Liver, Kidney & Pancreas Transplant Patients

Curriculum

Each fellow should be competent in the preoperative evaluation, intraoperative management and postoperative care of patients undergoing organ transplantation procedures. These include liver transplant procedures, liver-kidney transplant procedures, kidney transplant procedure and pancreas transplant procedures. The Anesthesia for Liver, Kidney and Pancreas Transplant Patient rotation consists of six mandatory modules. An extra module is offered as an elective for those individuals who feel the need for extra exposure to the clinical experience in this area. During this rotation, fellows develop expertise in the management of organ transplant patients, including 20-30 liver transplant procedures. Some of these procedures will have the fellow as the primary anesthesiology provider, but most will have the fellow in a supervising/teaching role. The fellow will be responsible for implementation of pre-, intra- and postoperative evidence based knowledge into clinical practice and resident teaching. Additionally fellows will be involved in every aspect of care of the liver transplant recipient: from evaluating candidate’s acceptability for transplant to postoperative management in the ICU. Under supervision, fellows serve as consultants to evaluate potential liver transplant recipients. Fellows will attend weekly multidisciplinary meetings to discuss the suitability of candidates as well as participate in weekly multidisciplinary Morbidity and Mortality Liver Transplant Conferences to optimize and improve patient care.

Additionally at least ten kidney, and twp pancreas transplants should be performed. As above, some of these procedures will have the fellow as the primary anesthesiology provider, but most will have the fellow in a supervising/teaching role.

Competencies

At the conclusion of each module of this rotation, evaluation will depend on the fellow’s performance in each competency adjusted for expectations based on the length of time already completed in Transplant Anesthesia rotations.

Patient Care

At the conclusion of the six Clinical Transplant Anesthesia rotations, the fellow must be able to:

1. Perform a comprehensive pre-operative evaluation in organ transplant candidates
2. Understand the pre-, intra-, and post-operative pathophysiology/complication of organ transplant patients
3. Recognize the need for advanced airway management techniques to facilitate safe intubation
4. Understand patient baseline and pathophysiologic factors that may impact hemodynamic management during the transplantation procedure
5. Recognize when manipulation of hemodynamic parameters (HR, BP, CVP, PAP, CO, CI, SVR) is needed to maintain stable condition of the patient and function of the organ or control blood loss during surgery
6. Understand how organ protection may be achieved using pharmacologic and hemodynamic means
7. Know the effect of commonly used immunosuppressant medications and their effects on anesthetic management
8. Be able to place and manage central lines, pulmonary artery catheters, arterial lines, femoral arterial lines and venovenous bypass catheters
9. Be able to measure CVP, PAP, CO, CI using commonly used techniques and appropriately manage those parameters using pharmacologic and physiologic means
10. Be able to place a transesophageal echo probe, to interpret the findings and to adjust the anesthetic management based on the parameters
11. Be able to manage chest tube drains
12. Be able to appropriate position patients for the transplant procedures, be aware of complications of positioning and techniques to minimize the likelihood of complications
13. Recognize the importance of maintaining adequate oxygen delivery to the tissue and organs and be able to adjust hemodynamics, pharmacologic interventions to optimize
14. Be aware of anesthetic considerations in cases involving multiple organ transplants and be able to appropriately choose anesthetic techniques to optimize monitoring
15. Be able to place and manage epidural catheters for postoperative pain control

Medical Knowledge:

At the conclusion of the six Clinical Transplant Anesthesia rotations, the fellow must have acquired advanced knowledge of:

1. Normal anatomy and physiology of the liver and its surrounding organs, aorta and other major vessels.  Anatomy and physiology of pancreas and kidney
2. Hepatic blood supply and their changes in pathophysiologic conditions
3. Available options for organ protection and relevant pharmacologic and hemodynamic management principles
4. Basic pharmacology of common antiviral and immunosuppressant medications
5. Indications, contraindications, and potential complications of the following procedures: arterial catheterization, central venous catheterization, pulmonary artery catheterization, chest tube drain, transesophageal echocardiography
6. Impact of organ transplant pathology on the pharmacology of anesthetic drugs (all types)
7. Understands the physiology and pathophysiology of coagulation in organ transplants, especially liver.
8. Essentials, classification and pathophysiology of liver cirrhosis, kidney failure and pancreas disease
9. Understanding the physiology of hepatorenal, hepatopulmonary syndrome
10. Airway management options for patients with severe ascites
11. Essential classification of liver disease/cirrhosis, presentation and management issues unique to each type of cirrhosis
12. Essential classification of end stage kidney disease, pancreas insufficiency and management issues unique to each disease and severity

