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Bezinover D, Zerillo J, Chadha RM, Wagener G, Blasi A, Johnson T, Pan TLT, De Marchi L. Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE. Transplantation 2024; 108:1570-1583. [PMID: 38383955 DOI: 10.1097/tp.0000000000004943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
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.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeron Zerillo
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ryan M Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | - Gebhard Wagener
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, NY
| | - Annabel Blasi
- Anesthesia Department, Hospital Clinic, IDIBAPS (Institut d´Investigacions Biomèdiques Agustí Pi i Sunyé), Barcelona. Spain
| | - Taylor Johnson
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Hershey Medical Center, Hershey, PA
| | - Terry Ling Te Pan
- Department of Anaesthesia, National University Hospital, Singapore, Singapore
| | - Lorenzo De Marchi
- Department of Anesthesiology, MedStar-Georgetown University Hospital, Washington DC
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2
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Hansebout C, Desai TV, Dhir A. Utility of transesophageal echocardiography during orthotopic liver transplantation: A narrative review. Ann Card Anaesth 2023; 26:367-379. [PMID: 37861569 PMCID: PMC10691562 DOI: 10.4103/aca.aca_186_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/10/2023] [Accepted: 02/21/2023] [Indexed: 10/21/2023] Open
Abstract
Orthotopic liver transplantation (OLT) is the standard of care for patients suffering from end stage liver disease (ESLD). This is a high-risk procedure with the potential for hemorrhage, large shifts in preload and afterload, and release of vasoactive mediators that can have profound effects on hemodynamic equilibrium. In addition, patients with ESLD can have preexisting coronary artery disease, cirrhotic cardiomyopathy, porto-pulomary hypertension and imbalanced coagulation. As cardiovascular involvement is invariable and patient are at an appreciable risk of intraoperative cardiac arrest, Trans esophageal echocardiography (TEE) is increasingly becoming a routinely utilized monitor during OLT in patients without contraindications to its use. A comprehensive TEE assessment performed by trained operators provides a wealth of information on baseline cardiac function, while a focused study specific for the ESLD patients can help in prompt diagnosis and treatment of critical events. Future studies utilizing TEE will eventually optimize examination safety, quality, permit patient risk stratification, provide intraoperative guidance, and allow for evaluation of graft vasculature.
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Affiliation(s)
- Christopher Hansebout
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Tejal V. Desai
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Achal Dhir
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
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3
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Sharma S, Saner FH, Bezinover D. A brief history of liver transplantation and transplant anesthesia. BMC Anesthesiol 2022; 22:363. [PMID: 36435747 PMCID: PMC9701388 DOI: 10.1186/s12871-022-01904-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/13/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we describe the major milestones in the development of organ transplantation with a specific focus on hepatic transplantation. For many years, the barriers preventing successful organ transplantation in humans seemed insurmountable. Although advances in surgical technique provided the technical ability to perform organ transplantation, limited understanding of immunology prevented successful organ transplantation. The breakthrough to success was the result of several significant discoveries between 1950 and 1980 involving improved surgical techniques, the development of effective preservative solutions, and the suppression of cellular immunity to prevent graft rejection. After that, technical innovations and laboratory and clinical research developed rapidly. However, these advances alone could not have led to improved transplant outcomes without parallel advances in anesthesia and critical care. With increasing organ demand, it proved necessary to expand the donor pool, which has been achieved with the use of living donors, split grafts, extended criteria organs, and organs obtained through donation after cardiac death. Given this increased access to organs and organ resources, the number of transplantations performed every year has increased dramatically. New regulatory organizations and transplant societies provide critical oversight to ensure equitable organ distribution and a high standard of care and also perform outcome analyses. Establishing dedicated transplant anesthesia teams results in improved organ transplantation outcomes and provides a foundation for developing new standards for other subspecialties in anesthesiology, critical care, and medicine overall. Through a century of discovery, the success we enjoy at the present time is the result of the work of well-organized multidisciplinary teams following standardized protocols and thereby saving thousands of lives worldwide each year. With continuing innovation, the future is bright.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
