Management Of Orthotopic Liver Transplantation Research Articles

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

Background.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.

Serious gaming for orthotopic liver transplant anesthesiology: A randomized control trial.

Anesthetic management of orthotopic liver transplantation (OLT) is complex. Given the unequal distributions of liver transplant surgeries performed at different centers, anesthesiology providers receive relatively uneven OLT training and exposure. One well-suited modality for OLT training is the "serious game," an interactive application created for the purpose of imparting knowledge or skills, while leveraging the self-motivating elements of video games. We therefore developed a serious game designed to teach best practices for the anesthetic management of a standard OLT and determined if the game would improve resident performance in a simulated OLT. Forty-four residents on the liver transplant rotation were randomized to either the gaming group (GG) or the control group (CG) prior to their introductory simulation. Both groups were given access to the same educational materials and literature during their rotation, but the GG also had access to the OLT Trainer. Performance on the simulations were recorded on a standardized grading rubric. Both groups experienced an increase in score relative to baseline that was statistically significant at every stage. The improvements in scores were greater for the GG participants than the CG participants. Overall score improvement between the GG and CG (mean [standard deviation]) was statistically significant (GG, 7.95 [3.65]; CG, 4.8 [4.48]; P = 0.02), as were scores for preoperative assessment (GG, 2.67 [2.09]; CG, 1.17 [1.43]; P = 0.01) and anhepatic phase (GG, 1.62 [1.01]; CG, 0.75 [1.28]; P = 0.02). Of the residents with game access, 81% were "very satisfied" or "satisfied" with the game overall. In conclusion, adding a serious game to an existing educational curriculum for liver transplant anesthesia resulted in significant learning gains for rotating anesthesia residents. The intervention was straightforward to implement and cost-effective. Liver Transplantation 23 430-439 2017 AASLD.

Effects of Cardiac Valve Dysfunction on Perioperative Management of Liver Transplantation

Objective Our aim was to investigate the effects of cardiac valve dysfunction on perioperative management of orthotopic liver transplantation (OLT) among a retrospective cohort. Patients and Methods Three hundred forty-six patients underwent echocardiographic (ECHO) examination prior to OLT. Data of patients with valvular dysfunctions were compared to subjects with normal ECHO. We evaluated patient characteristics, operation variables, hemodynamic course, blood products, fluid and drug requirements, extubation, and mortality rates. Results Ninety-five patients (27.5%) with cardiac valve dysfunction were classified as mitral valve insufficiency (MVI; n = 32), tricuspid valve insufficiency (TVI; n = 23), or both MVI and TVI (n = 40). One hundred fifty-two patients displayed normal ECHO examinations (control). Ninety-nine patients with other pathologies were excluded from the study. Systemic vascular resistance was significantly lower among the MVI group, and cardiac output (CO) significantly higher in the MVI and both MVI and TVI groups compared with controls. More MVI and both MVI and TVI patients required epinephrine compared with controls. The number of patients who required blood transfusion was higher in the MVI than the control group ( P < .05). Patient characteristics, end-stage liver failure scores, duration of operations, hemodynamic variables, incidence of postreperfusion syndrome, mean doses of ephedrine and epinephrine, red blood cells, fresh frozen plasma and fluid requirements, number of patients extubated immediately after surgery, and mortality rates were not different between the groups. Conclusions Our study demonstrated that cardiac valve dysfunction may be associated with end-stage liver disease among patients undergoing OLT. Patients with MVI or both MVI and TVI required more care in perioperative management.

Perioperative management of orthotopic liver transplantation in patients with severe hepatitis

Objective To evaluate and summarize the experience in perioperative management of orthotopic liver transplantation(0LT)in patients with severe hepatitis. Methods The clinical data of 218 patients with severe hepatitis undergoing OLT in our hospital from June 2004 to June 2006 were retrospectively analyzed. Results The survival rate in perioperative period was 92.7%(202/218).in which the acute severe hepatitis was 90.4%(57/63),chronic severe hepatitis was 93.5%(145/155). The common complications included infection(74.7%),liver transplantation related encephalopathy (65.6%)and acute renal failure(14.7%).Conclusion Perioperative mortality is high in patients with severe hepatitis receiving liver transplantation. Effective perioperative management iS important to improve survival rate of the patients with severe hepatitis after 0LT. Key words: Liver transplantation; Severe hepatitis; Perioperative management

Pulse Contour Cardiac Output System Use in Pediatric Orthotopic Liver Transplantation: Preliminary Report of Nine Patients

Anesthetic management of orthotopic liver transplantation (OLT) in pediatric patients is challenging in terms of intraoperative bleeding, fluid management, and hemodynamic monitoring. The pulse contour cardiac output (PiCCO) system, a relatively new device based on the single-indicator transaortic thermodilution technique, may be useful for intraoperative hemodynamic monitoring in pediatric patients. This is a preliminary report of PiCCO use in nine children (aged 9.8 ± 4.7 years) undergoing OLT. Hemodynamic volumetric parameters monitored by the PiCCO system were mean arterial pressure (MAP), cardiac index (CI), intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), systemic vascular resistance index (SVRI), and stroke volume variability (SVV). All parameters were recorded at anesthesia induction (T 0), at the end of the anhepatic phase (T anhepatic), and at the end of operation (T end). The PiCCO system revealed similar MAP, CI, EVLWI, SVV, and SVRI values at all measurement intervals. Despite similar central venous pressure measurements, ITBVI values indicated significantly lower values at T anhepatic than at T 0 (627 ± 160 mL/m 2 and 751 ± 151 mL/m 2, respectively, P = .013). There were no PiCCO catheter-related complications in any patient. These findings demonstrate that the PiCCO system is a safe, continuous, multiparameter invasive monitoring device for use in pediatric patients undergoing OLT. This system may provide valuable data during pediatric OLT and appears to be a promising monitoring tool in these patients.

Perioperative management of orthotopic liver transplantation in 48 cases of fulminant hepatitis

目的 总结重型肝炎病人肝移植围手术期若干问题处理的经验.方法对我院2002年1月至2004年2月完成的48例重型肝炎病人的围手术期处理进行回顾性分析.结果本组48例重型肝炎病人肝移植后存活40例(83.3%,存活1个月至2年),其中31例出现急性肾功能衰竭,22例出现肝移植相关性脑病,19例并发严重肺部感染.术前合并严重感染、严重肺动脉高压、肾功能衰竭或APACHEⅡ评分>20分者,肝移植后死亡风险较大.结论术前评估及适当调理和有效的围手术期处理是提高重型肝炎病人肝移植成功率的关键。

Intraoperative transesophageal echocardiography in orthotopic liver transplantation in a patient with hypertrophic cardiomyopathy

With improvements in the surgical technique for orthotopic liver transplantation, patients with significant underlying systemic disease are considered candidates for transplantation, thus increasing the complexity of the medical management of these patients and necessitating additional monitoring in order to minimize the anesthetic risk. We describe the anesthetic management of orthotopic liver transplantation for a patient with severe hypertrophic cardiomyopathy and mitral insufficiency. In this case, transesophageal echocardiography proved useful in the management of the postreperfusion period of the surgical procedure.