Liver Transplant Fast-Track With an Emphasis on Reduced Delirium: A Multidisciplinary Approach to Reducing Length of Stay

Abstract

Enhanced recovery after surgery protocols have been shown to reduce length of stay in transplant patients. The purpose of our study was to evaluate the impact of a standardized protocol in liver transplant recipients (LTR) on length of stay (LOS) and delirium during the index hospitalization post-LT. Elements of the protocol included reduced intraoperative corticosteroids (from methylprednisolone 1000 to 250 mg), conversion of steroid taper to be administered once-daily instead of BID, optimal end-of-case intraoperative extubation, multimodal analgesia, early removal of surgical drains, implementation of dietary and physical therapy plans and education for multidisciplinary providers and patients about expected LOS. The primary outcome was post-LT LOS. Secondary outcomes included incidence of delirium, ICU LOS, rejection at 60 days and readmission within 30 days of discharge. A total of 125 LTRs were included. Baseline characteristics were similar between groups. The median LOS was 12 days (IQR, 9–19) and 10 days (IQR, 8–15) in the pre- and post-implementation groups, respectively (p = 0.025). ICU LOS was 2.9 (IQR, 2.1–4) and 2.7 (IQR, 1.9–3.7) in the pre- and post-implementation groups, respectively (p = 0.525). In the pre- and post-implementation groups, the incidence of delirium was 17 (25.8%) and 5 (8.6%), respectively (p = 0.013). The incidence of treated rejection at 60 days was 3% (0.0–10.1) and 5.2% (2.9–15.2) in the pre- and post-implementation groups, respectively (p = 0.550). Implementation of a Fast Track protocol in a high acuity LTR was feasible and safe and was associated with a reduction in LOS.