What is the optimal anesthetic monitoring regarding immediate and short‐term outcomes after liver transplantation?—A systematic review of the literature and expert panel recommendations

• Published in: Clinical transplantation Vol. 36; no. 10; pp. e14643 - n/a
• Main Authors: Fernandez, Thomas M.A., Schofield, Nick, Krenn, Claus G, Rizkalla, Nicole, Spiro, Michael, Raptis, Dimitri Aristotle, De Wolf, Andre M, Merritt, William T.
• Format: Journal Article
• Language: English
• Published: Denmark John Wiley and Sons Inc 01.10.2022
• Subjects: cardiac output or hemodynamic monitoring; central venous access; Central Venous Pressure; Humans; hyperthermia; hypothermia; LiDCO; liver transplantation; Liver Transplantation - adverse effects; monitoring; Monitoring, Intraoperative; or FloTrac; PiCCO; pulmonary artery catheter; Retrospective Studies; Review; thermoregulation; transesophageal echocardiography; Vasoconstrictor Agents; venous or arterial access; hyperthermia; pulmonary artery catheter; LiDCO; monitoring; thermoregulation; PiCCO; cardiac output or hemodynamic monitoring; venous or arterial access; central venous access; hypothermia; or FloTrac; transesophageal echocardiography; liver transplantation
• ISSN: 0902-0063; 1399-0012
• DOI: 10.1111/ctr.14643

Background Liver transplant centers vary in approach to intraoperative vascular accesses, monitoring of cardiac function and temperature management. Evidence is limited regarding impact of selected modalities on postoperative outcomes. Objectives To review the literature and provide expert panel recommendations on optimal intraoperative arterial blood pressure (BP), central venous pressure (CVP), and vascular accesses, monitoring of cardiac function and intraoperative temperature management regarding immediate and short‐term outcomes after orthotopic liver transplant (OLT). Methods Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Recommendations made for: (1) Vascular accesses, arterial BP and CVP monitoring, (2) cardiac function monitoring, and (3) Intraoperative temperature management (CRD42021239908). Results Of 2619 articles screened 16 were included. Studies were small, retrospective, and observational. Vascular access studies demonstrated low rates of insertion complications. TEE studies demonstrated low rates of esophageal hemorrhage. One study found lower hospital‐LOS and 30‐day mortality in patients monitored with both PAC and TEE. Other monitoring studies were heterogenous in design and outcomes. Temperature studies showed increased blood transfusion and ventilation times in hypothermic groups. Conclusions Recommendations were made for; routine arterial and CVP monitoring as a minimum standard of practice, consideration of discrepancy between peripheral and central arterial BP in patients with hemodynamic instability and high vasopressor requirements, and routine use of high flow cannulae while monitoring for extravasation and hematoma formation. Availability and expertise in PAC and/or TEE monitoring is strongly recommended particularly in hemodynamic instability, portopulmonary HT and/or cardiac dysfunction. TEE use is recommended as an acceptable risk in patients with treated esophageal varices and is an effective diagnostic tool for emergency cardiovascular collapse. Maintenance of intraoperative normothermia is strongly recommended.