Epidemiology and Prognostic Significance of Rapid Response System Activation in Patients Undergoing Liver Transplantation.

Marcus Robertson,Peter Angus,Andy K H Lim,William Chung,Paul Gow,Elise Cannan,Andrew Huynh,Daryl Jones,Ashley Bloom,Tessa O’Halloran,Ben Johnstone,Andrew Tsoi

doi:10.3390/jcm10235680

Abstract

Patients undergoing liver transplantation have a high risk of perioperative clinical deterioration. The Rapid Response System is an intensive care unit-based approach for the early recognition and management of hospitalized patients identified as high-risk for clinical deterioration by a medical emergency team (MET). The etiology and prognostic significance of clinical deterioration events is poorly understood in liver transplant patients. We conducted a cohort study of 381 consecutive adult liver transplant recipients from a prospectively collected transplant database (2011–2017). Medical records identified patients who received MET activation pre- and post-transplantation. MET activation was recorded in 131 (34%) patients, with 266 MET activations in total. The commonest triggers for MET activation were tachypnea and hypotension pre-transplantation, and tachycardia post-transplantation. In multivariable analysis, female sex, increasing Model for End-Stage Liver Disease score and hepatorenal syndrome were independently associated with MET activation. The unplanned intensive care unit admission rate following MET activation was 24.1%. Inpatient mortality was 4.2% and did not differ by MET activation status; however, patients requiring MET activation had significantly longer intensive care unit and hospital length of stay and were more likely to require inpatient rehabilitation. In conclusion, liver transplant patients with perioperative complications requiring MET activation represent a high-risk group with increased morbidity and length of stay.

Highlights

Liver transplantation (LT) remains a life-saving intervention for patients with acute liver failure, end-stage liver disease and hepatocellular carcinoma
Two patients were excluded as multivisceral transplant recipients
In the post-LT analysis, patients with a primary diagnosis of hepatocellular carcinoma had a lower odds for Medical Emergency Team (MET) activation but this was not independent of the adjusted Charlson Comorbidity Index (ACCI) or Model for End-stage Liver Disease (MELD) scores

Summary

Introduction

Liver transplantation (LT) remains a life-saving intervention for patients with acute liver failure, end-stage liver disease and hepatocellular carcinoma. Recent studies indicate that LT candidates are becoming older, have a greater comorbidity burden, and increasing. Model for End-stage Liver Disease (MELD) score, all of which increase the risk of perioperative clinical deterioration and complications [1,2]. Patients undergoing LT are commonly profoundly unwell, have a high risk for rapid clinical deterioration, and require significant hospital resources and intensive care unit (ICU) support [3]. Postoperative clinical deterioration is associated with mortality and poor graft survival [4,5]. The Rapid Response System (RRS) is a hospital-wide approach for the early recognition and management of inpatients identified as ‘high risk’ for acute clinical deterioration

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