The Division of Liver Transplant Anesthesia is one of the most active clinical programs worldwide. The Recanati-Miller Transplantation Institute has a long history of excellence in clinical care and research. Since the inception of the liver transplantation program, more than 2,000 patients have received cadaveric or living donor transplants at Mount Sinai. Mout Sinai is also a leading center for living donor hepatic transplantation. Our anesthesiology team consists of a core group of seven attending anesthesiologists. The division also has five pediatric anesthesiologists that cover the pediatric liver transplantation. The institution performs 150 to 200 liver transplants per year, and approximately 25 to 30 of these are pediatric cases.
Great strides in improving the clinical and academic initiatives of the Transplantation Institute anesthesia team were achieved in the 2007 to 2008 academic year. With the introduction of intraoperative porto-systemic shunts during liver transplantation by the surgical team, the anesthesia team, upon review of its computerized database, is now facing cases with dramatically improved hemodynamic stability. In addition, this technique appears to assist the team in reducing blood-product administration. The anesthesia team is developing a group of best practices, with increasing utilization of thromboelastography, intraoperative use of transesophageal echocardiography in consultation with cardiac anesthesiologists, and a concerted effort to reduce blood-product administration by working with the Blood Bank and surgeons. The stability of the attending anesthesiology and surgical teams devoted to Transplantation Institute procedures further contributes to adherence to best practices and superlative communication between the specialties.
The academic productivity of the Transplantation Institute anesthesia team is continually improving. The 2008 meeting of the International Anesthesia Research Society will include a presentation of survey data gathered by the anesthesia team that characterizes national trends in liver transplant anesthesia. Dr. Corey Scher moderated a panel and lectured at the American Society of Anesthesiologists Annual Meeting in October 2007 on Controversies in Liver Transplantation. His focus was on reperfusion injury during liver transplantation. Dr. David Wax is analyzing hundreds of computerized anesthesia records to ascertain whether there are associations between hemodynamics and kidney transplantation outcomes. The group is now preparing a protocol that assesses the hypercoagulability that develops in some patients following transplantation and its possible associations with anti-fibrinolytic therapy and platelet transfusions.
Liver transplantation anesthesiology is a tremendous clinical challenge—the ultimate in the integration of knowledge and technical skills. Trainees learn cardiovascular, respiratory, and hepatic physiology, and the application of this knowledge to hepatic transplantation, major hepatic resections, and all aspects of perioperative management. The use of invasive monitoring is pervasive—pulmonary artery catheters are used routinely and the use of ultrasonic vessel finders is ubiquitous in coagulopathic patients.
The Transplantation Institute's educational mission has been enhanced by the creation of a fellowship in Liver Transplantation Anesthesia. Currently, we have one position annually. The addition of the fellow refines the experience of the anesthesia residents during Transplantation Institute rotations by allowing for increased intraoperative instruction.
The cases are notable for massive transfusion in all age groups, hyperdynamic states, marked vasodilation, and the state-of-the-art in therapy of coagulopathies. Our staff also has extensive experience and training in transesophageal echocardiography and use in selected cases to enhance the monitoring and educational experience. The trainee will gain experience with rapid infusion systems, cell salvaging, veno-veno bypass, and all forms of anesthesia monitoring.