Adult liver transplant recipient pathway

Steering group

• Derek Manas (DMM) Medical Director, OTDT, NHSBT
• Lisa Burnapp (LB) – Project Chair, Associate Medical Director, Living Donation and Transplantation, NHSBT
• Carrie Scuffell (CS) SME for ERAS in Transplantation, Transplant development Manager NHSBT
• Aimen Amer (AA) Consultant Surgeon, Freeman Hospital, Newcastle
• Emily Bonner (EB) Consultant Anaesthetist, Freeman Hospital, Newcastle
• Aisling Courtney (AC) Consultant Nephrologist, Belfast Health and Social Care Trust
• Erica Fairburn (AF) Liver transplant recipient, expert by experience, Newcastle
• Jen Hobbs (JH) Senior Marketing and Campaigns Officer, NSHBT
• Jess Hollingsworth, Liver transplant Clinical Nurse Specialist Leeds
• Elaine Jolly, Consultant Nephrologist, Cambridge University Hospital
• Sapna Marwaha (SM) Lay Member, NHS Blood and Transplant
• Olivia Quinn (OQ) Secretary, Medical Director and Group Support, OTDT, NHSBT
• Michael Spiro (MS) Consultant Anaesthetist, Intensive care medicine, The Royal Free Hospital, London
• Ben Stutchfield (BS) Consultant Surgeon, Royal Infirmary of Edinburgh
• Rachel Thomas, Consultant Surgeon, Edinburgh

Adult liver transplant recipient working group

Working group Co-leads

• Ben Stutchfield (BS) Consultant Surgeon, Royal Infirmary of Edinburgh
• Michael Spiro (MS) Consultant Anaesthetist, Intensive care medicine, The Royal Free Hospital, London

Members

• Mathew Armstrong, Consultant Hepatologist Queen Elizabeth Hospital Birmingham
• Rebecca Bateman, Lead nurse ERAS in Colorectal, HPB and liver transplant,  ​The Royal Free Hospital, London
• Jane Chappell, Liver recipient Transplant Coordinator, Addenbrookes Hospital, Cambridge
• Thomas Crame, Liver transplant Dietetic Practitioner, Freeman Hospital Newcastle
• Abigail Greenwell, Clinical Lead Physiotherapist for Liver Transplant and Surgery, The Royal Free Hospital, London
• Jess Hollingsworth, Liver transplant Clinical Nurse Specialist, Leeds Teaching Hospitals
• Ilya Kantsedikas, Anaesthetic trainee, London,
• Catherine McAnenny, Advanced Dietetic Practitioner, Royal Infirmary of Edinburgh
• Aubrey McCallum Clinical Specialist Physiotherapist, Royal Infirmary of Edinburgh
• Bryan O’Farrell, Lead Pharmacist, Intensive Care & Theatres, The Royal Free, London
• Gemma Wells, Hepatology Trainee, London
• Felicity Williams, ​ Consultant Physiotherapist in Hepatology, Queen Elizabeth Hospital, Birmingham

Patient panel

(With thanks to Joan Beddlington at Liver North and the British Liver Trust for their help in reaching out to recipients.)

• Erica Fairburn​
• Jayne Pilkington​
• Nathen Raffle​
• Sarah Barker​
• Katherine Walcot​

Additional contributors

• Benoy Babu Consultant Surgeon, Edinburgh
• Dr Chenchu Ramu Chimakurthi, hepatologist, Leeds
• Ms Miriam Cortes-Cerisuelo, surgeon, Kings
• James Cuell, Consultant anaesthetist, Birmingham
• Dr Anish Gupta, anaesthetist, Kings
• Mr Abdul Rahman Hakeem, surgeon, Kings
• Dominik Krzanicki, Consultant anaesthetist Royal Free
• Dr Tasneem Pirani, intensivist, Kings
• Joerg Pollok, Consultant Surgeon and HPB Surgery lead Royal Free
• Dr Anand Puttappa, anaesthetist, Addenbrookes
• Suehana Rahman, Consultant anaesthetist and peri-op research co-lead, Royal Free
• Helen Usher Consultant anaesthetist, Edinburgh

Core elements include:

• Introduction to principles of ERAS
• Patient education around components of the pre, peri and post-operative period
• Identification of individual circumstances which may pose barriers to recovery and discharge from hospital

Desirable elements include:

• Dedicated ERAS nurse specialist to lead pre-operative education/counselling sessions
• Accessible learning resources - additional languages, adjustments for hearing, visual impairment and neurodivergence
• Provision of a standardised ERAS information/patient shared care plan

Prehabilitation programs are increasingly used as part of ERAS protocols outside of liver transplantation, improving postoperative outcomes.

High quality evidence specific to liver transplantation is scarce, however prehabilitation has benefits on functional status. All patients should receive tailored prehabilitation recommendations and follow up prior to their operation.

Core elements include:

• Dietetic assessment and creation of an individualised nutrition plan/targets
• Physiotherapy review and creation of an individualised fitness plan/targets
• Smoking cessation/alcohol/substance misuse support if indicated
• Optimisation of liver disease and other comorbidities whilst on the waiting list (diabetes mellitus, anaemia, etc)
• Assessment of social circumstances and support network, with referral to occupational therapy/community support/social worker where appropriate
• Consider psychological assessment/referral to community mental health services

Desirable elements include:

• Regular review of patients on the waiting list to target more intensive prehabilitation measures if indicated

Download supporting evidence for prehabilitation (Word 28KB)

Core elements include:

• Aim to optimise nutrition/hydration status with 'sips until sending' strategy, minimising fasting time pre-operatively to 6 hours where possible
• Consider intravenous fluids or variable rate insulin infusion for diabetic patients whilst fasting

Desirable elements include:

• Consider the use of carbohydrate drinks pre-operatively

Download supporting evidence for nutrition on the day of surgery (Word 16KB)

Core elements include:

• Central and arterial access must be established for all patients undergoing liver transplantation, with additional wide bore venous access
• Access to cardiac output monitoring, pulmonary artery catheter placement, transoesophageal echocardiography and relevant expertise should be available if required

Desirable elements include:

• Consider proximal (e.g. femoral) and/or dual arterial line placement if significant haemodynamic instability is anticipated from listing meeting and/or anaesthetic pre-assessment

Download supporting evidence for lines and monitoring (Word 16KB)

Core elements include:

• Use of volatile anaesthetic agents
• Tailored lung protective ventilation strategy (e.g. target tidal volumes 6 to 8ml/kg ideal body weight, optimal positive end expiratory pressure, target oxygenation PaO2 10 to 14 kPa
• Lung recruitment manoeuvres post removal of surgical retractors
• Identification of patients appropriate for early extubation considering preoperative patient factors and intraoperative events

Desirable elements include:

• Consider multimodal pain control techniques to reduce opioid usage such as local anaesthetic wound catheter infiltration (provided patient is not felt to be at prohibitive risk of bleeding complications due to abdominal varices or severe coagulopathy)
• Depth of anaesthesia monitoring

Download supporting evidence for anaesthesia conduct (Word 23KB)

Core elements

• Moderately restrictive or replacement only strategy with avoidance of sustained hypervolaemia
• Tailor fluid and pressors administration to achieve mean arterial pressure greater than 60 to 65mmHg
• Choice of fluid (Crystalloid or colloid) at the discretion of the anaesthetist

Download supporting evidence for the use of fluids (Word 16KB)

Core elements include:

• Use of blood products and antifibrinolytics (tranexamic acid) as per point of care test results – thromboelastography or rotational thromboelastometry
• Venous thromboembolism prophylaxis with compression stockings or intermittent pneumatic compression devices
• Calcium monitoring and replacement
• Routine use of cell salvage
• Use of factor/fibrinogen concentrates where available in patients at risk of transfusion related circulatory overload or with uncontrolled haemorrhage 

Download supporting evidence for coagulation management (Word 17KB)

Core elements include:

• Inverted L incision where possible
• Drain insertion is not considered mandatory, however selective drain insertion may be used at the discretion of the operating surgeon

Desirable elements include:

• Consider the use of machine perfusion to optimise graft selection and logistical considerations
• Recommendation against routine use of veno-venous bypass and temporary porto-caval shunt, except when indicated in specific patients

Download supporting evidence for surgical considerations (Word 25KB)

There is a wide range of evidence to suggest that routine ventilation post-operatively following liver transplantation may not be necessary and may be harmful.

Appropriate early extubation is not associated with increased risk of reintubation and supports the delivery of other ERAS components by permitting early mobilisation and oral intake and reducing the duration of vasopressor support, sedative medication and intensive care unit (ICU) length of stay.

Core elements include:

• All patients to be assessed for appropriateness for early extubation (i.e. <6 hours following transplant) either in theatres or once transferred to the intensive care unit
• The decision to proceed with early extubation should be agreed between the transplant anaesthetist, operating surgeon and intensivist

Desirable elements include:

• Early extubation criteria to be agreed locally between anaesthetic, surgical and intensive care teams
• Optimisation of sedation/avoidance of excessive long-acting opioids intra-operatively to facilitate early extubation
• Consider the development of nurse led extubation criteria in ICU

Not all patients will be suitable for early extubation due to pre-existing comorbidities, intraoperative events or postoperative instability. Several centres have already implemented local early extubation pathways. For those who do not have a pathway, suggested criteria to identify patients likely to be appropriate for early extubation are outlined below, based on existing pathways from multiple UK transplant centres.

• pH >7.3
• Lactate <6 and falling
• Base excess <-8 and improving
• Low vasopressor support e.g. single agent noradrenaline <0.2mcg/kg/min
• No active need for transfusion >2 units post-operatively
• No immediate/imminent plan for re-laparotomy
• Minimal ventilatory support (PaO2 >10 on 40% oxygen, PaCO2 <6 with RR 10-20)
• Appropriately timed opioids and neuromuscular blockers with full neuromuscular blockade reversal
• Temperature 36.5 to 37.5 degrees celcius
• Obeying commands

Download supporting evidence for early extubation (Word 24KB)

Core elements include:

• Encouragement of breathing exercises/supported coughing in the early post-operative period
• Achievable mobility programme with daily targets based on anticipated mobility post-transplant, tailored to individual considerations 

Desirable elements include:

• Patient record of mobility achievements in the shared care plan
• Dedicated physiotherapist available to work with patients with specific individual mobility needs

Download supporting evidence for early mobilisation (Word 16KB)

Core elements include:

• Aim to commence oral fluids an nutrition at the earliest opportunity, unless specifically contraindicated
• Monitor and record food and fluid intake
• Consider oral nutritional supplements +/- NG feeding if unable to meet nutritional requirements
• Dietetic review for patients not meeting nutritional requirements or high risk on nutrition screening score

Download supporting evidence for postoperative nutrition (Word 16KB)

Early removal of indwelling devices promotes early mobilisation and patient autonomy, as well as reducing the risk of catheter-associated infections. Removal of indwelling devices should therefore be considered early in the post-operative period.

Core elements

• Central venous catheter, wide bore access and bypass lines to be removed on post-operative day 1. Provided the patient is stable, off cardiovascular support, has no requirement for TPN and adequate peripheral access is in place
• Consider removal of nasogastric tube on table or immediately following extubation in intensive care
• Urinary catheter to be removed, provided that renal function and urine output are adequate and the patient is able to transfer
• Early removal of abdominal drains unless concerns regarding quantity of output or biliary anastomotic leak

Download supporting evidence for removal of indwelling devices (Word 24KB)

Core elements include:

• Aim to reduce opioid requirements
• Local anaesthetic techniques such as wound infiltration catheters may be used as an adjunct to opioid analgesia, depending on local experience and patient suitability
• Regular paracetamol and immediate release opioids once enteral route established, aiming to avoid or reduce the use of patient controlled analgesia

Desirable elements include:

• Pain team review as required
• Considered intra-operative ketamine use to reduce opioid requirements

Download supporting evidence for post-operative analgesia (Word 25KB)

There is no clear consensus on the optimal timing of hospital discharge following liver transplantation.

However, in patients who have had a straightforward postoperative course in a centre with robust outpatient follow up, discharge may be considered at day 6 to 8 post-op.

Core elements include:

• Aim to discharge from level 2/3 care according to ICU discharge criteria with agreement of intensive care, hepatology and surgical teams
• Early discharge planning aiming to identify and address any potential barriers to discharge
• Standardised post-transplant education programme including recognition of common post-transplant complications, medication counselling, self-administration of medication, follow up arrangements, post-transplant exercise and nutritional advice
• Provision of post discharge follow up appointment prior to discharge
• Provision of medication list
• Provision of contact details for transplant team/transplant coordinators
• Timely completion of discharge medications and discharge paperwork

Desirable elements include:

• Provision of ongoing tailored rehabilitation plan from physiotherapy and dietetic teams

Download supporting evidence for discharge planning (Word 24KB)