| | - Fuat H Saner
- Department of General, Visceral, and Transplant Surgery, Medical Center University Essen, Hufeland 55, 45147, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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4
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Mazilescu LI, Bezinover D, Paul A, Saner FH. Unrecognized Esophageal Perforation After Liver Transplantation. J Cardiothorac Vasc Anesth 2018; 32:1407-1410. [DOI: 10.1053/j.jvca.2017.10.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Indexed: 11/11/2022]
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Zerillo J, Hill B, Kim S, DeMaria S, Mandell MS. Use, Training, and Opinions About Effectiveness of Transesophageal Echocardiography in Adult Liver Transplantation Among Anesthesiologists in the United States. Semin Cardiothorac Vasc Anesth 2018; 22:137-145. [DOI: 10.1177/1089253217750754] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Study Objective. Describe transesophageal echocardiography (TEE) use, preparatory training and opinions about clinical importance, and future training pathways in a sample of liver transplant anesthesiologists. Design. Online survey questionnaire. Setting. Liver Transplant Centers in the United States. Participants. Director of Liver Transplant Anesthesia or designated alternate respondent. Results. A total of 79 Directors or alternates from 111 (71%) centers were identified. There were 56 responses (71%) representing 433 transplant anesthesiologists who cared for 63.3% of liver transplant cases performed in 2015. Basic TEE certification was reported more frequently (64%) than advanced (53.6%). At least one team member used TEE in over 90% of responding centers. Most respondents (83.9%) agreed TEE provided unique and valuable clinical information but were equally divided about future training pathways (on the job learning vs basic TEE certification). Conclusion. TEE use in liver transplantation is growing with a substantial increase in basic TEE certified users. Transplant anesthesiologists support basic certification but an equal number believe there should be more applied training at the site of care.
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Affiliation(s)
- Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan Hill
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sang Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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De Pietri L, Mocchegiani F, Leuzzi C, Montalti R, Vivarelli M, Agnoletti V. Transoesophageal echocardiography during liver transplantation. World J Hepatol 2015; 7:2432-2448. [PMID: 26483865 PMCID: PMC4606199 DOI: 10.4254/wjh.v7.i23.2432] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/22/2015] [Accepted: 09/09/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver transplant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the procedures as a result of both the disease process and the surgery. Transoesophageal echocardiography (TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. Moreover, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.
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7
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Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015; 28:40-56. [PMID: 25559474 DOI: 10.1016/j.echo.2014.09.009] [Citation(s) in RCA: 312] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Pai SL, Aniskevich S, Feinglass NG, Ladlie BL, Crawford CC, Peiris P, Torp KD, Shine TS. Complications related to intraoperative transesophageal echocardiography in liver transplantation. SPRINGERPLUS 2015; 4:480. [PMID: 26361581 PMCID: PMC4559558 DOI: 10.1186/s40064-015-1281-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/27/2015] [Indexed: 12/17/2022]
Abstract
Purpose Intraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation (OLT) out of concern about rupture of esophageal varices. Complications associated with TEE in OLT were evaluated. Methods We retrospectively reviewed charts and TEE videos of all OLT cases from January 2003 through December 2013 at Mayo Clinic (Jacksonville, Florida). Results Of the 1811 OLTs performed, we identified 232 patients who underwent intraoperative TEE. Esophageal variceal status was documented during presurgical esophagogastroduodenoscopy in 230 of the 232 patients. Of these, 69 (30.0 %), had no varices; 113 (49.1 %), 41 (17.8 %), and 7 (3.0 %) had grades I, II, and III varices, respectively. Two patients (0.9 %) had no EGD performed because of acute liver failure. During OLT, 1 variceal rupture (0.4 %) occurred after placement of an oral gastric tube and TEE probe; the patient required intraoperative variceal banding. Most patients had preexisting coagulopathy at the time of probe placement. The mean (SD) laboratory test results were as follows: prothrombin time, 21.7 (6.6) seconds; international normalized ratio, 1.9 (1.3); partial thromboplastin time, 43.8 (13.3) seconds; platelet, 93.7 (60.8) × 1000/μL; and fibrinogen, 237.8 (127.6) mg/dL. Conclusion TEE was a relatively safe procedure with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices and coagulopathy undergoing OLT. It appeared to effectively disclose cardiac information and allowed rapid reaction for proper patient management.
