addition of liposomal bupivacaine abdominal wall blocks to a multimodal analgesic regimen improves postoperative numeric rating scale pain scores and reduces opioid consumption in patients undergoing living liver donation. PATIENTS AND METHODS: We conducted a single-center, retrospective review of patients who underwent living liver donation from January 1, 2011, through February 19, 2016, and received multimodal analgesia with (block group) or without (control group) abdominal wall blockade. The block solution consisted of liposomal bupivacaine (266 mg) mixed with 30 mL of 0.25% bupivacaine. Both groups received intrathecal hydromorphone. Main outcome measures were pain scores, opioid requirements, time to full diet, and bowel activity. RESULTS: Postoperative day 0 pain scores were significantly better in the block group (n=29) than in the control group (n=48) (2.4 vs 3.5; P=.002) but were not significantly different on subsequent days. Opioid requirements were significantly decreased for the block group in the postanesthesia care unit (0 vs 9 mg oral morphine equivalents; P=.002) and on postoperative day 0 (7 vs 18 mg oral morphine equivalents; P=.004). Median (interquartile range) time to full diet was 23 hours (14-30 hours) in the block group and 38 hours (24-53 hours) in the control group (P=.001); time to bowel activity was also shorter in the block group (45 hours [38-73 hours] vs 67 hours [51-77 hours]; P=.01). CONCLUSION: Abdominal wall blockade with liposomal bupivacaine after donor hepatectomy provides an effective method of postoperative pain control and decreases time to full diet and bowel activity.

Organ Donor Management: Part 1. Toward a Consensus to Guide Anesthesia Services During Donation After Brain Death.

Worldwide 715 482 patients have received a lifesaving organ transplant since 1988. During this time, there have been advances in donor management and in the perioperative care of the organ transplant recipient, resulting in marked improvements in long-term survival. Although the number of organs recovered has increased year after year, a greater demand has produced a critical organ shortage. The majority of organs are from deceased donors; however, some are not suitable for transplantation. Some of this loss is due to management of the donor. Improved donor care may increase the number of available organs and help close the existing gap in supply and demand. In order to address this concern, The Organ Donation and Transplantation Alliance, the Association of Organ Procurement Organizations, and the Transplant and Critical Care Committees of the American Society of Anesthesiologists have formulated evidence-based guidelines, which include a call for greater involvement and oversight by anesthesiologists and critical care specialists, as well as uniform reporting of data during organ procurement and recovery.

Adapting the Surgical Apgar Score for Perioperative Outcome Prediction in Liver Transplantation: A Retrospective Study.

BACKGROUND: The surgical Apgar score (SAS) is a 10-point scale using the lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL) during surgery to predict postoperative outcomes. The SAS has not yet been validated in liver transplantation patients, because typical blood loss usually exceeds the highest EBL category. Our primary aim was to develop a modified SAS for liver transplant (SAS-LT) by replacing the EBL parameter with volume of red cells transfused. We hypothesized that the SAS-LT would predict death or severe complication within 30 days of transplant with similar accuracy to current scoring systems. METHODS: A retrospective cohort of consecutive liver transplantations from July 2007 to November 2013 was used to develop the SAS-LT. The predictive ability of SAS-LT for early postoperative outcomes was compared with Model for End-stage Liver Disease, Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation III scores using multivariable logistic regression and receiver operating characteristic analysis. RESULTS: Of 628 transplants, death or serious perioperative morbidity occurred in 105 (16.7%). The SAS-LT (receiver operating characteristic area under the curve [AUC], 0.57) had similar predictive ability to Acute Physiology and Chronic Health Evaluation III, model for end-stage liver disease, and Sequential Organ Failure Assessment scores (0.57, 0.56, and 0.61, respectively).Seventy-nine (12.6%) patients were discharged from the ICU in 24 hours or less. These patients' SAS-LT scores were significantly higher than those with a longer stay (7.0 vs 6.2, P < 0.01). The AUC on multivariable modeling remained predictive of early ICU discharge (AUC, 0.67). CONCLUSIONS: The SAS-LT utilized simple intraoperative metrics to predict early morbidity and mortality after liver transplant with similar accuracy to other scoring systems at an earlier postoperative time point.

Frequency and Outcomes of Patients With Increased Mean Pulmonary Artery Pressure at the Time of Liver Transplantation.

