Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations.

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.

Anesthesia for Patients with Concomitant Hepatic and Pulmonary Dysfunction.

Hepatic function and pulmonary function are interrelated with failure of one organ system affecting the other. With improved therapies, patients with concomitant hepatic and pulmonary failure increasingly enjoy a good quality of life and life expectancy. Therefore, the prevalence of such patients is increasing with more presenting for both emergent and elective surgical procedures. Hypoxemia requires a thorough evaluation in patients with end-stage liver disease. The most common etiologies respond to appropriate therapy. Portopulmonary hypertension and hepatopulmonary syndrome are associated with increased perioperative morbidity and mortality. It is incumbent on the anesthesiologist to understand the physiology of liver failure and its early effect on pulmonary function to ensure a successful outcome.

Meeting report of the 2014 joint international congress of the International Liver Transplantation Society, Liver Intensive Care Group of Europe, and European Liver and Intestinal Association.

The 2014 Annual Meeting of the International Liver Transplantation Society was held in London, England. This was the 20th meeting of the Society and was marked by a joint meeting including the European Liver and Intestinal Association as well as the Liver Intensive Care Group of Europe. The meeting included symposia, invited lectures, debates, oral presentations, and posters. The principal themes were living donation, expanding the deceased donor pool, machine preservation, and new oral therapies for hepatitis C virus. This report highlights the scientific discussions of this meeting.

Meeting report of the 19th Annual International Congress of the International Liver Transplantation Society (Sydney Convention and Exhibition Centre, Sydney, Australia, June 12-15, 2013).

The International Liver Transplantation Society held its annual meeting from June 12 to 15 in Sydney, Australia. More than 800 registrants attended the congress, which opened with a conference celebrating 50 years of liver transplantation (LT). The program included series of featured symposia, focused topic sessions, and oral and poster presentations. This report is by no means all-inclusive and focuses on specific abstracts on key topics in LT. Similarly to previous reports, this one presents data in the context of the published literature and highlights the current direction of LT.

Postoperative care/critical care of the transplant patient.

Critical care of the general surgical patient requires synthesis of the patient's physiology, intraoperative events, and preexisting comorbidities. Evaluating an abdominal solid-organ transplant recipient after surgery adds a new dimension to clinical decisions because the transplanted allograft has undergone its own physiologic challenges and now must adapt to a new environment. This donor-recipient interaction forms the foundation for assessment of early allograft function (EAF). The intensivist must accurately assess and support EAF within the context of the recipient's current physiology and preexisting comorbidities. Optimizing EAF is essential because allograft failure is a significant predictor of recipient morbidity and mortality.

Hepatic and renal protection during cardiac surgery.

Hepatic injury in cardiac surgery is a rare complication but is associated with significant morbidity and mortality. A high index of suspicion postoperatively will lead to earlier treatment directed at eliminating or minimizing ongoing hepatic injury while preventing additional metabolic stress from ischemia, hemorrhage, or sepsis. The evidence-basis for perioperative renal risk factors remains hampered by the inconsistent definitions for renal injury. Although acute kidney injury (as defined by the Risk, Injury, Failure, Loss, End-stage criteria) has become accepted, it does not address pathogenesis and bears little relevance to cardiac surgery. Although acute renal failure requiring renal replacement therapy after cardiac surgery is rare, it has a devastating impact on morbidity and mortality, and further studies on protective strategies are essential.

The side effects of morphine and hydromorphone patient-controlled analgesia.

BACKGROUND: Despite "clinical lore" among health care providers that treatment with hydromorphone results in improved pain control and fewer adverse side effects, morphine continues to be the first-line medication for postoperative patient-controlled analgesia (PCA). In this study, we compared the efficacy and side-effect profiles of morphine and hydromorphone at concentrations producing equivalent drug effect measured by pain score and miosis. METHODS: We conducted a prospective, randomized, double-blind trial of 50 general and gynecological surgery patients. Subjects were randomly assigned to receive either morphine (1 mg/mL) or hydromorphone (0.2 mg/mL) via PCA after surgery and were followed for a period of 8 h. The primary outcome was nausea. Secondary outcome variables were pruritus, vomiting, sedation, pain report, pupillary miosis, and patient satisfaction. RESULTS: The side effect profile was not different between drugs. The incidence of nausea did not differ between morphine and hydromorphone-treated patients (1 h: 44% vs 52%, 8 h: 68% vs 64%), vomiting (1 h: 4% vs 0%, 8 h: 0% vs 4%), or pruritus (1 h: 4% vs 16%, 8 h: 40% vs 40%). There was no difference in the amount of medication required to treat side effects or patient satisfaction. The average ratio of morphine to hydromorphone use was about 7:1. The patients used 10.9+/-6.0 mg morphine versus 1.57+/-1.0 mg hydromorphone after 1 h and 29.0+/-18.0 mg morphine versus 3.9+/-2.5 mg hydromorphone after 8 h. There was no difference between the morphine and hydromorphone groups with respect to postoperative pain scores with movement at 1 h (7.9+/-2.3 vs 7.1+/-2.4) or 8 h (5.7+/-2.8 vs 5.9+/-2.7). There was also no difference in pain at rest or miosis between groups. CONCLUSIONS: We found no systematic difference between morphine and hydromorphone in opioid-related side effects. Neither was there any difference in efficacy of pain control or patient satisfaction when patients self-titrated to equal drug effect as measured by equianalgesia and pupillary miosis. The choice between morphine and hydromorphone for use in PCA should be guided by patient history, as there may be idiosyncratic reactions to either drug.

Monitoring hepatic and renal function.

Liver disease represents a serious risk factor for patients requiring anesthesia and surgery. Even subclinical liver disease increases perioperative morbidity and mortality. Perioperative renal dysfunction and failure have similar implications. Thus, detection of early hepatic and renal dysfunction and monitoring of their progress is essential. This article discusses methods for monitoring hepatic and renal function in patients who have high risk for liver or renal injury in the perioperative period.

Donor health assessment after living-donor liver transplantation.

OBJECTIVE: To elicit donor opinions on liver living donation through use of a survey that protected the anonymity of the respondent and to assay long-term (follow-up > 1 year) donor health by a widely recognized instrument for health assessment. SUMMARY BACKGROUND DATA: Living-donor liver transplantation is an accepted technique for children that has recently been extended to adults. Limited donor outcomes data suggest favorable results, but no outcomes data have been reported using an instrument that elicits an anonymous response from the donor or employs a widely recognized health survey. METHODS: Forty-one living-donors between June 1992 and June 1999 were identified and included in this study, regardless of specific donor or recipient outcome. Each donor received a 68-question survey and a standard McMaster Health Index. RESULTS: Survey response was 80%. All donors were satisfied with the information provided to them before donation. Eighty-eight percent of donors initially learned of living donation only after their child had been diagnosed with liver disease: 44% through the transplant center, 40% by popular media, 12% by their pediatrician, and 4% by their primary care physician. Physical symptoms, including pain and the surgical wound, were recurrent items of concern. Perception of time to "complete" recovery were less than 3 months (74%), 3 to 6 months (16%), and more than 6 months (10%). Donors' return to physical activities was shown by above-mean McMaster physical scores; scores for social and emotional health were not different from population data. There were no reported changes in sexual function or menstruation after donation, and five of six donors procreated. CONCLUSIONS: Donors overwhelmingly endorsed living donation regardless of recipient outcome or the occurrence of a complication. Eighty-nine percent advocated "increased" application of living donation beyond "emergency situations," and no donor responded that living donation should be abandoned or that he or she felt "forced" to donate.