Focus On: Transplant Anaesthesia and Critical Care

 

 

Figure 10.1. This figure depicts the transition from organ donor to transplant recipient. Organ resuscitation is embedded in this cycle and aims to prevent ischemic injury by optimizing the perioperative care of the donor, modulating cell death during ex-vivo organ preservation, and reversing reperfusion injury of the graft during reperfusion in the recipient; all are within the future purview of the perioperative care provided by the Transplant anaesthesiologist. 

 

Reproduced from Oxford Textbook of Transplant Anaesthesia and Critical Care, edited by Ernesto A Pretto, Jr., Gianni Biancofiore, Andre DeWolf, John R. Klinck, Claus Niemann, Andrew Watts, and Peter D.Slinger, 2015, Oxford University Press. DOI:10.1093/med/9780199651429.001.0001

 

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.

 

Organ Resuscitation:
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 (see figure above), 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.


 

Ernesto A. Pretto, Jr., Professor and Chief, Division of Transplant and Vascular Anesthesia, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miami Transplant Institute, University of Miami Miller School of Medicine/Jackson Memorial Hospital, USA
 

 

Further reading:

 

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.

2. C. J. E Watson, J. H. Dark. Organ transplantation: historical perspective and current practice. Br. J. Anaesth. (2012) 108(suppl 1): i29-i42.doi: 10.1093/bja/aer384

3. ICU Care of the Abdominal Organ Transplantation. Edited by Ali Al-Khafaji. Oxford University Press, 2013

4. Death, Dying and Organ Transplantation: Reconstructing medical ethics at the end of life. Franklin D. Miller and Robert G. Truog. Oxford University Press, 2015.

5. D. W. McKewoen, R.S. Bonser. J. A. Kellum. Management of the heart beating brain dead Donor. Br. J. Anaesth. (2012) 108 (Suppl 1): i96-i107.

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.

10. http://www.scientificamerican.com/article/supercooled-livers-last-for-days/

 

11. ResearchGate: Liver Preservation With Machine Perfusion and a Newly Developed Cell-Free Oxygen Carrier Solution Under Subnormothermic Conditions

 

Oxford Medicine Online publishes a wealth of content relevant to clinical transplantation. Oxford University Press also has relevant information in other web services such as Oxford e-learning, and in our journals. Our coverage takes in many perspectives, from the student to the specialist. Read previous homepage articles at our Article Archive.

 

Read previous homepage articles at our Article Archive.