Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations

Abstract

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time‐related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.

A systematic review of auxiliary liver transplantation of small-for-size grafts in patients with chronic liver disease

“…These complex procedures must be undertaken exclusively by experienced transplant surgeons in high-volume centres. [87] , [88] , [89] …”

“…Within the IDEAL framework (which describes the stages through which surgical therapy innovation normally passes, and the characteristics of each of five stages: Idea, Development, Exploration, Assessment and Long-term follow-up) 86 , the program proposed here qualifies for a stage 2b study (novel technique investigated in a prospective multicentric cohort). These complex procedures must be undertaken exclusively by experienced transplant surgeons in high-volume centers [87][88][89] .…”

Preoperative cardiac assessment in liver transplant candidates

“…The average candidate quite often presents with the peculiar cardiovascular profile associated with End Stage Liver Disease (ESLD), namely high cardiac output, low systemic vascular resistances and splanchnic vasodilatation. The more severe the condition, the more pronounced are the cardiovascular alterations, with consistent differences in case of cholestatic, tumoral or cirrhotic etiology of the ESLD [2][3][4]. As experienced by every anesthesiologist involved in a LT program, during surgery the patient may have to tolerate periods (minutes to hours) of tachycardia, severe hypotension, acute blood loss, extreme anemia, markedly reduced venous return, prolonged and resistant vasoplegia after reperfusion of the graft, or, on the contrary, massive transfusion and acute right or left ventricular overload in the various phases of the LT [2][3][4].…”

“…The more severe the condition, the more pronounced are the cardiovascular alterations, with consistent differences in case of cholestatic, tumoral or cirrhotic etiology of the ESLD [2][3][4]. As experienced by every anesthesiologist involved in a LT program, during surgery the patient may have to tolerate periods (minutes to hours) of tachycardia, severe hypotension, acute blood loss, extreme anemia, markedly reduced venous return, prolonged and resistant vasoplegia after reperfusion of the graft, or, on the contrary, massive transfusion and acute right or left ventricular overload in the various phases of the LT [2][3][4]. To survive such a stressful scenario unscathed, an appropriate (or optimized) cardiovascular performance status is mandatory for the candidate [1][2][3][4], as mandatory is the thorough, extensive, tailored preoperative cardiovascular assessment [2][3][4][5][6].…”

The Society for the Advancement of Transplant Anesthesia (SATA) enters a new partnership with Clinical Transplantation

“…SATA has recently worked with members from other transplant specialties and organizations to articulate clear roles and responsibilities for anesthesia liver transplant teams 6 . These newly published recommendations promulgate more uniform practices and strengthen the intent underlying the OPTN/UNOS requirement to have a Director of Anesthesia for Liver Transplant at every program.…”