Focus On: Transplant Anaesthesia and Critical Care
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Transplant anaesthesia has been emerging as a subspecialty of anaesthesiology since the early 1980s, primarily due to the advent of heart and liver transplant surgery. In the ensuing decades the acquisition of specialized expertise by anaesthesiologists working in this field, coupled with advances in medical technology applied to the perioperative care of the heart and liver transplant recipient, has had a major positive impact on survival. Today, the ever-increasing complexity and clinical challenges of a wide range of thoracic and abdominal organ transplant surgical procedures demand specialized fellowship training in either cardiac or liver transplant anaesthesia. Evidence points to the fact that when the transplant anaesthesiologist is actively engaged in the entire spectrum of perioperative transplant care, including the ‘extra-operative’ activities pertaining to the evaluation, screening and selection of the transplant candidate, and the post operative/intensive care of the transplant recipient, outcomes are better.
The ever-increasing demand for suitable organs will require meticulous perioperative management and novel approaches to the care of the deceased organ donor. Organ resuscitation focuses on preventing deterioration of graft function during the 5 critical stages of the perioperative transplant cycle as follows: 1) protection of the organ donor prior to and during procurement (protection/pre-conditioning); 2) mitigation of ischemia-anoxic injury (ex-vivo preservation), and; 3) prevention of graft reperfusion/reoxygenation injury in the recipient (post-conditioning).
Evidence is beginning to emerge on novel therapies to positively impact outcome of the graft. Most notably, Niemann et al have recently demonstrated that the induction of therapeutic hypothermia in the organ donor (protection) improves renal graft function in the recipient. Akhtar et al suggest that future primary targets for donor pharmacological preconditioning are the hypoxia inducible factor pathways. Major technological advances are being made in the development of portable machines that continuously deliver oxygen and nutrients during ex-vivo preservation of organs. This is proven to improve the duration of safe preservation and permits qualitative assessment of graft function, especially those of marginal quality, thus preventing the implantation of grafts that are irreversibly damaged. Lastly, research on reperfusion and re-oxygenation injury, a phenomenon that occurs when oxygen is re-introduced to the previously ischemic graft in the recipient, suggest that treatments such as low pH, magnesium, aimed at the prevention of mitochondrial damage via the mitochondrial permeability transition pore or MPTP will improve graft function (Halestrap et al). In conclusion, Transplant Anesthesiologists involved in the perioperative management of donors and recipients are well suited to engage in drug discovery and development of novel therapies aimed at organ resuscitation.
1. Oxford Textbook of Transplant Anaesthesia and Critical Care. Edited by Ernesto A Pretto, Jr., Gianni Biancofiore, Andre DeWolf, John R. Klinck, et al, Oxford University Press.DOI:10.1093/med/9780199651429.001.0001, Oxford University Press, 2015.
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6. Organ Donation and Transplantation after Cardiac Death. Edited by David Talbot and Anthony D’Alessandro. Oxford University Press, 2009.
7. Hall TH, Dhir A. Anesthesia for Liver Transplantation. Semin Cardiothorac Vasc Anesth 2013 Sep: 17(3):180-94
8. Niemann et al. Therapeutic hypothermia in deceased organ donors and kidney graft function. N Engl J Med 2015; 373:405-415
9. Ahktar M.Z. Sutherland A. I., Huang H., et al. The role of hypoxia-inducible factors in organ donation and transplantation: The current perspective and future opportunities. Am J Transplant. 2014; 14 (7): 1481-1487.
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