VII. Perioperative Care and Facility Support
The donor surgeon should have primary concern and responsibility for the donor’s care and welfare throughout his or her entire hospital stay.
A. Preoperative Preparation
- Transplant centers should have the ability to allow donors to bank a minimum of one unit of blood before surgery. Facilities should have the ability to handle autologous blood donations.
- Surgeries should be scheduled only when sufficient staffing will be available for the postoperative period (preferably the early part of the week). If surgery is scheduled during the latter part of the week, the hospital should ensure that there is adequate attending, resident physician, physician extender, and registered nursing coverage during the weekend.
- The transplant coordinator or another team member should be assigned the responsibility of providing updates to the families of both the donor and recipient during the surgical procedures.
B. Operative Teams
- There should be two liver transplant attending surgeons with live donor adult liver transplantation experience attending the live donor procedure. One such surgeon should be present for the entire procedure and both of these surgeons should be scrubbed and present for the critical portions of the procedure.
- A third liver transplant attending surgeon should be present in the recipient operating room. This surgeon should have experience in cadaveric liver transplantation but does not necessarily need expertise in live donor resectional surgery.
C. Qualifications of Surgical Team
- All three surgeons should be board certified in general surgery or an equivalent foreign certification acceptable to the New York State Department of Health.
- All three surgeons should have demonstrated experience in liver transplant surgery.
- Two surgeons should have demonstrated experience in live donor hepatectomy (15 procedures) or demonstrated experience in major hepatobiliary resectional surgery (20 procedures) or surgical fellowship at an American Society of Transplant Surgeons (ASTS) approved liver transplant fellowship program with demonstrated experience (15 procedures) with live donor hepatectomy. This should include written verification by the fellowship program director or by the director of the supervising transplant program of hands-on training at an institution performing live donor hepatectomy.
- For a new program with no experience in live donor adult liver transplantation, surgeons should have demonstrated experience in major hepatobiliary resectional surgery (20 procedures). Surgeons should also visit an established program and observe a minimum of five cases. Written verification should be obtained from the director of the hosting program.
- Two liver transplant attending surgeons with live donor liver resectional experience should operate on the donor. These two surgeons should be present for the critical parts of the surgery including the liver parenchymal transection. They should be available and scrubbed if needed for complications, however, only one surgeon need be present for the remainder of the donor operation. One experienced surgeon and a resident or a fellow operating on the donor during the critical parts of the surgery would not be acceptable.
- There should be two separate anesthesia attending physicians for the live donor adult liver transplantation donor and recipient operations. These anesthesia attendings should be present for the critical anesthetic and surgical portions of the procedures and immediately available at all other times. As one case is completed, either anesthesia attending can take responsibility for the ongoing case. The anesthesia attendings should have experience in liver transplant anesthesia and/or major hepatic resection surgery and/or cardiac surgery anesthesia.
- There should be two separate anesthesia teams in two operating rooms (one for the donor, one for the recipient).
- These teams should be directed by a separate anesthesia attending for the live donor and the recipient procedure. The team should consist of anesthesia attendings, chief residents and fellows (postgraduate year 3, 4 or 5), and/or qualified certified registered nurse anesthetists. They should have ongoing education and training in liver/cardiac surgery and have had anesthesia responsibility for major liver resections.
D. Postoperative Care
- Day 0-1: Live adult liver donors should receive intensive care (ICU or PACU).
- Day 2: If stable and cleared for transfer by the transplant team, donors should be cared for in a hospital unit that is dedicated to the care of transplant recipients or a hospital unit in which patients who undergo major hepatobiliary resectional surgery are cared for. Liver donors should not at any time be cared for on any other unit unless a specific medical condition of the donor warrants such a transfer.
- The donor should be evaluated at least daily by one of the qualified liver transplant attendings with documentation in the medical record.
- The transplant team should be responsible for the pain management of the donor. In institutions where a pain management team is available, the transplant team may delegate its responsibility to this team. However, there should be a written protocol in place for assessment and management of donor pain.
- If there is an identified member of the anesthesia care team with specific education and training in pain management of liver donors, that person should be available for consultation with the transplant team regarding the pain control of the donor.
- Since days 3 and 4 are generally the time when complications may occur (for example, gastric dilatation, wound infections, severe hypophosphatemia), the patient care staff should be familiar with the common complications associated with the donor and recipient operations and have appropriate monitoring in place to detect these problems should they arise.
- If there is an emergent complication requiring reoperation, these patients should be prioritized for access to the operating room by the institution.
E. Medical Staffing
- There should be 24 hour/seven day-a-week continuous coverage of the transplant service by general surgery residents at the postgraduate year 2 level or higher, transplant fellows, or physician extenders (nurse practitioners or physician assistants). Between the hours of 6 p. m. and 8 a. m. and at all times on weekends and holidays, the covering residents, fellows, nurse practitioners, or physician assistants should be dedicated to the transplant service and not covering other surgical and nonsurgical patients. An attending transplant surgeon should be available immediately as a resource for the residents, fellows, or physician extenders at all times.
- Any patient with abnormal vital signs or unusual symptoms as identified by the registered nurse should be evaluated immediately by the medical staff. Notification to the appropriate senior medical staff (fellow, chief resident, attending) should be made within 30 minutes. Facilities should have policies in place to assure this response occurs in an expedient manner.
F. Nursing Staffing
- Nursing staff should have ongoing education and training in live donor liver transplantation nursing care (donor and recipient). This should include education on the pain management issues particular to the donor. The registered nursing ratio should be 1: 2 in the ICU/PACU level setting, adjusted as appropriate for the acuity level of the patients.
- After the donor is transferred from the ICU/PACU, the registered nursing ratio should be 1: 4 on all shifts, adjusted as appropriate for the acuity level of the patients.
- The same registered nurse should not take care of both the donor and the recipient. This will minimize confusion if the surnames of the two are the same and will allow the nurse to focus solely on the needs of either the donor or the recipient.
- The nursing service should provide the potential donor with presurgical information including, if possible, a tour of the unit before surgery.
- The names and beeper numbers of the transplant team should be posted on all units receiving transplant donors.
Institutions performing live adult liver transplantation should have adequate radiological staff support including:
- a radiologist with demonstrated experience in evaluating preoperative imaging studies of a potential liver donor including computerized tomography (CT scan) and/or magnetic resonance imaging (MRI) with respect to liver volume estimates (right and left lobe) and detailed vascular and biliary anatomy;
- a radiologist with expertise in reviewing imaging studies in liver transplant recipients;
- radiologists with experience in interventional procedures (angiography) and ultrasound imaging studies in the live donor and liver transplant recipient (available on weekends and between the hours of 6 p.m. and 8 a.m.).
- If there is an emergent complication requiring radiology services, these patients should be prioritized for access to radiology services by the institution.