- Scope and purpose
The guideline under study is “Neurological problems in liver transplantation”, developed by Guarino et al. (2011). The guideline is dedicated to creating recommendations on preventing and combating several neurological problems that occur after orthopic and cadaveric liver transplantation. The six key conditions in medical practice include immunosuppresion neurotoxicity, seizures, central pontine myelinosys (CPM), neuromuscular disorders, cerebrovascular disorders and central nervous system (CNS) infections (Guarino et al., 2011, p.491). The body of the study consists of six subsections. Each of the subsections contains basic information about the conditions under study and recommendations that can be used to prevent the appearance of conditions and combat them in case they have already appeared. The purpose of the guidelines lies in mitigating the effects of neurological conditions that occur early after surgery and increase mortality, morbidity and the duration of hospital stays.
Topicality of elaborating on the guideline can be explained by high prevalence rates of neurological conditions in patients, who have recently undergone liver transplantation (Stracciari&Guarino, 2011, p.9-10). Objectives of the guidelines concern preventing and combating each of six neurological conditions under study. The target population of the guideline is represented by physicians, who take care of patients after they undergo liver transplantation.
- Stakeholder involvement
The document concerns transplantation professionals, who conduct liver transplantation and physicians, who specialize in the field of neurology. The document does not contain any information, concerning consultations with specialists. To my mind, this factor does not influence the quality of the guideline due to two reasons. Firstly, the guideline is developed by specific Task Force that was set up by European Federation of Neurological Sciences. The Task Force is comprised of specialists that have had significant experience in the field of neurology and researching into the interrelations between liver transplantation and appearance of neurological conditions, as well as their management. Secondly, the research is based on the wide range of sources in levels A to C of Classes I-III of evidence of EFNS guidelines.
- Rigor of development
The search strategy was based on each of group’s participants collecting data and conducting research individually. The data is reported to be collected through MEDLINE database of the National Library of Medicine (January 2005-June 2009), the Cochrane Library, as well as existing guidelines and textbooks. No evidence on the methods and criteria of selection of articles is presented in the guideline. However, the “Grading of recommendations” section suggests that the literature was analyzed giving the class of evidence (I-IV), according to EFNS guidelines. So, the recommendations section includes only the statements in levels A to C, derived from Classes I-III, when feasible. The recommendations that were based on Class IV scientific evidence were included in the text as Good Practice Points (GPP). The authors included the information into the guideline concerning benefits and risks for patients.
- Recommendations
Recommendations for approaching prevention of immunosuppresion neurotoxicity include careful management of the efficacious doses, strict monitoring of some indicators (e.g., plasma levels, electrolyte imbalance), as well as using the guidelines that are developed for preventing and managing the disorder in the general population of patients. Seizure prevention requires monitoring of metabolic parameters and immunosuppressant levels. Some recommendations on the drugs that need to be used are included. The recommendations in CPM case concern careful management of variations in serum sodium concentration. Prevention of neuromuscular disorders contains caution during catheterization and avoiding blinded cannulation and external compressions by blood pressure cuffs or tourniquets. Prevention of cerebrovascular disorders includes correction of coagulopathy before surgery, avoiding cerebral hyperinfusion and control of cerebrovascular risks after liver transplantation (e.g., hypertension). CNS prevention is based on early in-depth diagnostic approach that includes exhaustive search for latent infection both in donor and recipient. The recommendations for treating neurolisteriosis, brain aspergillosis and cryptococcal meningitis are included.
Nursing has an extremely important role of implementation of the recommendations at different stages of treatment. Before surgery, nurses may help conduct necessary diagnostic procedures. In terms of the operation nurses control particular parameters and assist the persons, who conduct surgery. Finally, nurses take care of the patients, who have undergone liver transplantations in hospital settings on the daily basis. Both for physicians (neurologists) and nurses it is important to understand that management of neurological diseases in patients, who have undergone liver transplantation, is different from managing these issues in the general population of patients as specific surgery-related issues need to be taken into account.
Implementation of the recommendations may require additional diagnostic equipment and medicines, as well as additional involvement of neurologists in preparing the patient for liver transplantation and post-surgery care of patients.
- Application
Potential barriers of recommendations’ implementation are determined by the costs of their implementation. The need for additional equipment, medicine and involving neurologists into the process of preparing patients to transplantation and post-surgery care is likely to significantly increase the costs of liver transplantation and related care. Other barriers may be concerned with the lack of neurologists, who are fully aware of the differences between treating the general population of the patients and those, whose neurological concerns stem from liver transplantation issues. It can be hard to conduct the changes at hospitals in different regions of the country simultaneously. The assessment of the initiative’s success can be conducted with the help of such criteria as morbidity, mortality and the duration of hospital stays of the patients, who had undergone liver transplantation. Attention needs to be focused on conditions that emerge in the first six months after surgery.
References
Guarino, M., Benito-Leon, J., Decruyenare, J., Schmutzhard, E., Wissenborn, K., Stracciari, A. (2011). Neurological problems in liver transplantation. European Handbook of Neurological management, 1, pp.491-499
Stracciari A , Guarino M .(2001). Neuropsychiatric complications of liver transplantation. Metabolic Brain Diseases, 16, pp. 3 – 11 .
