A New Partnership in Transplant Critical Care & Transplant Anesthesiology

A milestone in transplantation was recently announced by United Network for Organ Sharing (UNOS) commemorating the completion of over one million transplants in the United States.¹ This achievement reflects a steady increase in annual transplant volumes with over 400,000 transplant recipients alive today. It is commonly understood that anesthesiologists are instrumental in peri-operative care of both organ donors and organ recipients. Less widely recognized, but equally important, is the involvement of anesthesiologists in patient selection, risk assessment, coordination of care for pre-operative optimization, and post-operative care. This includes the provision of critical care services for potential transplant candidates with end-stage organ failure, care of high acuity post-operative patients, management of post-transplant complications, and supportive care for organ donors.²

SOCCA and Society for the Advancement of Transplant Anesthesia (SATA) have formed a working group to collaborate on projects involving transplant critical care and transplant anesthesiology. Both societies are dedicated to the support and development of anesthesiologists in their respective sub-specialties. These focused societies can foster the formation and maintenance of a tightly knit community with others. Anesthesiologists with an interest in critical care and transplantation are encouraged to become active members in this collaborative effort.

Many aspects of transplant care that are vital to the continued success and growth of transplant programs occur behind the scenes and may not be apparent to patients, our colleagues, or institutional leaders. As an example, for liver transplantation in the United States, the Organ Procurement and Transplantation Network, a public-private partnership which falls under the U.S. Department of Health and Human Services, has specific mandates for the involvement of transplant anesthesiologists.³ These include peri-operative consults and participation in candidate selection, morbidity and mortality conferences, and development of intra-operative guidelines based on existing and published knowledge. More extensive participation is specified and required of the Director of Liver Transplant Anesthesia. Of note, fellowship training in Critical Care Medicine, Cardiac Anesthesiology, or a Liver Transplant Fellowship are required for this position, formally highlighting the intersection of multiple fields in the care of transplant patients. Despite this federal guidance, support for these activities is not uniform across institutions, nor is a standard funding mechanism in place. Obtaining resources to back the essential work of anesthesiologists outside of the operating room which enable transplant care remains a challenge.⁴

The proposed collaboration between SOCCA and SATA is meant to be broadly inclusive and address the needs of those involved in all transplant care. This includes those clinicians caring for all organ recipients including, but not limited to, heart, lung, liver, pancreas, and kidney, as well as those involved in donor care in the ICU and OR. As the field of transplant medicine evolves, the role of anesthesiologists in organ transplantation will likely continue to grow in the ICU, the OR, and via multidisciplinary collaboration.

Possible areas of focus for this initiative, to be determined and driven by members, include formal and informal education; facilitating clinical discussions across institutions, regions, and countries; and development of clinical statements and guidelines. Examples of recent efforts include work to define fellowship competencies and milestones in a variety of organ transplant fields.^5-7 As multiple fellowship training becomes more common in anesthesiology, one avenue for collaboration is the exploration of the integration of critical care and transplant anesthesiology training. As mentioned, the practice of transplant anesthesia is heterogenous across institutions, but is largely uncharacterized. Similarly, we know little about the practice of critical care anesthesia is the United States, but the role of member-driven societies is essential to help understand the environment in which we work. A recent survey of SOCCA members shed light on demographics, training, practice characteristics, compensation, coverage models, and practice environment.⁸ Such work is essential to support our field as we must understand our practice to effectively advocate and promote the role of anesthesiologists and intensivists in the care of transplant patients in all phases of their clinical journey.

More immediate avenues of cooperation could include opportunities for presentation of critical care and transplant topics across both SOCCA and SATA, allowing members of each society to gain access to materials developed by colleagues. This can occur via multiple platforms. SOCCA offers a webinar series, a board review course, and a spring annual meeting. SATA has an online platform with a lecture series, multiple regional meetings, and a spring annual symposium. Both societies have options for either discounted or free membership for medical students, fellows, and medical students. Those interested in the care of transplant patients are encouraged to participate to help drive the field forwards. Membership information can be found at socca.org and www.transplantanesthesia.org. Members interested in getting involved in the transplant collaboration between SOCCA and SATA are encouraged to email the author at akacha@dacc.uchicago.edu.

References

1. United Network for Organ Sharing. Accessed September 10, 2022. https://unos.org/news/u-s-reaches-1-million-transplants/
2. Kotloff RM, Blosser S, Fulda GJ, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med. Jun 2015;43(6):1291-325. doi:10.1097/CCM.0000000000000958
3. Organ Procurement and Transplantation Network Bylaws. Updated July 14, 2022. Accessed September 8, 2022. https://optn.transplant.hrsa.gov/media/lgbbmahi/optn_bylaws.pdf
4. Hendrickse A, Crouch C, Sakai T, et al. Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. Apr 2020;26(4):582-590. doi:10.1002/lt.25711
5. Nguyen-Buckley C, Wray CL, Zerillo J, et al. Recommendations From the Society for the Advancement of Transplant Anesthesiology: Liver Transplant Anesthesiology Fellowship Core Competencies and Milestones. Seminars in cardiothoracic and vascular anesthesia. Dec 2019;23(4):399-408. doi:10.1177/1089253219868918
6. Souki FG, Chadha R, Planinsic R, et al. Recommendations From the Society for the Advancement of Transplant Anesthesiology Fellowship Committee: Core Competencies and Milestones for the Kidney/Pancreas Component of Abdominal Organ Transplant Anesthesia Fellowship. Seminars in cardiothoracic and vascular anesthesia. 2021;26(1):15-26. doi:10.1177/10892532211058574
7. Souki FG, Chadha R, Planinsic R, et al. Recommendations From the Society for the Advancement of Transplant Anesthesiology Fellowship Committee: Core Competencies and Milestones for the Kidney/Pancreas Component of Abdominal Organ Transplant Anesthesia Fellowship. Seminars in cardiothoracic and vascular anesthesia. Mar 2022;26(1):15-26. doi:10.1177/10892532211058574
8. Shaefi S, Pannu A, Mueller AL, et al. Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians-A Survey to Members of the Society of Critical Care Anesthesiologists. Anesth Analg. Aug 10 2022;doi:10.1213/ANE.0000000000006160

Author

Aalok Kacha, MD, PhD, FASA

University of Chicago Medicine

Chicago, Illinois