he ASA Committee on Transplant Anesthesia evolved from the ASA Task Force on Representation to the United Network for Organ Sharing (UNOS). This task force was established in April 2003 by then President James E. Cottrell, M.D., as a result of communication with UNOS pertaining to qualifications for anesthesiologists involved in liver transplantation. The initial members of the task force were Steven R. Rettke, M.D., Chair; Edmond Cohen, M.D.; Marie E. Csete, M.D.; Paul J. Dadic, M.D.; Andre M. De Wolf, M.D; Yoogoo Kang, M.D.; M. Susan Mandell, M.D.; William T. Merritt, M.D.; Randolph H. Steadman, M.D.; and Russell H. Wiesner, M.D., (UNOS Representative).

The charge of the task force was fourfold: 1) review the current demographics of liver transplantation in the United States; 2) review published outcomes data for liver transplantation to determine any associations between patient outcome, models of anesthesia care and the qualification of anesthesia providers; 3) review UNOS bylaws to understand the process involved in establishing regulations pertaining to qualifications for anesthesiologists who are involved in the perioperative care of liver transplantation; and 4) specifically address if ASA should recommend to UNOS that it establish a bylaw or other regulatory statement on the qualifications required for anesthesiologists involved in the perioperative care of liver transplantation. Currently there are UNOS bylaws defining criteria for directors of liver transplant surgery and hepatology, but none defining a director of liver transplant anesthesiology.

The task force sent a questionnaire to 103 liver transplant programs and received responses from 53. The group also evaluated UNOS data and the pertinent medical literature. UNOS center volume data for 2002 revealed that two-thirds of the programs perform less than 49 liver transplants per year, and this accounts for one-third of the liver transplants performed in the United States. Responses to the questionnaire indicate that seven of the programs offer a liver transplant fellowship, and only a total of eight fellows completed training from 1996-03.

The anesthesia coverage for these programs is well managed. Most have small, well-defined groups taking liver transplant call. Ninety percent of the programs had written protocols dealing with the management of liver transplant patients and a designated director of the program. The directors tended to be older with a mean age of 46 years and 12 years of liver transplantation experience. Regarding outcome data, there are none pertaining to qualifications for appropriate training in liver transplant anesthesia.

The committee discussed whether the establishment of qualifications would be problematic especially in programs that perform a low volume of liver transplants. The committee felt that if qualifications are established, they should be within the framework of training, continuing medical education and day-to-day work in the operating room rather than setting a specific number of liver transplant anesthetics.

The task force recommendations were to:

• Temporarily defer the issue on whether qualifications for liver transplant anesthesiologists should be included in UNOS Bylaws;
• Establish an ASA Ad Hoc Committee on Transplant Anesthesia addressing all transplant surgery;
• Identify a director of each liver transplant program; and
• Establish formal liaison with UNOS.

In October 2003, the task force became the ASA Ad Hoc Committee on Transplant Anesthesia, and in 2004, the ASA House of Delegates recognized the importance of anesthesia for transplant surgery by formalizing a standing Committee on Transplant Anesthesia in the ASA Bylaws. This approval by the House of Delegates demonstrated the commitment of anesthesiologists to the provision of quality anesthesia care for transplant donors and recipients. The committee members are: Dr. Rettke, Chair; Tricia E. Brentjens, M.D.; Dr. Csete; William R. Furman, M.D.; E. H. Jerome, M.D.; Dr. Kang; Dr. Mandell; Joseph J. Quinlan, M.D.; Kerri M. Robertson, M.D.; Dr. Steadman; and Thomas H. Swygert, M.D.

The committee has responded to the charge of establishing liaison with UNOS. The chair is on the UNOS Committee on Membership and Professional Standards and acts as liaison with ASA and UNOS. ASA has had representation on the UNOS Pediatric Brain Death Advisory Council. Dr. Kang was the representative on the UNOS O.R. Staff Advisory Council, and Dr. Robertson is the representative to the UNOS Donation After Cardiac Death Consensus Conference. Dr. Mandell is the Region Eight representative to the UNOS Communications Committee and is also Chair of the O.R. Advisory Staff Council on Donation After Cardiac Death.

The committee responded to UNOS public comment proposals. One was the lung allocation scoring system implemented by UNOS this year. Previously patients within a region were prioritized based on blood type and waiting time. With the new system, waiting time is not considered, but rather a scoring system is used based on 12 variables, including laboratory values, test results and disease diagnosis. This method of prioritizing patients according to their lung allocation score will result in the neediest patients coming first and the greatest chance of success after the transplant. The committee’s response stated that the implementation of this scoring system would not have a significant impact upon our practice. Under this new system, patients may indeed have a higher ASA Physical Status; however, as anesthesiologists, we are well equipped to care for this patient population. The committee also responded to UNOS public comment proposals regarding evaluation and postoperative pain control in living liver and kidney donors. The committee felt that the donor should be evaluated by an anesthesiologist experienced in liver and kidney transplantation, and postoperative pain consultation should be available.

A future area of discussion is liver transplant anesthesia program director criteria. This is especially significant in view of the fact that UNOS has established a subcommittee to evaluate the wording of surgery and medical director criteria. The committee will continue to develop liaison with UNOS and be involved in its committee structure. The UNOS Consensus Conference and discussions dealing with organ donation after cardiac death and how they impact us as a specialty need to be studied. Also working with other transplant organizations should be encouraged to promote educational and research endeavors.

Improving donor and recipient care and optimizing the limited resource of donor organs are important goals of the committee. We welcome input from the ASA membership regarding transplantation issues.

Steven R. Rettke, M.D., is Associate Professor of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota.