Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE.

BACKGROUND: Anesthesiologists frequently use intraoperative transesophageal echocardiography (TEE) to aid in the diagnosis and management of hemodynamic problems during liver transplantation (LT). Although the use of TEE in US centers continues to increase, data regarding international use are lacking. METHODS: This prospective, global, survey-based study evaluates international experience with TEE for LT. Responses from 252 LT (105 US and 147 non-US) centers representing 1789 anesthesiologists were analyzed. RESULTS: Routine use of TEE in the United States has increased in the last 5 y (from 37% to 47%), but only 21% of non-US LT anesthesiologists use TEE routinely. Lack of training (44% US versus 70% non-US) and equipment (9% non-US, versus 34% US) were cited as obstacles. Most survey participants preferred not to perform a complete cardiac examination but rather use only 6 of 11 basic views. Although non-US LT anesthesiologists more frequently had additional clinical training than their US counterparts, they had less TEE experience (13% versus 44%) and less frequently, TEE certification (22% versus 35%). Most LT anesthesiologists agreed that TEE certification is essential for proficiency. Of all respondents, 89% agreed or strongly agreed that TEE provides valuable information needed for immediate clinical decision-making, and >86% agreed or strongly agreed that that information could not be derived from other sources. CONCLUSIONS: The use of TEE for LT surgery in the US LT centers is currently higher compared with non-US LT centers. This may become a standard monitoring modality during LT in the near future.

The use of simulation in liver transplantation anesthesiology fellowship training: A survey of fellowship program directors in the United States.

INTRODUCTION: Liver transplantation surgeries are challenging cases for anesthesiologists. While intra-operative teaching is paramount, simulation has emerged as an educational tool to augment clinical training. A variety of simulation modalities have been described in the literature, but no study has aimed to assess the use of simulation in liver transplantation fellowship training. METHODS: A 20-question survey detailing the use of simulation, including simulation modalities used and barriers to simulation use, was developed and distributed to 22 program directors for liver transplantation anesthesiology fellowships. An exploratory analysis was performed on multiple-choice and free-text responses. RESULTS: Thirteen program directors completed the survey and were included in our analysis. Most programs (61.5%) did not report the use of simulation for liver transplantation fellow training. Of the programs that did use simulation, four required it as a mandatory component of their curriculum. Task trainers and screen-based simulators were more commonly used by these programs. Faculty availability and interest, as well as a lack of an established curriculum, were cited as major limitations to simulation use. CONCLUSIONS: Simulation is an important component of anesthesiology trainee education, as evidenced by the requirement for simulation during residency by the American Council for Graduate Medical Education. Our findings suggest that simulation is an underutilized educational tool that we believe could greatly augment the training of liver transplantation anesthesiology fellows by providing exposure to a wide range of clinical challenges.

International Liver Transplantation Society/Society for Advancement of Transplant Anesthesia Consensus Statement on Essential Attributes of a Liver Transplant Anesthesiologist.

BACKGROUND: We sought to establish consensus on the essential skills, knowledge, and attributes that a liver transplant (LT) anesthesiologist should possess in a bid to help guide the further training process. METHODS: Consensus was achieved via a modified Delphi methodology, surveying 15 identified international experts in the fields of LT anesthesia and critical care. RESULTS: Key competencies were identified in preoperative management and optimization of a potential LT recipient; intraoperative management, including hemodynamic monitoring; coagulation and potential crisis management; and postoperative intensive and enhanced recovery care. CONCLUSIONS: This article provides an essential guide to competency-based training of an LT anesthesiologist.

A Retrospective Study of the Role of Perioperative Serum Albumin and the Albumin-Bilirubin Grade in Predicting Post-Liver Transplant Length of Stay.

INTRODUCTION: Serum albumin's association with liver transplant outcomes has been investigated with mixed findings. This study aimed to evaluate perioperative albumin level, independently and as part of the albumin-bilirubin (ALBI) grade, as a predictor of post-liver transplant hospital and intensive care unit (ICU) length of stay (LOS). METHODS: Adult liver-only transplant recipients at our institution from September 2011 to May 2019 were included in this retrospective study. Repeat transplants were excluded. Demographic, laboratory, and hospital course data were extracted from an institutional data warehouse. Negative binomial regression was used to assess the association of LOS with ALBI grade, age, BMI, ASA score, Elixhauser comorbidity index, MELD-Na, warm ischemia time, units of platelets and cryoprecipitate transfused, and preoperative serum albumin. RESULTS: Six hundred and sixty-three liver transplant recipients met inclusion criteria. The median preoperative serum albumin was 3.1 [2.6-3.6] g/dL. The median postoperative ICU and hospital LOS were 3.8 [2.4-6.8] and 12 [8-20] days, respectively. Preoperative serum albumin predicted hospital but not ICU LOS (ratio .9 [95% confidence interval (CI) .84-.99], P = .03, hospital LOS vs ratio .92 [95% CI 0.84-1.02], P = .10, ICU LOS). For patients with MELD-Na ≤ 20, ALBI grade-3 predicted longer hospital and ICU LOS (ratio 1.40 [95% CI 1.18-1.66], P < .001, hospital LOS vs ratio 1.62 [95% CI 1.32-1.99], P < .001, ICU LOS). These associations were not significant for patients with MELD-Na > 20. CONCLUSIONS: Serum albumin predicted post-liver transplant hospital LOS. ALBI grade-3 predicted increased hospital and ICU LOS in low MELD-Na recipients.

Intraoperative intracardiac thrombus in liver transplantation: A 9-year retrospective review focusing on treatment and outcomes.

This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016-2020) compared with the pre-TEE era (2011-2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End-Stage Liver Disease-sodium (MELD-Na) scores, pretransplant hospitalization, malignancy, drug-induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver-kidney transplantation. The patients with ICT were similar, except patients in the pre-TEE era had higher MELD-Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre-TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30-day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p = 0.002). The 30-day mortality rate was 36% (9/25) in the TEE era (p = 0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.

Research priorities in liver transplant anesthesiology: Results of a survey of liver transplant anesthesiologists.

Optimal perioperative care contributes to improved patient outcomes, as demonstrated in the field of liver transplant (LT). The evolution in perioperative care over the past two decades has been driven by research in areas such as preoperative testing, coagulation management, and intraoperative monitoring. However, much of this research is driven by local institutional pressures and practices with a dearth of studies emanating from research consortia or other groups of experts within the field. To better characterize the top research questions in the field, we queried a group of 128 LT anesthesiologists representing 87 international liver transplant centers with a response from 71 practitioners (59.2%). Three experts then codified the responses into the top 20 questions, which were sent to the survey recipients as a second survey to rank order. Seventy-five respondents (61.5%) provided responses, which were merged into a weighted ranked priority list and analyzed by respondent location and center size. The highest ranked question was, "What intraoperative anesthetic management/interventions affect graft outcome?" Most of the top research questions focused on preoperative risk factor management or optimization and intraoperative management techniques. In general, this priorities list may serve as a guide for transplant anesthesiology researchers to focus future research endeavors on shared interests that improve patient care.

Postreperfusion syndrome in liver transplantation: Outcomes, predictors, and application for recipient selection.

BACKGROUND: This study aimed to identify risk factors for postreperfusion syndrome (PRS) and its impact on LT outcomes. METHODS: Data analysis was performed in 1021 adult patients undergoing donation after brain death (DBD) LT to identify PRS incidence, the risk factors for PRS development, and its impact on LT outcomes. RESULTS: The overall incidence of PRS was 16.1%. Independent risk factors for PRS included donor age (odds ratio (OR) 1.01, P = .02), donor body mass index (BMI) (OR 1.04, P = .003), moderate macrosteatosis (OR 2.48, P = .02), and cold ischemia time (CIT) (OR 1.06, P = .02). On multivariable analysis for 30-day graft failure, PRS (hazard ratio (HR) 3.49; P < .001) and Model for End-stage Liver Disease (MELD) score (HR 1.01; P = .05) were independent risk factors. Patients were categorized into four distinct groups based on PRS risk groups and MELD groups, which showed different 1-year graft survival (P < .001). There were comparable outcomes between low PRS risk - high MELD and high PRS risk - low MELD group (P = .33). CONCLUSIONS: Donor age, donor BMI, moderate macrosteatosis, and CIT were identified as risk factors for the development of PRS in LT using DBD grafts. PRS risk evaluation may improve donor-to-recipient matching based on their MELD scores.

