Justification for routine intensive care after liver transplantation
Department of Anesthesiology, Baylor University Medical Center, Dallas, TX
Address reprint requests to Michael Ramsay, M.D., Department of Anesthesiology, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246. Telephone: 214-820-3296; FAX: 214-820-6612; E-mail: firstname.lastname@example.org
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Risk, Injury, Failure, Loss, and End-Stage Kidney Disease
survival outcomes following liver transplantation
The use of the intensive care unit (ICU) for the management of some critically ill patients before liver transplantation and for all recipients immediately after transplantation is the normal pattern of care at most centers.
Immediate extubation of the trachea with transfer to a post-anesthesia care unit (PACU) and then the general surgical ward has been described in some centers for select patients.
The advantages of a fast-track protocol are cost and resource savings: also, there is a potential for improved hemodynamics, including improved cardiac output, increased venous return, increased hepatic blood flow, and improved early graft function. The potential for a reduction in nosocomial infections exists with early extubation.
The disadvantages of a fast-track protocol include the delayed detection of respiratory, renal and graft insufficiencies and the delayed detection of postoperative hemorrhaging, sepsis, and rejection.
There a need for increased vigilance and technology on the general floor that could reduce the risk of fast-tracking.
The selection criteria for the immediate transfer to the ICU after transplantation are defined, as are those criteria for possible inclusion in a fast-track protocol.
The routine management of postoperative liver transplant recipients is a period of time in the intensive care unit (ICU) during which hemodynamics, coagulation, renal function, ventilation, brain function (in some cases), and graft function are critically managed; pain is also managed, and there is careful screening for the early onset of infection. The stay in the ICU may be prolonged because of preexisting conditions in the recipient and the graft, intraoperative complications, and postoperative events. Some patients will not require mechanical ventilation and will be extubated immediately at the end of surgery. Some of these patients will still require intensive care but some may be candidates to be transferred from the operating room to the PACU OR step-down unit and then to the general ward.
The term fast-tracking when it is applied to liver transplantation (LT), may mean early extubation, immediate extubation, ICU care or no ICU care. The reports of any substantial number of patients undergoing fast-tracking come from a few centers.[1-7]
Liberation from mechanical ventilation and removal of the endotracheal tube have been demonstrated to be possible for select patients over the last 16 years.[1-5] Initially the ICU was used for these patients, but gradually, with experience, in some centers, inclusion and exclusion criteria were developed and select patients were not admitted to the ICU but to step down units (Figs. 1-3).[6, 7]
These reports were not detailed to draw definite conclusions on the safety or advisability of bypassing the ICU, but they have demonstrated that it is possible to do this with some patients. The transfer of these patients is to step down units where all the nursing care and monitors of the ICU appear to be available except mechanical ventilation. In the surgical ward described in the largest study so far, 1:1 nursing was available and hemodynamic and respiratory stability were confirmed before discharge from the PACU. Therefore a much higher level of care was available than would be found on the usual general floor.
DONOR AND RECIPIENT CHARACTERISTICS THAT PREDICT THE LENGTH OF STAY IN THE INTENSIVE CARE UNIT
In the latest and largest single center series of fast track patients sent to the PACU and then the ward, the decision to go to the ICU was left to the medical judgment of the transplant team. The graft and patient survival rates were similar between the fast-track group and the ICU group, and specifically the 30-day mortality rate was the same between groups. This however does not demonstrate equality of care, and perhaps the goal should have been zero mortality for the fast-tracked group of patients. Could better monitoring and care have detected an adverse event developing at a time that it could have been treated and reversed?
Increased donor risk indices (DRIs) and high Model for End-Stage Liver Disease (MELD) scores have been associated with poorer outcomes.[8-10] The new balance of risk (BAR) system provides a reliable tool for detecting unfavorable donor and recipient factors that predict outcomes and, therefore, perhaps patients that should not be fast-tracked. In the ICU setting, the early detection of sepsis can reduce the major cause of posttransplant morbidity and mortality. Early detection of acute kidney injury may prevent renal failure, and the early detection of a poorly functioning graft may allow an intervention that may result in a good outcome. Close hemodynamic monitoring may allow the early detection of postoperative bleeding, coagulopathy and sepsis, again at a time when an intervention could be curative. Effective transplant critical care allows a team to consider high-risk donors and high-risk recipients (Figs 4 and 5).
RAISING THE TECHNOLOGY BAR FOR FAST-TRACKED PATIENTS
If the decision is made to fast-track patients, then it seems reasonable to deploy the latest technologies to detect early deterioration of patient or graft function. Perhaps the surgical ward should be equipped with continuous oxygenation and ventilation monitors with a closed loop so that there is continuous monitoring of the monitors. This has been demonstrated to reduce the need for escalation of care in post surgery patients. Hemoglobin can also be monitored continuously, as can respiratory rate; this allows bleeding, sepsis, and opioid-induced respiratory depression to be detected.
Graft function may be monitored with microdialysis catheters for early detection and to distinguish rejection from ischemia in liver grafts.[16, 17]
The avoidance of ICU care after liver transplantation has not yet been shown to be safe for patients or grafts. Assessment of donor and recipient risk should be taken into account together with continuous recipient and graft monitoring, and then a large multicenter prospective trial should be considered. The loss of one graft or recipient due to inadequate monitoring is unacceptable.