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Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Stephen Aniskevich
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Neil G Feinglass
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Beth L Ladlie
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Claudia C Crawford
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Prith Peiris
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Klaus D Torp
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
| | - Timothy S Shine
- Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA
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Soong W, Sherwani SS, Ault ML, Baudo AM, Herborn JC, De Wolf AM. United States practice patterns in the use of transesophageal echocardiography during adult liver transplantation. J Cardiothorac Vasc Anesth 2014; 28:635-9. [PMID: 24447499 DOI: 10.1053/j.jvca.2013.10.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To characterize contemporary practice patterns in the use of transesophageal echocardiography during adult liver transplantation and to identify factors preventing more frequent use. DESIGN Online questionnaire. SETTING Liver transplantation centers in the United States performing 12 or more adult liver transplants in 2011. PARTICIPANTS One representative from each qualifying center: The transplant anesthesiology director, a transplant anesthesiologist personally known to the authors, or the department of anesthesiology chair. INTERVENTIONS Three e-mail attempts were made to solicit participation in the study between June and August 2012. MEASUREMENTS AND MAIN RESULTS Of the 97 institutions identified, an anesthesiologist from each of 79 (81.4%) centers completed the questionnaire; 38.0% of centers reported routine use and 57.0% for special circumstances or rescue situations, yielding an overall use rate of 94.9%. This distribution was consistent regardless of operative volume, practice size, or academic affiliation. The sole factor predictive of routine transesophageal echocardiography use was an overlap between an institution's cardiac and transplant anesthesiology teams. In practices not routinely employing the technology, the most compelling reason was a sense that it was not necessary. Although 69.9% of transplant anesthesiologists reportedly were proficient in echocardiography, inadequate anesthesiologist training was also a strongly cited hindrance. CONCLUSIONS Transesophageal echocardiography during adult liver transplantation in the United States has become widely prevalent, with notable growth in its use as a routine diagnostic and monitoring modality. Almost all institutions now use the technology at least occasionally, with the participation of cardiac anesthesiologists being predictive of a center's routine use.
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Affiliation(s)
- Wayne Soong
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Saadia S Sherwani
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael L Ault
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew M Baudo
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joshua C Herborn
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andre M De Wolf
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Lu SY, Matsusaki T, Abuelkasem E, Sturdevant ML, Humar A, Hilmi IA, Planinsic RM, Sakai T. Complications related to invasive hemodynamic monitors during adult liver transplantation. Clin Transplant 2013; 27:823-8. [PMID: 24033433 DOI: 10.1111/ctr.12222] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 01/10/2023]
Abstract
The rate of complications directly related to invasive monitors during liver transplantation (LT) was reviewed in 1206 consecutive adult LTs performed over 8.6 yr (1/1/2004-7/31/2012). The designated anesthesiologists placed intra-operative monitors, including two arterial catheters (via the radial and the right femoral arteries), central venous catheters (a 9 Fr. catheter and an 18 Fr. veno-venous bypass [VVB] return cannula in an internal jugular vein), a pulmonary artery catheter, and a transesophageal echocardiography (TEE) probe. A 17 Fr. VVB drainage cannula was placed via the left femoral vein. No Clavien-Dindo Grade V (death) or Grade IV (organ dysfunction) complication was identified. Nine Grade III complications (requiring surgical intervention) and 15 Grade II complications (conservative treatment) were noted. Seven (0.58% in 1206 cases) were related to a femoral arterial line with Grade III of four; seven (0.58%) were due to VVB return cannula in the femoral vein with Grade III of one; four (0.33%) were related to central venous catheters with Grade III of two; four (0.33%) were due to a TEE probe with Grade III of two; and two minor complications (0.17%) that were related to a radial arterial line. No complication was observed with a pulmonary arterial catheter. Current invasive monitors placed during LT have an acceptable risk.
