Patients Undergoing Liver Transplant Surgery Research Articles

Risk Factors for Unplanned Readmission in Adult Liver Transplant Patients: A Retrospective Study

IntroductionUnplanned readmission is an important indicator for evaluating medical care quality. Adult liver transplant patients have high risk for readmission, which seriously affects their recovery. As there is currently a lack of research on risk factors for unplanned readmission of adult liver transplant patients in China, the purpose of this study was to elucidate such risk factors. MethodsData for patients undergoing liver transplantation surgery at a tertiary hospital in Zhejiang Province from March 2018 to July 2022 were retrospectively collected. Patients were divided into readmission and nonreadmission groups based on whether unplanned readmission occurred within 90 days. Univariate analysis and logistic regression were used to analyze risk factors for unplanned readmission. ResultsIn total, 123 adult liver transplant patients were included; 38 had unplanned readmission, for a rate of 30.8%. There was a statistically significant difference between the groups in terms of age, educational level, operation time, intraoperative bleeding volume, number of complications, postoperative hospital stay, and hemoglobin (P < .05). Logistic regression analysis showed that age [OR = 1.085, 95% CI (1.022, 1.152)], operation time [OR = 1.010, 95% CI (1.001, 1.020)], postoperative hospital stay [OR = 1.124, 95% CI (1.023, 1.235)], and number of complications [OR = 4.487, 95% CI (1.234, 16.319)] were independent risk factors for unplanned readmission in adult liver transplant patients (P < .05). ConclusionsThe current situation of unplanned readmission for adult liver transplant patients cannot be ignored, indicating that staff should identify risk factors for unplanned readmission as soon as possible and take targeted personalized measures and health education to reduce readmission risk.

Prolonged Tracheal Intubation in the ICU as a Possible Risk Factor for Arytenoid Dislocation After Liver Transplant Surgery: A Retrospective Case-Control Study.

BACKGROUND Arytenoid dislocation (AD) is a rare complication of general anesthesia with tracheal intubation, with a published incidence of 0.009-0.097%. This retrospective case-control study aimed to identify risk factors associated with AD in patients who underwent liver transplantation. MATERIAL AND METHODS This study included 476 patients who underwent liver transplantation between January 2013 and December 2022. Patients with AD who underwent surgery were included in the AD group. For each case of AD, 4 patients matched by anesthesia type and anesthetist were randomly selected as the non-AD group. Data on patient characteristics, anesthetic factors, and surgical factors were collected and compared between patients with and without AD. Logistic regression analysis was performed to determine the risk factors for AD after liver transplantation. RESULTS Of the 476 patients who underwent liver transplantation, 17 (3.57%) had AD. AD occurred on the left side in 13 patients and on the right side in 4 patients. The 17 patients who experienced AD and 68 matched non-AD patients were enrolled. Patients in the AD group had a greater intubation depth (24 [23-24] vs 24 [24-24], P=0.043), a higher level of hemoglobin (134.5 [118-147.5] vs 112 [96.25-125], P=0.014), and prolonged tracheal intubation in the ICU (19.75 [15.87-31.87] vs 13 [10.62-15], P<0.001) compared to those in the non-dislocation group. Multivariate logistic regression analysis showed that prolonged tracheal intubation in the ICU was independently associated with the occurrence of AD in patients who underwent liver transplantation (P=0.013). CONCLUSIONS This study showed that the incidence of AD was 3.57% in patients undergoing liver transplant surgery and that prolonged tracheal intubation in the ICU was a possible risk factor for AD.

S2501 Cardiopulmonary Failure and Stroke in a Patient With PFO Following Liver Transplant: A Case Report