Recommendations From the Society for the Advancement of Transplant Anesthesiology Fellowship Committee: Core Competencies and Milestones for the Kidney/Pancreas Component of Abdominal Organ Transplant Anesthesia Fellowship.

The Society for the Advancement of Transplant Anesthesia (SATA) is dedicated to improving patient care in all facets of transplant anesthesia. The anesthesia fellowship training recommendations for thoracic transplantation (heart and lungs) and part of the abdominal organ transplantation (liver) have been presented in previous publications. The SATA Fellowship Committee has completed the remaining component of abdominal transplant anesthesia (kidney/pancreas) and has assembled core competencies and milestones derived from expert consensus to guide the education and overall preparation of trainees providing care for kidney/pancreas transplant recipients. These recommendations provide a comprehensive approach to pre-operative evaluation, vascular access procedures, advanced hemodynamic monitoring, assessment of coagulation and metabolic abnormalities, operative techniques, and post-operative pain control. As such, this document supplements the current liver/hepatic transplant anesthesia fellowship training programs to include all aspects of "Abdominal Organ Transplant Anesthesia" recommended knowledge.

The Optimal Cell Salvage Settings to Maximize Hematocrit and Minimize Potassium Using the Cobe BRAT2 Autologous Blood Recovery Unit.

OBJECTIVE: The objective was to determine the optimal cell saver device settings (infusion rate and wash rate) at which hematocrit is preserved and potassium and lactate are removed from banked red blood cells (RBC). DESIGN: Red cells were washed using the Cobe BRAT 2 Autologous Blood Recovery Unit and sampled for electrolyte composition and hematocrit pre- and postwash. SETTING: This was a single-center study. INTERVENTIONS: Red cells were washed using six infusion rates (100-1,000 mL/min) and six wash rates (100-1,000 mL/min) for a total of 36 combinations. Hematocrit, potassium, glucose, and lactate were evaluated before and after washing. MEASUREMENTS AND MAIN RESULTS: At wash rates ≤400 mL/min, hematocrit increased independent of infusion rate. At wash rates ≥400 mL/min, slower infusion rates were associated with higher hematocrit compared to faster infusion rates (p < 0.0001 for a wash rate 400-800 mL/min, p < 0.0005 for a wash rate 1,000 mL/min). Maximal wash speeds were associated with decreasing hematocrit. Infusion and wash rate were both independent predictors of potassium change; slower rates were associated with a larger decrease in potassium. Glucose decreased proportionally as infusion and wash rate decreased. Lactate did not show an association with either infusion or wash rate. CONCLUSION: Red-cell washing produces higher hematocrit and lower potassium as infusion rate and wash rate decrease. A 340-mL unit of RBC can be processed in 4.26 minutes without loss of hematocrit or an increase in potassium when both infusion and wash rates are set to 400 mL/min.

Analysis of urgent/emergent conversions from monitored anesthesia care to general anesthesia with airway instrumentation.

BACKGROUND: Monitored Anesthesia Care (MAC) is an anesthetic service involving the titration of sedatives/analgesics to achieve varying levels of sedation while avoiding general anesthesia (GA) and airway instrumentation. The goal of our study was to determine the overall incidence of conversion from MAC to general anesthesia with airway instrumentation and elucidate reasons and risk factors for conversion. METHODS: In this retrospective observational study, all non-obstetric adult patients who received MAC from July 2002 to July 2015 at Mount Sinai Hospital were electronically screened for inclusion via a clinical database. Patient, procedure, anesthetic, and practitioner data were all collected and analyzed to generate descriptive analyses. Subsequent univariate and multivariate analyses were used to identify specific risk factors associated with conversion to GA. RESULTS: Overall, 0.50% (1097/219,061) of MAC cases were converted to GA. Approximately half of conversions were due to the patient's "intolerance" of MAC (with or without failed regional anesthesia), while the other half were due to physiologic derangements. Body mass index, male sex, American Society of Anesthesiologists Physical Status Classification, anesthesia team composition, and surgical specialty were all associated with risk of conversion to GA. CONCLUSIONS: This is one of the first and largest retrospective studies aimed at identifying reasons and risk factors associated with the conversion of MAC to GA. These findings may be used to help better anticipate or prevent these events.

Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA.

Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.

Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States.

BACKGROUND: Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS: Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS: ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS: We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

A Case Report of Venoarterial ECMO as Salvage Therapy for Prolonged Cardiac Arrest Following Post-Reperfusion Intracardiac Thrombosis During Orthotopic Liver Transplantation.

In this report we describe the use of intraoperative venoarterial ECMO as salvage therapy in a unique case of post-reperfusion intracardiac thrombosis during liver transplantation with prolonged ACLS and coagulopathy. The limited literature on intraoperative ECMO as salvage therapy in liver transplantation is reviewed.

Safety and Benefit of Transesophageal Echocardiography in Liver Transplant Surgery: A Position Paper From the Society for the Advancement of Transplant Anesthesia (SATA).

More anesthesiologists are routinely using transesophageal echocardiography (TEE) during liver transplant surgery, but the effects on patient outcome are unknown. Transplant anesthesiologists are therefore uncertain if they should undergo additional training and adopt TEE. In response to these clinical questions, the Society for the Advancement of Transplant Anesthesia appointed experts in liver transplantation and who are certified in TEE to evaluate all available published evidence on the topic. The aim was to produce a summary with greater explanatory power than individual reports to guide transplant anesthesiologists in their decision to use TEE. An exhaustive search recovered 51 articles of uncontrolled clinical observations. Topics chosen for this study were effectiveness and safety because they were a major or minor topic in all articles. The pattern of clinical use was a common topic and was included to provide contextual information. Summarized observations showed effectiveness as the ability to make a new and unexpected diagnosis and to direct the choice of clinical management. These were reported in each stage of liver transplant surgery. There were observations that TEE facilitated rapid diagnosis of life-threatening conditions difficult to identify with other types of monitoring commonly used in the operating room. Real-time diagnosis by TEE images made anesthesiologists confident in their choice of interventions, especially those with a high risk of complications such as use of anticoagulants for intracardiac thrombosis. The summarized observations in this systematic review suggest that TEE is an effective form of monitoring with a safety profile similar to that in cardiac surgery patients.

Abdominal Organ Transplantation: Noteworthy Literature in 2019.

In the year 2019, we identified and screened over 400 peer-reviewed publications on pancreatic transplantation, over 200 on intestinal transplantation, and over 1900 on kidney transplantation. The liver transplantation section focuses on and features selected articles among 70 clinical trials published in 2019. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a broad range of topics, including risks for and prediction of perioperative complications, updated indications for transplantation, recommendations on perioperative management, including Enhanced Recovery After Surgery programs, and topics relevant to optimization of patient and graft outcomes and survival.

Intravenous Fluid Management Practices in Kidney Transplant Patients: A Multicenter Observational Cohort Pilot Study.

BACKGROUND: Limited evidence exists with regard to best practices in fluid management during kidney transplantation, which may directly affect the incidence of DGF. The authors of this study embarked on a collaborative observational multicenter pilot study to evaluate fluid administration practices in different transplant centers, with a focus on the relationship between total administered crystalloid volume and its association with DGF. METHODS: Twenty consecutive kidney transplant patients were included from 9 academic medical centers in the United States. One hundred eighty patients were included in the final cohort and variables were compared between patients with and without DGF. Administered crystalloid volume was the primary variable of interest; however, additional patient and surgical variables were compared between patients with and without DGF. Variation in crystalloid administration was explored between centers by comparing median administered crystalloid volumes per kilogram of body weight. Also, unadjusted and adjusted logistic regression analyses were performed to determine which variables were independently associated with DGF. RESULTS: Multivariable regression modeling demonstrated that cold ischemic time and ephedrine use during surgery were independently associated with DGF. There was no independent association between administered crystalloid volume and DGF. CONCLUSION: In this study of patients having kidney transplantation, we did not find an independent association between administered crystalloid volume and DGF, although there was significant variability in crystalloid administration between centers. Our data suggest that DGF was driven mainly by surgical factors such as cold ischemic time. Ephedrine was also independently associated with DGF, which should be explored in future studies.