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Affiliation(s)
- Shu Y Lu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Early echocardiographic detection of a massive intracardiac thrombus in a patient scheduled for orthotopic liver transplantation. J Clin Anesth 2012; 24:404-6. [DOI: 10.1016/j.jclinane.2011.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 10/25/2011] [Accepted: 11/16/2011] [Indexed: 11/24/2022]
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Fiegel M, Cheng S, Zimmerman M, Seres T, Weitzel NS. Postreperfusion Syndrome During Liver Transplantation. Semin Cardiothorac Vasc Anesth 2012; 16:106-13. [DOI: 10.1177/1089253212444791] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Sara Cheng
- University of Colorado Denver, Aurora, CO, USA
| | | | - Tamas Seres
- University of Colorado Denver, Aurora, CO, USA
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13
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Rando K, Niemann CU, Taura P, Klinck J. Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to medium-income countries. Liver Transpl 2011; 17:1247-78. [PMID: 21837742 DOI: 10.1002/lt.22405] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) is a highly effective treatment, it has been considered too costly for publicly funded health systems in many countries with low to medium average incomes. However, with economic growth and improving results, some governments are reconsidering this position. Cost-effectiveness data for LT are limited, especially in perioperative care, and the techniques and costs vary widely between centers without overt differences in outcomes. Anesthesiologists working in new programs find it difficult to determine which modalities are essential, which are needed only in exceptional circumstances, and which may be omitted without effects on outcomes. We investigated key elements of preoperative evaluations, intraoperative management, and early postoperative care that might significantly affect costs in order to develop a best-value approach for new programs in resource-limited health systems. We identified all modalities of care commonly used in anesthesia and perioperative care for adult LT along with their costs. Those considered to be universally accepted as minimum requirements for safe care were excluded from the analysis, and so were those considered to be safe and low-cost, even when evidence of efficacy was lacking. The remaining items were, therefore, those with uncertain or context-restricted value and significant costs. A systematic review of the published evidence, practice surveys, and institutional guidelines was performed, and the evidence was graded and summarized. With respect to costs and benefits, each modality was then cited as strongly recommended, recommended or optional, or no recommendation was made because of insufficient evidence. Sixteen modalities, which included preoperative cardiovascular imaging, venovenous bypass, pulmonary artery catheterization, high-flow fluid warming devices, drug therapies for hemostasis, albumin, cell salvage, anesthetic drugs, personnel (staffing) requirements, and early extubation, were assessed. Only high-flow fluid warming was strongly recommended. The recommended modalities included preoperative echocardiography, cell salvage, tranexamic acid and early extubation. Six others were rated optional, and there was insufficient evidence for 5 modalities. We conclude that some costly techniques and treatments can be omitted without adverse effects on outcomes.
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Affiliation(s)
- Karina Rando
- Department of Hepatic Diseases, Military Hospital, Montevideo, Uruguay
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Continuous right ventricular end-diastolic volume in comparison with left ventricular end-diastolic area. Eur J Anaesthesiol 2009; 26:272-8. [PMID: 19276913 DOI: 10.1097/eja.0b013e328319be8e] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Intraoperative management of patients with end-stage liver disease undergoing liver transplantation requires fluid administration to increase cardiac output and oxygen delivery to the tissues. Filling pressures have been widely shown to correlate poorly with changes in cardiac output in the critically ill patient. Continuous right ventricular end-diastolic volume index (cRVEDVI) and left ventricular end-diastolic area index (LVEDAI) monitoring have been increasingly used for preload assessment. The aim of this study was to compare cRVEDVI, LVEDAI, central venous pressure and pulmonary artery occlusion pressure with respect to stroke volume index (SVI) during liver transplantation. METHODS Measurements were made in 20 patients at four predefined steps during liver transplantation. Univariate and multivariate panel-data fixed effect regression models (across phases of the surgical procedure) were fitted to assess associations between SVI and cRVEDVI, pulmonary artery occlusion pressure, central venous pressure and LVEDAI after adjusting for ejection fraction (categorized as <or=30, 31-40, >40). RESULTS SVI was associated with continuous right ventricular ejection fraction. The model showing the best fit to the data was that including cRVEDVI: even after adjusting for continuous right ventricular ejection fraction and phase, the regression coefficient of cRVEDVI in predicting SVI was statistically significant and indicated an increase in SVI of 0.21 ml m(-2) for each increase of 1 ml m(-2). At the multivariate analysis, an increase in LVEDAI of 1 cm m(-2) led to an increase in SVI of 1.47 ml m(-2) (P = 0.054). CONCLUSION cRVEDVI and LVEDAI gave a better reflection of preload than filling pressure, even if only cRVEDVI reached statistical significance.
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Wax DB, Torres A, Scher C, Leibowitz AB. Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States. J Cardiothorac Vasc Anesth 2008; 22:811-3. [PMID: 18834818 DOI: 10.1053/j.jvca.2008.07.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Transesophageal echocardiography (TEE) during liver transplantation (LT) has been shown to be helpful in managing fluid therapy, monitoring myocardial function, and identifying intraoperative LT complications. The present study sought to investigate the current utilization of TEE by anesthesiologists during LT as well as issues of training and credentialing in this monitoring modality. DESIGN A survey distributed by electronic mail. SETTING LT centers in the United States in which more than 50 liver transplantation procedures were performed annually. PARTICIPANTS Survey respondents were contact persons in the LT divisions of the anesthesiology department of selected centers. INTERVENTIONS Data collection only. MEASUREMENT AND MAIN RESULTS A total of 40 high-volume LT centers were identified, and survey responses were received from 30 of those. Among 217 anesthesiologists, 86% performed TEE in some or all LT cases. Most users performed a limited-scope examination, although some performed a comprehensive TEE examination during LT. Most users acquired their TEE skills informally. Only 12% of users were board certified to perform TEE, and only 1 center reported having a policy related to credentialing requirements for TEE. CONCLUSIONS There is high utilization of intraoperative TEE by anesthesiologists to perform limited-scope examinations during LT cases. Training to perform such examinations is mostly informal, and credentialing processes are lacking. An opportunity exists to establish guidelines, training programs, and standards for quality assurance in the use of this valuable monitoring modality.