INTRODUCTION: Patent foramen ovale (PFO) is the most common congenital heart anomaly, and currently affects roughly 20–25% of adults worldwide. This defect allows direct blood flow between the right and left atria with interatrial shunting and increased risk of stroke due to paradoxical embolism. These potential complications are particularly concerning in patients undergoing liver transplant especially those with hepatopulmonary syndrome (HPS) and when using the piggyback operative technique. Two studies evaluated short-term outcomes including neurologic events in patients undergoing liver transplant surgery. Both reported no statistically significant difference in outcomes/neurologic events between patients with or without PFO undergoing transplant. The purpose of this case report is to discuss a patient with known PFO without closure who underwent liver transplantation, and suffered from an MRI-proven stroke and significant cardiopulmonary compromise. CASE DESCRIPTION/METHODS: A 60-year-old female with history of NASH cirrhosis, HPS, and atrial fibrillation with known, asymptomatic PFO as evidenced by interatrial shunting on transthoracic echocardiogram underwent liver transplant with uncomplicated surgery. However, her hospital course was complicated by pneumonia. She was difficult to wean from the ventilator, prompting initiation of extracorporeal membranous oxygenation (ECMO) ten days post-transplant. She remained on ECMO for eleven days, and due to her continued desaturation when weaning from ECMO, underwent percutaneous PFO closure. Roughly two-weeks post-PFO closure, she was noted to have right-sided weakness and right-sided facial droop when weaned from sedation. MR brain showed infarction in the anterior left medulla. DISCUSSION: The etiology of this patient's complicated post-operative course is multifactorial including pneumonia, underlying HPS and underlying PFO. This case questions the current standard of care for patients pre-transplant with known PFO. While the existing data suggests there is no indication for prophylactic PFO closure, some authors recommend considerations for closure in the presence of HPS. Some liver transplant centers recommend routine closure of PFO prior to liver transplant. Further studies are needed to define the population at high risk for paradoxical embolization and other complications of shunting that would benefit from PFO closure prior to liver transplant.

P.147: The effect of transversus abdominis plane block for analgesia in patients undergoing liver transplantation: A systematic review and meta-analysis.

Background: Adequate analgesia for patients undergoing liver transplant (LT) surgeries is a major challenge for the transplant teams. We undertook this meta-analysis to consolidate the available evidence and to quantify the analgesic potential/opioid sparing capability of TAP block in patients undergoing liver transplant surgeries. Methods: We used a population, intervention, control, and outcome study (PICOS) format for the identification of the potential trials that could be included in the present meta-analysis. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgery (donors) were included as the primary outcome in the analysis. Search strategy: The preliminary data search was performed by two independent researchers in Cochrane Central Register of Controlled Trials and PubMed. Comparative trials published until April, 2018 were included in the analysis. Results: There were a total of 627 articles regarding TAP Block in PubMed and 405 in Cochrane database of which a total of 6 articles were about comparative assessment in liver transplant patients. 2 articles were in duplicate thus giving 4 eligible articles whose full texts were read for inclusion in systematic review. Pooled effect size by random effects model showed that TAP group had 27.59 mg (95% CI: 33.47 – 21.70) lower requirement of morphine at 24 hours for pain mitigation. It also showed that TAP group had less PONV. Conclusions: TAP-block significantly lowers the cumulative postoperative 24-h opioid consumption and PONV in LT donors and recipients. The technique of the block needs standardization for patients undergoing LT surgeries.

Utility of Basal Regional Oximetry as an Early Predictor of Graft Failure After Liver Transplant

IntroductionAdequate perfusion and oxygenation to liver graft after transplantation is essential for its viability. Hepatic oximetry (hepatic tissue oxygenation [LSrO2]) through near infrared spectroscopy (NIRS) can help by showing real time oxygen content of the graft. MethodsIn this prospective study, we enrolled 50 consecutive patients undergoing liver transplant surgery from deceased donors.Liver NIRS (LSrO2) was continuously measured for 24 hours then analyzed and correlated with other clinical data such as hemoglobin (Hb), mixed venous oxygen saturation, cardiac index (CI), central venous pressure, arterial gases, diuresis, blood lactate, liver biochemistry, and normalized index ratio (INR). Severity disease scales and cold-warm ischemia time were also measured, as well as Doppler ultrasound (DUS) at hour 24. A statistical analysis with IBM SPSS 22 using Pearson correlation was carried out. ResultsLSrO2 could anticipate serious bleeding and hemodynamic events showing a decrease >10% from basal data.We found a significant correlation between LSrO2 with CI at 3 hours (P=.044), hemoglobin (Hb) at hour 3 and 24 (P = .004 and P = .002, respectively), and with Apache II (P=.041).A significant correlation was also detected between cold ischemia and INR at hour 24 (P=.016).No correlation of LSrO2 was found with lactate, liver biochemistry, and DUS data.

Effect of Instructional Scheme for Patients undergoing liver transplantation Surgery on Their Performance

Effect of Instructional Scheme for Patients undergoing liver transplantation Surgery on Their Performance

Identifying the Prognosis Factors in Death after Liver Transplantation via Adaptive LASSO in Iran

Despite the widespread use of liver transplantation as a routine therapy in liver diseases, the effective factors on its outcomes are still controversial. This study attempted to identify the most effective factors on death after liver transplantation. For this purpose, modified least absolute shrinkage and selection operator (LASSO), called Adaptive LASSO, was utilized. One of the best advantages of this method is considering high number of factors. Therefore, in a historical cohort study from 2008 to 2013, the clinical findings of 680 patients undergoing liver transplant surgery were considered. Ridge and Adaptive LASSO regression methods were then implemented to identify the most effective factors on death. To compare the performance of these two models, receiver operating characteristic (ROC) curve was used. According to the results, 12 factors in Ridge regression and 9 ones in Adaptive LASSO regression were significant. The area under the ROC curve (AUC) of Adaptive LASSO was equal to 89% (95% CI: 86%–91%), which was significantly greater than Ridge regression (64%, 95% CI: 61%–68%) (p < 0.001). As a conclusion, the significant factors and the performance criteria revealed the superiority of Adaptive LASSO method as a penalized model versus traditional regression model in the present study.

