Purpose: Surgical clinical pathways have been shown to be effective for enhanced recovery and cost reductions, yet have not be tested in liver transplant (LT) patients. We undertook a prospective, observational study to examine the effect on clinical outcomes of a standardized intensive care unit (ICU) pathway for postoperative care of LT patients.

Methods: Patients undergoing LT from 11.1.2013- 10.31.2014 were enrolled in a standardized, enhanced recovery pathway that focused on the following milestone-based elements of ICU care: early extubation, hemodynamic management, standardized transfusion targets, and goal-based discharge triggers. We excluded patients who had intraoperative hemorrhagic complications that necessitated a planned reoperation. Patient outcomes were compared to outcomes in transplant recipients from the year prior to implementation. Multivariable regression adjusted for age, sex, MELD score, ASA class, and intraoperative transfusions were used to assess the association of the implementation of the clinical pathway on clinical outcomes such as ICU length of stay (LOS), hospital LOS, and the probability of receiving product transfusions in the ICU.

Results: The intervention group and control group included 141 and 106 patients, respectively. There were no differences in baseline demographics between the two groups. Median ICU LOS was reduced from 4.4 to 2.6 days (p < 0.001) and hospital LOS from 6.5 to 5.6 (p=0.05). ICU direct encounter costs were reduced in the post implementation phase [median $4,797 (IQR 2,946-7,979) vs. $6,490 (IQR 4,444-12,204) (p=<0.001]. Patients in the post implementation group had a greater likelihood of faster ICU discharge [HR 2.01 (95% CI, 1.55-2.62, p<0.0001)] and hospital discharge [HR 1.30 (95% CI , 1.0-1.68, p=0.046)], a 69% lower probability of receiving a FFP transfusion in the ICU (p < 0.001) and a 65 percent lower probability for receiving packed red blood cells (p < 0.001). There was not a significant effect of the standardized pathway on hospital mortality (p=0.40), ICU readmission rates (p=0.75), re-operative rates (p=0.07), or postoperative infections (urinary tract infections: p=0.09; pneumonia: p=0.27)

Conclusions: Our study demonstrated that standardization of postoperative ICU management led to reductions in ICU LOS and ICU direct costs without an increase in postoperative complications such as readmission to the ICU, need for re-operations or post-operative infections.

CITATION INFORMATION: Kensinger C, King A, Karp S, Pandharipande P, Wright K, Weavind L. Intensive Care Unit Enhanced Recovery Pathway for Liver Transplant Recipients: A Prospective, Observational Study. Am J Transplant. 2017;17 (suppl 3).

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