Targeting Delirium May Help Reduce Length of Stay After Liver Transplant

Delirium reduction may play an important role in reducing patients’ length of stay (LOS) following receipt of a liver transplant (LT), according to findings from a recent study.1

Results showed implementation of a standardized novel fast-track protocol focused on intra- and postoperative management was associated with a lower incidence of delirium and reduced LOS following LT without increasing the risks of allograft rejection or 30-day readmission.1

In 2023, 10,660 liver transplants were performed in the United States, the most ever recorded in a single year and the first time the country has eclipsed 10,000.2 The sole curative treatment for patients with end-stage liver disease, liver transplantation is associated with high in-hospital costs related to surgical care, postoperative hospital stays, and specialized multidisciplinary care.1

“[Multiple] analyses support the proof of concept that LOS after liver transplant can be reduced through systematic interventions,” David Salerno, PharmD, a clinical pharmacy manager, liver transplantation at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and colleagues wrote.1 “However, previously unstudied modifiable factors may also contribute to LOS in liver transplant recipients.”

To evaluate the impact of a novel standardized fast-track protocol on LOS and delirium during the index hospitalization post-LT, investigators conducted a retrospective chart review comparing consecutive patients in the first year of the fast-track protocol, from June 2022–May 2023, to those of the preceding year, from June 2021–May 2022.1

The protocol was designed to provide a framework for standardized, personalizable LT recipient care. A multidisciplinary group of physicians, surgeons, pharmacists, and physician assistants selected the variables of interest by consensus based on existing literature and clinical experience.1

Outcomes were assessed until 12 months post-LT. Patients were excluded if they were unable to tolerate tacrolimus for 30 days postoperatively.1

The primary outcome was LOS of the index hospitalization for LT, defined as the total number of days from the date of LT to the date of discharge. Secondary outcomes included incidence of allograft rejection at 60 days and 12 months post-LT; 30-day readmission rate; ICU LOS; JP drain output(s) in the 24-hour time period before being taken out; and episodes of delirium during index hospitalization.1

The presence of delirium was determined via a manual chart review of daily progress notes by 2 of the investigators independently and then compared for differences. Factors used to identify delirium included documentation of confusion, disorientation, or agitation, use of antipsychotic medications, and need for 1:1 observation.1

The final analysis included 125 patients, including 67 in the pre-protocol group and 58 in the post-protocol group. Among the cohort, the median age was 56.3 (interquartile range [IQR], 47.7 to 64.3) years, the majority of LT recipients were male (62.4%), and the most common etiologies of liver disease were alcohol-associated liver disease (29.6%) and metabolic dysfunction-associated steatohepatitis (23.2%).1

The median LOS was 12 (IQR, 9 to 19) days and 10 (IQR, 8 to 15) days in the pre- and post-implementation groups, respectively (P = .025). LOS ≤ 10 days was achieved by 22 (32.8%) and 30 (51.7%) patients in the pre- and post-protocol groups, respectively (P = .033). After adjusting for the need for reoperation, investigators noted the likelihood of discharge from the hospital within 10 days of LT was greater in the postprotocol group (adjusted-relative risk ratio, 2.58; 95% confidence interval [CI], 1.21–5.52; P = .014).1

In the pre-implementation group, the incidence of delirium was 17 (25.8%), compared with 5 (8.6%) in the post-implementation group (P = .013). Additionally, 13 (20.3%) and 1 (1.7%) patients experienced delirium that required pharmacologic intervention (P = .001), respectively.1

In multivariate regression, factors independently associated with LOS included history of hepatic encephalopathy (β = 4.29; P = .043); days to extubation following LT (β = −2.5; P = .023); take back to the operating room post-LT (β = 6.81; P = .019); and ICU LOS (β = 2.68; P <.001).1

On multivariate analyses, variables independently associated with delirium included psychiatric history (odds ratio [OR], 7.13; P = .004) and time to extubation (OR, 2.59; P = .007).1

“This novel fast-track protocol was associated with a lower incidence of delirium and reduced LOS following LT without increasing the risks of unintended consequences including that of allograft rejection or 30-day readmission,” investigators concluded.1 “Prospective research aimed at addressing modifiable risk factors for delirium should be a major focus point for future research on enhanced recovery after surgery pathways to reduce LOS.”

References

1. Salerno DM, Genovese M, Jesudian A, et al. Liver Transplant Fast-Track With an Emphasis on Reduced Delirium: A Multidisciplinary Approach to Reducing Length of Stay. Clinical Transplantation. https://doi.org/10.1111/ctr.70111

2. United Network for Organ Sharing. A decade of record increases in liver transplant. February 13, 2024. Accessed February 25, 2025. https://unos.org/news/in-focus/a-decade-of-record-increases-in-liver-transplant/