BACKGROUND: Pulmonary hypertension (PH) exists when mean pulmonary artery pressure (mPAP) is 25 mm Hg or greater. mPAP of 35 mm Hg or greater, with increased pulmonary vascular resistance from portopulmonary hypertension, has been associated with increased post-liver transplant (LT) mortality. However, mPAP of 35 mm Hg or greater can also occur in the setting of normal pulmonary vascular resistance from a high flow state and/or increased pulmonary venous volume. We describe the frequency of patients with mPAP of 35 mm Hg or greater at LT and correlate their clinical outcomes with hemodynamic characteristics. METHODS: We reviewed hemodynamics of 300 consecutive adult patients undergoing LT. Primary and secondary outcomes were transplant hospitalization mortality and 1-year mortality. RESULTS: Overall, PH was documented in 117 (39%) of 300 transplant recipients. Five patients were receiving ongoing treatment for portopulmonary hypertension at the time of transplant. mPAP of 35 mm Hg or greater was seen in 31 of 300 patients (10.3%; median, 38 mm Hg; range, 35-46 mm Hg). No intraoperative deaths occurred. Transplant hospitalization mortality was 0% for those with mPAP of 35 mm Hg or greater (vs 2.2% if mPAP < 35 mm Hg, P = 1.0). One-year mortality was similar for patients with and without mPAP of 35 mm Hg or greater (3.2% vs 6.0%, P = 1.0). No deaths were associated with right heart failure. CONCLUSIONS: At the time of LT, 39% of recipients had PH (mPAP ≥ 25 mm Hg) and 10.3% had mPAP ≥ 35 mm Hg. When associated with a high flow state and/or increased volume, transplant hospitalization and 1-year posttransplant outcomes were not adversely affected.

The perioperative management of patients undergoing combined heart-liver transplantation.

BACKGROUND: Combined heart-liver transplantation (CHLT) is an uncommonly performed procedure for patients with coexisting cardiac and liver disease. METHODS: A retrospective review was performed of patients undergoing CHLT at our institution from 1999 to 2013. Information related to preoperative organ function, intraoperative management, surgical approach, transfusions, postoperative findings, and 30-day mortality was reviewed. RESULTS: Twenty-seven CHLT were performed, with 4 of the 27 including simultaneous kidney transplantation. Familial amyloidosis was the indication for 21 CHLTs (78%), and 12 of these explanted livers were used for domino transplantations. Nineteen patients (70%) were receiving inotropic infusions at the time of organ availability. Median preoperative model for end-stage liver disease score was 12. Liver transplantation immediately preceded cardiac transplantation in 2 of the 27 cases because of the presence of high titer donor-specific antibodies and the potential of the liver to lead to a reduction in the antibody titer. Venovenous bypass was used in 14 operations (52%) which were performed with the caval interposition approach to liver transplantation, cardiopulmonary bypass during liver transplantation in two cases (7%), and no bypass in 11 operations (41%) performed with caval sparing (piggyback) surgical technique. Postoperatively, median duration of mechanical ventilation, intensive care unit stay, and hospital stay until discharge were 1 day, 5.5 days, and 15 days, respectively. Transfusions in the first 48 hr after CHLT were not substantial in most patients. One patient died within 30 days of CHLT. CONCLUSION: Combined heart-liver transplantation is a life-saving operation that is performed with relatively low mortality and can be successfully performed in select patients with congenital or acquired cardiac disease.

Patient selection and preoperative evaluation for transplant surgery.

Candidates for abdominal transplant undergo a pretransplant evaluation to identify associated conditions that may require intervention or that may influence a patient's candidacy for transplant. Coronary artery disease is prevalent in candidates for abdominal organ transplantation. The optimal approach to identify and manage coronary artery disease in the peri-transplant period is currently unclear. In liver transplant candidates portopulmonary hypertension and hepatopulmonary syndrome should be screened for. Identification of the patient who is too sick to benefit from transplant is problematic; with no good evidence available decisions should be individualized and made after multidisciplinary discussion.

Changes in transfusion practice over time in adult patients undergoing liver transplantation.

OBJECTIVE: The aim of this study was to investigate changes in transfusion practice over time in liver transplantation surgery and to evaluate potential causes for changes in practice and report associated perioperative morbidity and mortality. DESIGN: A retrospective cohort study. SETTING: A single tertiary referral academic hospital. PARTICIPANTS: Two cohorts of 100 sequential adult primary liver transplant recipients: Early practice (1990-1991) and recent practice (2005-2006). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Perioperative transfusion and hemoglobin data were recorded. Mortality and postoperative complications were identified up to 30 days postoperatively. Appropriate intergroup statistical comparisons were made; p ≤ 0.05 was considered statistically significant. Compared with the early group, the recent group had significantly fewer perioperative allogeneic red blood cell transfusions, intraoperative autotransfusions, and transfusions of other blood products. No change in perioperative transfusion triggers was identified. There were no significant alterations in perioperative morbidity or mortality. CONCLUSIONS: When compared with patients in the early group, recent cohort patients received significantly fewer blood transfusions. The authors attribute this observation to changes in surgical technique rather than a significant alteration in transfusion triggers over the studied time period.