Practical Protocol for Management of Severe Hyponatremia in Patients Undergoing Liver Transplant Surgery

Practical Protocol for Management of Severe Hyponatremia in Patients Undergoing Liver Transplant Surgery

Balance of pro- and anti-inflammatory cytokines in cirrhotic patients undergoing liver transplantation

This study was prospectively aimed at having better information about the natural history of serum cytokines in cirrhotic patients undergoing liver transplant surgery and at assessing their ability to set up an appropriate dynamic relationship between pro-inflammation and anti-inflammation. The levels of six cytokines (TNF-α, IL-1, IL-2, IL-6, IL-8, IL-10) were measured in blood samples collected at different time points before, during and after (48h) the transplant procedure from the radial artery of 62 consecutive cirrhotic patients who underwent orthotopic liver transplantation.IL-1 always stayed within the normal range; IL-2 showed elevated baseline levels but decreased up to half at the end of the study (p<0.0001). IL-6 peaked at the end of surgery and returned to baseline 48h afterwards. The same happened to IL-8 concentrations. IL-10 levels shown above the normal threshold at baseline, peaked at the end of surgery (p<0.0001) and were halved at the end of the study (p<0.0001). TNF-α peaked at the end of surgery without, however, being different from baseline levels (p=0.6). The physiologic pattern of cytokine release and their dynamic relationship was found to be preserved with a quick return to a balance between pro-inflammation and anti-inflammation as shown by the IL-6/IL-10 and TNF-α/IL10 ratios (used to assess the inflammatory balance). A correlation was found between perioperative pro-inflammatory cytokine levels and the severity of the liver disease necessitating OLT. In summary, cirrhotic patients can achieve a balanced inflammatory response to surgery which is considered a primary requirement for uneventful grafts and patients' postoperative recovery.

Solvent detergent vs. fresh frozen plasma in cirrhotic patients undergoing liver transplant surgery: a prospective randomized control study

Although orthotopic liver transplantation (OLT) is nowadays considered standard practice at experienced centres, it can still be affected by a significant risk of massive bleeding and its related complications. Solvent/detergent plasma (S/D Plasma) has been proposed as an alternative to fresh frozen plasma (FFP) to curtail such complications. This study aimed at evaluating the efficacy of S/D Plasma in OLT patients by comparing it to FFP. Sixty-three OLT patients were randomized into two groups depending on whether they were transfused with FFP or S/D plasma. A thromboelastography-based protocol aimed at achieving and maintaining predetermined coagulation goals was used to guide plasma transfusions. At the beginning and the end of surgery, standard laboratory coagulation tests were performed together with the assessment of the VII, VIII, V, XII factors and S protein blood levels. The two study groups equally achieved the thromboelastography goals but with a reduced amount of transfusions in the S/D plasma group (P < 0.0001). At the end of surgery, factors V and XII and S protein blood levels were lower in the S/D plasma patients who also showed lower INR, aPTT and antithrombin III levels. In cirrhotic patients undergoing OLT, the use of S\D plasma associated with thromboelastography allows the same clinical results but with a significant reduction in the amount of plasma transfusions.

Prognostic Value of Adenosine Stress Cardiac Magnetic Resonance Imaging in Patients with Known Coronary Artery Disease

of postoperative fluid use within first 48 h (7.1± 6.2 L vs 11.3± 7.8 L), but this was not statistically significant. Conclusion: Dynamic LVOTO during DSE does not predict to significant differences in intraoperative or postoperative haemodynamic response or MACE in patients undergoing liver transplant surgery. http://dx.doi.org/10.1016/j.hlc.2013.05.456

Increased B-Type Natriuretic Peptide During Liver Transplantation: Relationship to Invasively Measured Hemodynamic Parameters