Practice-Based Learning and Improvement:

At the conclusion of each module in this rotation the fellow should be able to evaluate their clinical experience by:

1. Participate actively in pro/con debates of issues with staff, residents and during problem based meetings
2. Active participation in journal club activities, and presentation of a transplant anesthesia lecture to the department

System Based Practice:

At the conclusion of each module from this rotation the fellow must:

1. Show an understanding of all elements of the health care system in relationship to patients undergoing organ transplant procedures, including the operating room team, transplant-surgery and transplant surgery nursing, surgical intensive care team and post anesthesia care team personnel
2. Be able to express issues in cost containment without compromising patient safety

Interpersonal & Communication Skills:

At the conclusion of each module in this rotation the fellow should:

• Be able to conduct an effective interview with patients preoperatively and explain the plan, risks, benefits, alternatives and personnel involved in the care of the patient
• Communicate and discuss the case with the attending and/or resident involved and provide a working plan in a time-efficient manner
• Communicate effectively with the preoperative nursing personnel, intraoperative team and postoperative recovery room attending, resident and nursing personnel regarding important issues involved in the care of the patient
• Participate as an active member of the pre-anesthetic check-in team at the start of the case and the check-out team at the end of the procedure
• Transfer the patient care to the accepting team, including ICU or PACU personnel by providing a concise and detailed report of the intraoperative events

Professionalism:

During each module the fellow should:

• Keep timely and accurate case logs, duty hours, moonlighting and call hours, as well as attendance at the conferences
• Complete all required evaluations
• Respect all personnel involved in the operating room as well as the perioperative area
• Show a high moral and ethical standard when caring for the patients, regardless of their socioeconomic, cultural or racial background and beliefs.

Curriculum

Fellows will be involved in perioperative and intraoperative care of liver resection (>10 cases) and selected whipple procedures (>10 cases). Selected whipple procedures are defined as patient who are presenting with extensive pancreas malignancy encasing the IVC or involving the liver. Depending on the size of the lesion both liver and pancreatic tumors can present with metabolic changes that need special preoperative and intraoperative monitoring. Additionally the anatomy of the lesion can have specific surgical challenges requiring close coagulation monitoring and transfusion by the anesthesiologist. The fellows should also participate in the educational conferences in the liver anesthesia department including problem based discussions, resident presentations and journal clubs.

Patient Care:

At the conclusion of this rotation the fellow should be able to:

1. Prepare a comprehensive preoperative evaluation of liver resection and pancreatic resection patients, imaging review, physical exam and laboratory data
2. Be prepared for difficult coagulation monitoring and transfusion
3. Gain experience with placing invasive monitoring (a-line, central line, pulmonary artery catheter)
4. Implement knowledge acquired during rotation in adult transplant anesthesiology regarding hemodynamic monitoring, intraoperative monitoring, pharmacologic effects of chemotherapeutic medications, and understand the differences in each disease process

Medical Knowledge:

At the conclusion of this rotation the fellow must have acquired advanced knowledge of:

1. Basic anatomic and physiologic differences in the pathophysiology of hepatic and pancreatic tumors
2. Pharmacologic effects of anesthetic and chemotherapeutic medications in those patients
3. Metabolic changes and their anesthetic considerations
4. Indications, contraindications and possible complications in invasive monitoring
5. Monitoring coagulation and management of blood loss and transfusion

