Transplant critical care: Standards for intensive care of the patient with liver failure before and after transplantation

Patients with impending or established single or multiple organ system failure are described as critically ill. Patient outcomes are optimized by skilled nursing units led by physicians trained in critical care medicine— intensivists. The impetus for subspecialization in the practice of critical care is the identification of groups of critically ill patients who require specialized knowledge, experience, and monitoring techniques that are outside the mainstream of critical care medicine. Well-recognized areas of expertise include neonatology, pediatrics, cardiology/cardiac surgery, and neurology/neurosurgery. In each area, intensive care is provided by physicians or surgeons who have subspecialty knowledge and skills as well as critical care training. Similarly, critically ill solid organ transplant candidates and recipients benefit from specialized transplant critical care. These specialists are versed in the care of patients with end-stage organ failure, attendant critical illnesses, and in the perioperative management of these patients at the time of transplantation. Preoperatively, transplant critical care intensivists attempt to optimize a transplant candidate with a specific type of end-organ failure so that the patient remains eligible for transplantation. Postoperatively, the targets of critical care are both the posttransplant patient and the newly implanted allograft. Essentially, postoperative care has to be provided to 2 different biological systems that require individual attention and may not always align with respect to treatment options. Large transplant programs may have dedicated transplant critical care services with focused, highly trained nurses and physicians. However, most transplant centers have an insufficient case volume to support such teams. Critical care for transplant candidates and recipients then is often guided by medical and surgical intensive care unit protocols. Those in the transplant community who provide perioperative care to these patients are responsible for identifying areas of concern so that guidelines can be tailored to the specific needs of transplant candidates and recipients. Adherence to the protocolized management of intensive care unit patients has resulted in improved survival. There is every reason to expect that a reduction in practice variations within and among centers will also improve outcomes for critically ill transplant patients. Effective transplant critical care does not happen in isolation. For liver transplantation, it requires the coordination of care provided by transplant surgeons, hepatologists, intensivists, anesthesiologists, and nephrologists, among others. The best management protocols can be developed and implemented by these specialists. The protocols then can be consistently executed even in their physical absence. Intensivists can serve as liaisons between specialists and smooth the transitions to and from the intensive care unit, operating room, and ward. For example, intraoperative anesthetic management can be either a continuum of preoperative critical care (eg, an escalation of treatment for patients with