BackgroundThe role of B-type natriuretic peptide (BNP) concentration in predicting cardiac dysfunction has been extensively investigated in many clinical conditions. Little is known, however, about its relationships with hemodynamic parameters from right heart catheterization in patients undergoing liver transplant surgery. MethodsWe retrospectively evaluated 525 patients who underwent liver transplantation. Hemodynamic variables from a Swan-Ganz catheter and BNP concentrations were measured 1 hour after induction of general anesthesia. Patients were stratified by quintiles of BNP concentrations. Univariate and multivariate logistic regression analysis were used to identify hemodynamic parameters associated with BNP ≥ 135 pg/mL, a cutoff point for the 5th quintile. ResultsUnivariate analysis showed that factors significantly associated with BNP ≥ 135 pg/mL included model for end-stage liver disease (MELD) score, diastolic blood pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure (PCWP), cardiac index, right ventricular end-diastolic volume index (RVEDVI), systemic vascular resistance index, pulmonary vascular resistance index (PVRI), and right ventricular stroke work index. Multivariate analysis revealed that MELD score (odds ratio [OR] = 1.059, P < .001), PCWP (OR = 1.116, P = .026), RVEDVI (OR = 1.010, P = .009), and PVRI (OR = 1.009, P = .002) were independent determinants of BNP ≥ 135 pg/mL. ConclusionsSeverity of liver disease, preload dependent hemodynamic parameters, and pulmonary vascular resistance were found to be significantly associated with increased BNP concentration, reinforcing the utility of BNP as a marker of cardiac strain and ventricular volume overload in liver failure patients undergoing liver transplant surgery.

Evaluation of the potential drug interactions in pharmacotherapy of post liver transplant patients in ICU

BackgroundThe main recurrent problem after liver transplantation is the rejection of the transplanted organ, which is why immunosuppressants are widely used as post-transplant drug therapy. This drug class has a...

Evaluation of a New Software Version of the FloTrac/Vigileo (Version 3.02) and a Comparison with Previous Data in Cirrhotic Patients Undergoing Liver Transplant Surgery

Reliable cardiac output monitoring is particularly useful in the cirrhotic patient undergoing liver transplant surgery, because cirrhosis of the liver is associated with a vasodilated and high output state, known as cirrhotic cardiomyopathy, that challenges the reliability of pulse contour cardiac output technology. The contractility of the ventricle in cirrhosis is impaired, which is tolerated even though the ejection fraction and cardiac output are elevated because of the low peripheral resistance. However, during surgery the cirrhotic patient can decompensate because of the physiological changes and stress of surgery. Recently, we showed that the FloTrac/Vigileo™ failed to perform in cirrhotic patients undergoing transplant surgery. In response, the company upgraded their software. Therefore, we have assessed the accuracy and reliability of this new third-generation (version 3.02) FloTrac/Vigileo algorithm software in the same setting. The cardiac index was measured simultaneously by single-bolus thermodilution (CI(TD)), using a pulmonary artery catheter, and pulse contour analysis, using the FloTrac/Vigileo (CI(V)). Readings were made at 10 time points during and after liver transplant surgery in 21 patients. Comparisons with data from our 2009 study, which used second-generation (version 01.10) software, were also made. Our new data show that version 3.02 software significantly reduced the adverse effect on pulse contour cardiac output reading bias in low peripheral resistance states, and thus improves the overall precision and trending ability of the system. Regression analysis between CI(TD) and CI(V) showed that the correlation was moderate (r =0.67, 95% confidence interval, 0.40 to 0.86). The Bland and Altman analysis showed that bias was 0.4 L.min(-1) · m(-2), and the percentage error was 52% (95% confidence interval, 49% to 55%). Trending ability of the new software also was improved but was still well below the current benchmarks. The new software (version 3.02) provided substantial improvements over the previous versions with better overall precision and trending ability. Further algorithm refinements will increase this technology's reliability to be extensively used in the highly complex setting of cirrhotic patients undergoing liver transplantation.

Perioperative Risk Predictors of Cardiac Outcomes in Patients Undergoing Liver Transplantation Surgery