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Affiliation(s)
- David B Wax
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Rocca GD, Costa MG, Feltracco P, Biancofiore G, Begliomini B, Taddei S, Coccia C, Pompei L, Di Marco P, Pietropaoli P. Continuous right ventricular end diastolic volume and right ventricular ejection fraction during liver transplantation: a multicenter study. Liver Transpl 2008; 14:327-32. [PMID: 18306366 DOI: 10.1002/lt.21288] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiac preload is traditionally considered to be represented by its filling pressures, but more recently, estimations of end diastolic volume of the left or right ventricle have been shown to better reflect preload. One method of determining volumes is the evaluation of the continuous right ventricular end diastolic volume index (cRVEDVI) on the basis of the cardiac output thermodilution technique. Because preload and myocardial contractility are the main factors determining cardiac output during liver transplantation (LTx), accurate determination of preload is important. Thus, monitoring of cRVEDVI and cRVEF should help with fluid management and with the assessment of the need for inotropic and vasoactive agents. In this multicenter study, we looked for possible relationships between the stroke volume index (SVI) and cRVEDVI, cRVEF, and filling pressures at 4 predefined steps in 244 patients undergoing LTx. Univariate and multivariate autoregression models (across phases of the surgical procedure) were fitted to assess the possible association between SVI and cRVEDVI, pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) after adjustment for cRVEF (categorized as < or =30, 31-40, and >40%). SVI was strongly associated with both cRVEDVI and cRVEF. The model showing the best fit to the data was that including cRVEDVI. Even after adjustment for cRVEF, there was a statistically significant (P < 0.05) relationship between SVI and cRVEDVI with a regression coefficient (slope of the regression line) of 0.25; this meant that an increase in cRVEDVI of 1 mL m(-2) resulted in an increase in SVI of 0.25 mL m(-2). The correlations between SVI and CVP and PAOP were less strong. We conclude that cRVEDVI reflected preload better than CVP and PAOP.
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Affiliation(s)
- Giorgio Della Rocca
- Department of Anesthesia and Intensive Care Medicine, University of Udine, Azienda Ospedaliera Universitaria, Udine, Italy.
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ICU Management of the Liver Transplant Patient. Intensive Care Med 2008. [DOI: 10.1007/978-0-387-77383-4_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Manzoni D, D'Ercole C, Spotti A, Carrara B, Sonzogni V. Congenital heart disease and pediatric liver transplantation: complications and outcome. Pediatr Transplant 2007; 11:876-81. [PMID: 17976122 DOI: 10.1111/j.1399-3046.2007.00755.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mild and moderate CHD in infants do not always need surgical correction but possibly augment the operative risk of patients with ESLD undergoing OLT. The aim of this study is to assess the intraoperative and post-operative complications and evaluate the outcome of these patients. The records of 196 patients were reviewed retrospectively in a cohort study, 50 CHD were found in 36 patients undergoing 41 OLT procedures. The prevalence of CHD during pediatric OLT was 18%. Our data identified no significant differences between the two groups of patients, regarding hypotension, desaturation, acidosis, and bleeding during the procedure. Post-operatively, no differences were observed in the hemodynamic, respiratory, and renal systems as no differences were detected for graft failure, surgical complications, infection, and rejection rates. Mortality is comparable in the two groups as are re-transplantation and recovery rates. The above mentioned results indicate that minor cardiac defects do not significantly influence the operative risk of these patients.
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Affiliation(s)
- Diego Manzoni
- Department of Anaesthesia and Intensive Care 1, Ospedali Riuniti di Bergamo, Largo Barozzi, Italy.