Curriculum

During this rotation the fellows will be exposed to critically ill patients with end stage organ problems.  The fellows will experience care of patients who are admitted from the emergency department or transported from an outside medical facility for medical management or for preoperative evaluation and preparation. They will also participate in the management of patients admitted to the surgical intensive care unit postoperatively. The fellows will participate in the rounds with the surgical intensive care unit (SICU) attending, obtain the initial history and physical exam and actively manage the care of these patients.  Management will include placement interpretation and management of invasive lines, intubations and airway management, and monitoring of CVP, PAP, CO, CI.  Fellows will be actively involved in writing orders for these patients under the supervision of the ICU attending.  Fellows will also manage common ICU problems including respiratory failure, sepsis, shock, bleeding, multiple organ failure and organ rejection,

Patient Care:

At the conclusion of this rotation the fellow must be able to:

1. Manage patients with organ transplant
2.  Manage septic patients with organ transplant
3. Manage postoperative surgical patients
4. Admit patients with history of critical end organ damage and appreciate the emergent need for organ transplant and be involved in optimization of these patients
5. Actively be involved in evaluating intubated patients for weaning and preparing for extubation
6. Manage chest tube and abdominal drains
7. Manage system infections on immunosuppressant
8. Evaluate and treat perioperative pneumonia and other types of infections
9. Manage common endocrine abnormalities in the organ transplanted critically ill patient
10. Evaluate and manage postoperative pain and implement appropriate analgesic regimens
11.  Actively be involved in multidisciplinary consultations and implementation of recommendations from consulting service.
12. Actively be involved in family meetings

Medical Knowledge:

At the conclusion of this rotation the fellow must have acquired advanced knowledge of:

1. Interpretation of hemodynamic and respiratory data in SICU
2. Hemodynamic effect of inotropic agents
3. Sedation and neurologic exam
4. Management principles of hemorrhagic shock
5. Diagnosis and management of cardiac abnormalities including ischemic changes in SICU patients
6. Management of dysrhythmias
7. Use of hyperosmolar therapy
8. Use of hypothermia in brain protection
9. Postoperative immunosuppressant management
10. Complication of organ transplant and their management
11. Hemodynamic goals in postoperative patients with cardiac vascular abnormalities
12. Postoperative sepsis and pneumonia
13. Mechanical ventilation modes
14.  Bioethics and end-of-life decisions; diagnostic criteria for brain death
15. Sedation and pain management in ICU
16. Advanced cardiac life support and resuscitation

Curriculum

During this rotation, fellows will be exposed to transesophageal echocardiography (TEE). The fellows should achieve an understanding of the basic interpretation of transesophageal echocardiography as well as the technical aspects of ultrasound and echocardiography. During the eight weeks of transesophageal echocardiography the fellow should be able to interpret and document >100 TEE cases.

By the end of the rotation, the fellows should be able to recognize common types of cardiac pathology on TEE and have participated in intraoperative hands-on anesthetic care of at least 50 TEE procedures. The fellow should obtain a Certification in Basic Perioperative Transesophageal Echocardiography at the end of the fellowship.

Patient Care:

At the conclusion of this rotation the fellow should be able to:

1. Identify the indications and contraindications for transesophageal echocardiography
2. Know the indications for different transesophageal echocardiography diagnostic modalities including functional and 3 dimensional diagnostic methods
3. Know the indication for Doppler-guided measurements of the cardiac anatomy and blood flow
4. Manage complications after transesophageal echocardiography procedures
5. Know preoperative procedures necessary for preparing patients for echocardiography procedures as well as essential postoperative clinical care methods

Medical Knowledge:

At the conclusion of this rotation the fellow must have acquired advanced knowledge of:

1. Principles of cardiac imaging with transesophageal echocardiography
2. Identification of mass, size, blood flow, valves, EF, ventricle function to estimate cardiac function
3. Differentiation of valve lesions and dysfunction
4. Differentiation of mechanical valves and dysfunction
5. Indications and contraindications for transesophageal echocardiography
6. Understand the cardiac anatomy
7. Principles of transcranial Doppler measurements of cardiac blood flow
8. Recognition of complications and essentials of their treatment in transesophageal echocardiography

Curriculum

Use of intraoperative coagulation monitoring in optimizing the surgical procedures and avoiding surgical complications has increased in the past few decades.  In many centers the task of monitoring and interpretation of the thromboelastogram (TEG) is by the transplant anesthesiologist. Adequate knowledge of the principles of thromboelastogram and cogulation monitoring is essential in the management of liver transplant patients and surgeries with major blood loss.  The fellow will attend a ROTEM® training session to learn how to operate the machine and to gain knowledge in interpretation. Monitoring will involve both liver transplant and non-liver transplant procedures. Additional rotations in blood bank, hematology or hepatology can be arranged.

