From early in his tenure as Children’s Hospital Los Angeles’ (CHLA) anesthesiology director of abdominal transplantation and radiology, Andrew Costandi, M.D., MMM, noticed prolonged intensive care unit (ICU) stays for the hospital’s liver transplantation patients and the effects they had on patients’ families and—ultimately—their recoveries.
He engaged his team to streamline the recovery process by extubating these patients while still in the operation room (OR) instead of the established practice of keeping them on ventilators for days post-surgery. Leveraging the success of OR extubation in adult liver transplant patients as well as retrospective published studies demonstrating safety in pediatric patients, Costandi and his team launched the Enhanced Recovery After Liver Transplantation (ERAL) protocol in 2019—the first of its kind for pediatric liver transplants, according to CHLA.
Since then, post-transplant ICU stays have fallen by 57%—from an average of seven days to three. The hospital is extubating more than 75% of its liver transplant patients in the OR—including infants as young as five months old—with no complications or reintubations related to the protocol.
Costandi spoke about the development and impact of the ERAL protocol and how other children’s hospitals may replicate its success.
You convened a multidisciplinary team of experts from across the organization in establishing the protocol. How significant is that aspect in its success?
I think it's extremely important. Perhaps the most important part is that it helped us understand the concerns and issues the other teams are facing to care for the same patients. We came together and filtered the concerns for each team, identified the priorities and how we could merge our efforts together so we can best serve the patients.
Sometimes there are conflicting concerns. For example, the liver team wants the patient to not be fluid overloaded, but if you put the patient in ICU on a ventilator, you must give more fluids—it becomes a vicious circle. If I want to give them more pain medication, the patient will require more fluids. That's not helpful for the liver graft itself because it could get congested. We thought, what's the best way? We determined the best way to minimize fluids to the patient is by extubating them earlier, allowing them to breathe spontaneously and maintain good pain management.
One of the key components of the ERAL protocol is a standardized approach to postoperative pain management that minimizes opioid use. How effective is that in improving outcomes for your patients?
Liver transplantation is a big procedure, so the standard practice has been to leave the patients intubated. To do that, we needed to give a lot of opioids so they could tolerate the ventilator and control their pain. Prolonged use of opioids can affect the gastrointestinal functions; those patients would have delayed bowel movements, which can cause a host of problems later.
The bigger issue is many patients end up leaving the hospital on longer-acting medications. If they are not actively managed, it could lead to chronic opioid use that often creates additional problems for the patient. Weaning them quickly off opioids while controlling the pain is a really big thing for us.
How has the relatively large number of liver transplants CHLA performs helped move the protocol forward?
The large volume helps us tweak the protocol to provide for the best outcomes. We’re also able to see how the protocol works on different patients with different presentations—not all liver transplant patients come for the same reasons.
The other benefit of the higher volume is that it allows us to adjust the protocol by a patient’s age. For example, we would increase the ketamine dose a little bit with younger kids because that helps control their pain without significant side effects while older kids would experience more side effects from that medication.
What advice would you give hospitals with fewer liver transplants looking to institute the ERAL protocol?
We are certainly sharing our protocol with other hospitals. Most hospitals already have the medications we are using, so the protocol is really about putting things together in appropriate dosages that we know work for these patients.
The important thing is to make sure you have agreement between all services—the surgeons, pathologists, pain service. Everyone must be on board. Make sure you have resources in place to address any complications that may arise. The protocol is about organizing efforts and resources and directing them to the patient at the right time for the right reason to get them out more quickly.