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Abstract
Assessing the optimal volemia in the perioperative course of liver transplantation is a challenge for the anesthesiologist. Traditional estimates of intravascular volume status, such as pulmonary artery occlusion pressure (PAOP), have been widely shown to poorly correlate with changes in cardiac output among critically ill patients. Hence, there has been recent interest in alternative, catheter-related, bedside device volume estimates using thermodilution. Continuous end diastolic volume (CEDVI) showed better correlations with cardiac performance than cardiac filling pressures in studies performed in critically ill patients. When compared with conventional pressure-derived data, preload monitoring estimated as intrathoracic blood volume index (ITBVI) with the PiCCO system based on an integrated transpulmonary thermodilution technique better reflected left ventricular filling both in critically ill patients and those who underwent liver transplantation. Moreover, in liver transplantation, the use of transoesophageal echocardiography (TEE) has been increasing for it provides rapid visualization of the dimension and function of heart chambers as well as the left ventricular end diastolic area index (EDAI) that seem to correlate with graded acute hypovolemia, although its validity as on preload index is still under discussion.
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Affiliation(s)
- M G Costa
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliera Universitaria, University of Udine, Udine, Italy.
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Feierman DE, Yudkowitz FS, Hojsak J, Emre S. Management of a cadaveric orthotopic liver transplantation in a pediatric patient with complex congenital heart disease. Paediatr Anaesth 2006; 16:669-75. [PMID: 16719884 DOI: 10.1111/j.1460-9592.2005.01823.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pediatric orthotopic liver transplantations (OLT) are commonly performed nowadays. Two primary reasons for OLT in children are complications from either extrahepatic biliary atresia (EHBA) or inborn errors of metabolism. However, congenital liver disease may be associated with significant other congenital abnormalities. We present a case of a successful OLT in a pediatric patient with a history of EHBA, situs inversus, and complex congenital heart disease. The cardiac anomalies include dextrocardia, absence of the atrial septum (single atrium), single atrioventricular valve (a-v canal), and an incomplete ventricular septum. Prior surgery include a Kasai procedure for EHBA, banding of the proximal main pulmonary artery, and Broviac catheter placement. We present the anesthesia concerns and management for this complicated case.
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Abstract
This article briefly discusses the cardiac status of liver transplant recipients and their preoperative cardiac evaluation. It describes in detail perioperative and early and late postoperative complications as well as the cardiac problems associated with immunosuppression. The preoperative cardiovascular status of patients is important in determining how they cope with the stresses imposed by liver transplantation. Minor early cardiac events are common and may influence longer term cardiac morbidity. Immunosuppressive therapy may have short term effects but is likely to adversely affect long term cardiac risk.
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Schumann R. Intraoperative resource utilization in anesthesia for liver transplantation in the United States: a survey. Anesth Analg 2003; 97:21-8, table of contents. [PMID: 12818937 DOI: 10.1213/01.ane.0000068483.91464.2b] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
UNLABELLED Among the intraoperative resources expended for liver transplantation, laboratory tests, personnel, high-flow infusion devices, high-tech monitoring equipment, and veno-venous bypass vary from institution to institution. Although of obvious interest to the anesthesia liver transplantation community and others, little is known regarding current utilization of these resources on a national level. To determine the resource utilization among liver transplantation centers in the United States, we conducted a national survey between April and July 2002. Results were stratified according to pediatric versus adult recipient populations and transplantation case volume. Of 99 centers that received the survey by mail, 66 (66.6%) responded. Pediatric liver transplantation programs were distinctly different in personnel, equipment, monitoring, and veno-venous bypass utilization when compared with adult or mixed-age programs. Among laboratory studies, statistically significant trends emerged for fewer intraoperative determinations of the activated clotting time, magnesium, and phosphate with increasing transplantation volume. The results describe national practice patterns and may be useful for programs to compare their approaches and develop clinical pathways. There is wide variation of resource use between centers. The survey results do not consistently correlate with the few recommendations found in the current literature. IMPLICATIONS Currently no comprehensive data are available describing the intraoperative use of laboratory tests, personnel, infusion and perfusion equipment, monitoring technology, and veno-venous bypass by liver transplantation programs. These postal survey results provide an overview of utilization of these resources in anesthesia for liver transplantation.
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Affiliation(s)
- Roman Schumann
- Department of Anesthesiology, Division of Liver Transplant Anesthesia, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.
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Preload and haemodynamic assessment during liver transplantation: a comparison between the pulmonary artery catheter and transpulmonary indicator dilution techniques. Eur J Anaesthesiol 2002. [DOI: 10.1097/00003643-200212000-00003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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