Bypassing the ICU after liver transplant

Aug. 15, 2023

More than half the patients who have liver transplantation at Mayo Clinic in Jacksonville, Florida, are fast-tracked after the procedure to the surgical ward, bypassing the intensive care unit (ICU). The practice, used in selected patients since 2002, lowers the risk of ICU-related morbidities as well as cost.

"We tailor the post-transplant approach to individual patients. If we can safely extubate and liberate them from the ventilator immediately after transplant, they become almost like any other surgical patients, and their recovery accelerates," says C. Burcin Taner, M.D., chair of the Transplant Center at Mayo Clinic's campus in Florida.

The only center in the United States that routinely allows selected liver-transplant patients to bypass the ICU, Mayo Clinic's campus in Florida has performed more than 4,000 liver transplants since fast-tracking began. Roughly half those patients were safely fast-tracked; the current fast-track rate is about 60 percent.

"Our liver transplantation outcomes are very strong. With detailed analysis of the fast-track practice, we have demonstrated that not every single patient needs to go to the ICU," Dr. Taner says.

In addition to avoiding ventilator-related infection, liver-transplant patients who are fast-tracked have considerably shorter hospital stays. The average length of hospital stay following liver transplantation at Mayo Clinic's campus in Florida is six days.

Individualized and collaborative decision-making

The decision about whether to fast track a patient is made during surgery by the liver-transplant surgeon and anesthesia team, based on the patient's needs. In the September 2014 issue of the American Journal of Transplantation, Dr. Taner and colleagues described a scoring system for evaluating fast-track eligibility. Variables incorporated into the scoring system include the patient's age, body mass index and primary diagnosis.

"We might have initial thoughts going into surgery about whether the patient will be fast-tracked, but those thoughts can change based on individual data points that we see during surgery," Dr. Taner says.

The fast-track decision also involves the consideration of factors such as:

Hemodynamic stability
The absence of ongoing hemorrhage
The absence of early graft dysfunction or vascular problems
The need for prolonged ventilatory support

Patients are excluded from fast-track consideration if they:

Go to the operating room from the ICU
Require intraoperative dialysis
Receive multiple organs
Undergo combined cardiac procedures at the time of liver transplantation

After liver transplantation, fast-tracked patients generally spend about two hours in the post-anesthesia care unit (PACU). A 1-to-1 nurse-patient ratio is maintained for about six to 24 hours, depending on the patient's needs. As a fully integrated practice, Mayo Clinic can provide evaluations by specialists in transplant surgery, anesthesiology and hepatology in the operating room, PACU or surgical ward at any time.

"The availability of our specialists and facilities around the clock makes fast-tracking possible. We work as a team in a fully integrated practice," Dr. Taner says.

In addition to the unique fast-tracking program, Mayo Clinic's campus in Florida provides expedited dismissal from the hospital for select patients. About 30 percent of all liver-transplant patients at the center are able to leave the hospital on the fourth or fifth day after surgery.

"We realized that a subset of patients doesn't need hospitalization for six or seven days. As a result, we have been able to compress our inpatient protocols in select patients. This expedited dismissal from hospital practice allows for an individualized approach to each patient without compromising the quality of care," Dr. Taner says.

"Mayo Clinic is committed to individualized care," he adds. "We don't make a blanket statement that every single liver-transplant patient needs to go to the ICU or has to stay in the hospital for a predetermined period. With a tailored approach, we can improve quality of care."