ISSUE: JUNE 2013 | VOLUME: 38:6
by David Wild
Experts are applauding new recommendations for the administration of anesthesia during liver transplant surgery that offer formal recognition that anesthesiologists are critical to optimizing transplant patient care.
The document, from the Organ Procurement and Transplant Network (OPTN)/United Network for Organ Sharing (UNOS), set qualification requirements for directors of liver transplant anesthesia.
“The recommendations are really a landmark development in that they urge closer cooperation and goodwill between the transplant and anesthesia communities and address the best interests of our patients,” said Susan Mandell, MD, PhD, professor of anesthesiology at the University of Colorado Health Sciences Center, in Aurora.
The recommendations, passed as an OPTN/UNOS bylaw, call for transplant centers to appoint a director of liver transplant anesthesia (see OPTN Bylaws, Appendix B, Attachments I-XI: Accessed March 29 at URL: http://optn.transplant.hrsa.gov/policiesandbylaws2/bylaws/optnbylaws/pdfs/bylaw_162.pdf). They also specify the educational and transplant experience that such directors should have in order to be appointed to the position, as well as their duties in the position (sidebar).
Although the recommendations are not binding, if OPTN/UNOS determines that lack of adherence to the guidelines contributes to poor outcomes at a center, it can recommend that the directorship guidelines be implemented. In addition, the Centers for Medicare & Medicaid Services has authority to decertify programs if they have poor outcomes, especially if recommended guidelines were not followed, Dr. Mandell explained.
While Dr. Mandell welcomed the new bylaw, she said it does not introduce new practices—a conclusion she arrived at after she and several of her co-investigators surveyed adult academic transplant centers and private programs and compared the recommendations with current practice (Liver Transpl 2013;19:425-430).
The 42 adult academic centers that responded to the survey indicated they already had a director in place before the recommendations were issued. Although most centers did not have formal directorship criteria, the majority of directors had the specialized liver transplant education and the experience in liver transplantation or a related high-acuity care specialty that the guidelines call for, Dr. Mandell said. Furthermore, most directors performed similar administrative duties to those specified in the OPTN/UNOS bylaw (Table).
Table. Selected Survey Responses From Academic Liver Transplant Centers
Survey Item Response (N=42)
Centers with directors of anesthesia for liver transplantation 100%
Centers with written criteria describing the directorship position 38%
Directors who completed a fellowship in liver transplantation 0%
Centers requiring a specific number of liver transplant cases to qualify as director 4.3%
Centers requesting that directors have post-graduate liver transplant experience 82%
Directors at small, medium and large centers earning ≤5 CME credits annuallya 47%, 35% and 31%
Directors attending transplant patient selection committees 65%
Centers with anesthesiologist-developed liver transplant patient care protocol 80%
CME, continuing medical education a Center size defined by annual volume of liver transplants. Small: 10-49; medium: 50-99; large: >100
Anesthesiologists “Essential” To Transplant Care
“The importance of these guidelines is really in their recognition of anesthesiologists as essential to achieving the best care possible for liver transplant patients,” Dr. Mandell said. “They support the emerging leadership in liver transplant anesthesia and bring greater uniformity to the directorship position.”
The recommendations strengthen a multidisciplinary model of liver transplantation by calling for directors to be involved in all aspects of care: perioperative consults, transplant candidate selection, morbidity and mortality conferences, postoperative patient visits and development of intraoperative guidelines.
Several studies have demonstrated that specialized liver transplant anesthesia teams can improve patient outcomes. For example, researchers at the University of Wisconsin showed that liver transplant anesthesiologists reduce the need for blood transfusions and shorten intensive care unit stays following liver transplantation (Liver Transpl 2009;15:460-465).
“This was one of the pieces of evidence that OPTN/UNOS considered in its deliberations about the role of anesthesiologists in the integrated care model,” Dr. Mandell said.
David J. Reich, MD, professor and chief of the Division of Multiorgan Transplantation and Hepatobiliary Surgery, at Drexel University College of Medicine and Hahnemann University Hospital, in Philadelphia, co-authored the survey study with Dr. Mandell and her colleagues. He said the guidelines “should improve liver transplant anesthesia support and partnership between transplant and anesthesia teams.”
“This can only bolster safety and high-quality outcomes,” said Dr. Reich, a past member of UNOS’ Liver and Intestine Transplant Committee and immediate past chair of the Standards Committee of the American Society of Transplant Surgeons (ASTS). “In every discipline, clinical programs are stretched in terms of resources. Because these guidelines have been issued by a governing organization, they provide transplant anesthesiologists with a strong case to ask hospital leadership for adequate resources so that they can ensure they meet the recommendations.”
Although the survey did not include low-volume and private liver transplant centers, if the reaction from Porter Adventist Hospital, in Denver, is an indication of the broader response from this subset of programs, the guidelines should not be onerous.
“The OPTN/UNOS guidelines are reasonable and manageable,” said Alan Qualls, MBA, the hospital’s director of Oncology, Robotics, and Transplant Services. His private medical center recently restarted its program and performs 10 to 15 liver transplants annually. “If the director is trained at a major center with a liver program, the requirements should already be in practice. Our director of liver transplant anesthesia already actively participates in the selection committee and clears patients medically with the primary liver surgeon during the evaluation process.”
The feedback Dr. Reich received to date has focused on requests for more continuing medical education (CME) opportunities so that directors can meet the CME requirement stipulated in the guidelines.
“The ILTS [International Liver Transplantation Society] has a one-day program for transplant anesthesiologists and the ASTS is increasing educational offerings to anesthesiologists,” he added. “We welcome collaboration with anesthesiologists and are trying to advertise educational opportunities, such as at the American Transplant Congress.”
Selected Points From OPTN/UNOS Director of Liver Transplant Anesthesia Recommendations
The director will be responsible for establishing internal policies for anesthesiology participation in perioperative transplant patient care.
The policy must establish a clear communication channel between the transplant anesthesiology service and other liver transplant disciplines.
The director should have fellowship training in critical care medicine, cardiac anesthesiology or liver transplant, including perioperative care of at least 10 liver transplant recipients or experience in the perioperative care of at least 20 liver transplant recipients within the past five years.
The director should earn a minimum of eight hours of credit in transplant-related educational activities within the three years preceding appointment.