Patient Care:

At the conclusion of this rotation the fellow must be able to:

1. Understand the indications and limitations of coagulation monitoring
2. Identify patients who might benefit from coagulation monitoring
3. Describe appropriate coagulation monitoring for the planned liver transplant or other surgical procedures
4. Identify complications associated with placement of coagulation monitoring
5. Recognize and minimize the disruption of anesthetic care which may be caused by some coagulation monitoring methods
6. Manage the impact of anesthetic and surgical technique on coagulation monitoring
7.  Identify clinically significant changes in coagulation monitoring, develop a differential diagnosis for causes and implement appropriate corrective anesthetic management if appropriate
8. Be able to interpret results of transcranial thromboelastogram studies

Medical Knowledge:

At the conclusion of this rotation the fellow must have acquired advanced knowledge of:

1. Principles of coagulation monitoring and thromboelastogram
2. Common thromboelastogram changes associated with liver transplant surgery
3. Understand drug induced coagulation and other non-surgical changes in thromboelastogram
4. Effects of pre-hepatic, an-hepatic, neo-hepatic phase in changes on thromboelastogram
5. Effect of surgical bleeding on thromboelastogram
6. Complications of thromboelastogram

Curriculum

The simulation curriculum is designed to train and educate residents in liver transplant anesthesia and transesophageal echocardiography. The fellow will be responsible to develop a protocol for liver transplant anesthesia simulation and will be in charge under supervision to perform simulations with residents. The goal is to prepare residents for liver transplant anesthesia and to educate them about preoperative, intraoperative and postoperative considerations they will encounter. Ultimately training the residents for liver transplant anesthesia should results in improvement in the quality of patient care and outcome.

The TEE simulation will be in combination with the cardic anesthesia fellow.  The goal is to train and educate the residents for the use of intraoperative TEE use and interpretation. Basic ultrasound knowledge and skills will be taught during the simulation session.

Patient Care:

At the conclusion of this rotation the fellow should

1. Have developed a simulation protocol for liver transplant anesthesia
2. The fellow should be able to run a simulation under supervision and know the basic fundaments in resident teaching and training for simulations

Curriculum

This module requires mentoring of the fellow by an attending faculty with experience in scholarly projects. The mentor need not be a liver transplant anesthesiologist and the level of support and advice will depend on fellow’s experience. The module can involve 1) designing and conducting a clinical investigation related to liver transplant anesthesia, critical care or related discipline, 2) preparation of a review article, book chapter, case report/series, or a database project. It is expected that the fellow will gain experience in oral presentation and submit written work for publication. This module should likely be conducted early in the year, such that the fellow has adequate time to pursue the research project. Alternatively, the project may be developed early in the fellowship and the research time can be distributed or allotted as needed to accomplish the project. It is expected that substantial basic or translational neuroscience projects will require a second year of fellowship/postdoctoral training.

Patient Care:

At the conclusion of this rotation the fellow should be able to (as appropriate):

1. Do at least one of the following: Prepare a paper using data from a clinical or basic research project; prepare a case report or review article; develop and publish a project that results in improvement in the quality of patient care and outcome
2. Understand the Institutional Review Board’s role in overseeing research, understand regulations in regard to patient care and patient advocacy

Medical Knowledge:

At the conclusion of this rotation the fellow must have acquired advanced knowledge of:

1. Critical review of published studies
2. Basic study design
3. Basic statistical methods
4. Preparation of a manuscript
5. Ethical principles of clinical investigation
6. Role of the Institutional Review Board (IRB) in the approval of studies and maintenance of ethical standards