Cardiac risk assessment for perioperative outcomes of liver transplantation patients is limited. We examined the outcomes of an older intermediate-cardiac-risk group of patients undergoing liver transplantation surgery. Patients who had liver transplantation surgery between 2001 and 2005 were studied. The 3 outcomes analyzed were nonfatal myocardial infarction, death, and either outcome within the first 30 days after the liver transplantation surgery. Of 403 patients (mean age, 52+/-9 years; 67% male), 106 (26%) were diabetic, 84 (21%) were hypertensive, and 173 (43%) had a history of smoking. There were 48 total events (12%), 25 myocardial infarctions (7%), and 38 deaths (9%) recorded during the perioperative period. From the final multivariate model, history of coronary artery disease, prior stroke, and postoperative sepsis predicted greater risk (P=0.014; odds ratio [OR], 4.0; 95% confidence interval [CI], 1.3 to 11.8; P=0.025; OR, 6.6; 95% CI, 1.3 to 33.8; and P<0.001; OR, 7.5; 95% CI, 3.3 to 17.1, respectively). Use of perioperative beta-blockers was protective (P=0.004; OR, 0.20; 95% CI, 0.1 to 0.6) for combined cardiac outcomes. For the outcome of death on multivariate analysis, postoperative sepsis and increased interventricular septal thickness predicted risk (P<0.001; OR, 8.6; 95% CI, 3.5 to 20.9; and P=0.027; OR, 2.8; 95% CI, 1.1 to 7.2, respectively), whereas the use of perioperative beta-blockers was again protective (P=0.012; OR, 0.07; 95% CI, 0.01 to 0.56). In our study of cardiac risk assessment for liver transplantation surgery, history of stroke, coronary artery disease, postoperative sepsis, and increased interventricular septal thickness were markers of adverse perioperative cardiac outcomes, whereas use of perioperative beta-blockers was significantly protective.

Radial to femoral arterial blood pressure differences during liver transplantation

This observational study compared femoral and radial arterial blood pressure in 72 patients undergoing liver transplant surgery. Simultaneous femoral and radial arterial blood pressures, cardiac index, core temperature and vasoconstrictor therapy were recorded at seven time points during the operation. No significant differences between radial and femoral pressures were found at the start of surgery. Femoral and radial systolic arterial blood pressures were statistically significantly different during liver reperfusion (mean (SD) arterial pressure = 92 (22) mmHg vs. 76 (22) mmHg, p < 0.01). Mean arterial blood pressures showed no statistically significant differences throughout the study. Vasoconstrictor drug administration was associated with a larger systolic pressure difference between femoral and radial arteries (28 (24) mmHg in patients being given vasoconstrictor drugs vs. 9 (19) mmHg in patients not needing vasoconstrictors during reperfusion, p < 0.001). In conclusion, differences in systolic arterial blood pressure occur between femoral and radial arterial monitoring sites during liver reperfusion, and in particular in patients being given vasoconstrictor therapy. Thus, if femoral arterial monitoring is not available, clinicians should rely on mean rather than systolic arterial pressure measurements from a radial artery catheter during liver transplantation.

CUIDADOS DE ENFERMERÍA DEL PACIENTE TRASPLANTADO HEPÁTICO EN LA UNIDAD DE HOSPITALIZACIÓN DE TRASPLANTES DEL HOSPITAL VIRGEN DE LA ARRIXACA.

This article describes the nursing care for patients undergoing liver transplant surgery in the Transplants Unit at the Virgen de la Arrixaca Hospital. This care is a part of a wider care in which participate many different professionals. In this work we deal specifically with nursing care before and after the liver transplant in our hospitalization unit, situated on the third floor at the Virgen de la Arrixaca University Hospital, in Murcia (Spain).

The impact of total plasma exchange on early allograft dysfunction

Introduction Early allograft dysfunction (EAD) is a rare but serious complication encountered among patients undergoing liver transplant surgery. Total plasma exchange (TPE) in EAD has been suggested, but its role is still considered investigational. We retrospectively assessed the efficacy of TPE in EAD and its impact on other parameters of liver function. Materials and methods Between 1995 and 2001, 25 orthotopic liver transplant recipients developed EAD, which was defined as early postoperative prothrombin time (PT) >17 seconds, aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) >2500 IU/L, and/or the presence of hepatic encephalopathy, and development of renal failure. Daily TPE was performed using the Cobe Spectra TPE (Gambro) for 4 hours until an adequate clinical response, the patient underwent retransplantation, or the patient died. International normalizing ratio (INR), partial thromboplastin time (PTT), fibrinogen, ALT, AST, gamma-glutanyl transpeptidase (GGT), blood urea nitrogen (BUN), ammonia, and total bilirubin were analyzed before and after TPE. Student t and chi-square tests were used for statistical analysis. Results Twenty-five patients with EAD included 13 females, 12 males of mean age 42.3 years (range, 1–63 years). Coagulopathy and hyperbilirubinemia significantly improved with TPE. Nineteen patients (76%) survived and 2 required retransplantation. Mean number of TPE sessions was 4.3. Conclusion TPE was effective to correct coagulopathy and improve liver function. These results suggest the benefit of potential temporary liver support until recovery or retransplantation, in the absence of sepsis or multi-system organ failure.