Perioperative care in acute liver failure: An anaesthesiologist perspective in the operating theatre.

Acute liver failure (ALF) is a life-threatening condition characterized by rapid liver function deterioration, necessitating a multidisciplinary approach for optimal perioperative care. This comprehensive review focuses on the critical role of the anaesthesiologist throughout the preoperative, intraoperative, and postoperative phases, addressing the unique challenges posed by ALF. The article begins with an exploration of ALF, underlining the urgency of timely referral to specialized hepatology centres. Liver transplantation emerges as a life-saving intervention, and the complex decision-making process is discussed, emphasizing the need for a multidisciplinary team to assess transplantation candidacy based on established prognostic criteria. In the preoperative phase, the review stresses the importance of early engagement with tertiary liver centres for timely referrals and identifies patients suitable for transplantation. Safe transport protocols are detailed, highlighting the meticulous planning required for the secure transfer of ALF patients between healthcare facilities. The intraoperative management section delves into the anaesthesiologist's key concerns, including neurological status, sepsis, acute kidney injury, body mass index, and preoperative fasting. Hemodynamic stability, fluid management, and coagulation balance during surgery are emphasized, with insights into anaesthesia techniques, vascular access, monitoring, and hemodynamic management tailored to the challenges posed by ALF patients. The postoperative care is thoroughly examined covering neurological, hemodynamic, metabolic, renal, and nutritional aspects. Management of ALF involves multidisciplinary team, including nephrology for continuous renal replacement therapy, transfusion medicine for plasma exchange, critical care for overall patient care, nutritionists for ensuring adequate nutrition, and hepatologists as the primary guides. In conclusion, the review recognizes the anaesthesiologist as a linchpin in the perioperative care of ALF patients. The integration of safe transport protocols and multidisciplinary approach is deemed crucial for navigating complexities of ALF, contributing to improved patient outcomes. This article serves as an invaluable resource for gastroenterologist and intensivists, enhancing their understanding of the anaesthesiologist's indispensable role in the holistic care of ALF patients in an ever-evolving healthcare landscape.

Pediatric Renal Transplant With Dilated Cardiomyopathy: A Stepwise Hemodynamic Management-A Case Report.

Here we have described the anesthetic management of a 10-year-old patient having uremia-induced dilated cardiomyopathy for a living-related adult to pediatric renal transplant. Maintaining optimal hemodynamics, especially during the reperfusion phase, is crucial for maintaining graft perfusion. However, dilated cardiomyopathy limits indiscriminate fluid administration as it may cause congestive heart failure and pulmonary edema. We have described the fluid therapy algorithm based on the plethysmography variability index and velocity time integral at the left ventricular outflow tract, which was able to limit excessive fluid administration and maintain adequate perfusion pressures.

Anaesthesia Challenges in a Neonate Having Supracardiac Total Anomalous Pulmonary Venous Return With Incidental Stridor for Non-operating Room Anaesthesia (NORA): Feed and Wrap Technique as a Rescue.

This case represents anaesthetic challenges while managing a neonate having a congenital cardiac anomaly with incidental stridor for the non-operating room anaesthesia (NORA). Anaesthesia management of neonates is demanding even for experienced anaesthetists in terms of vascular access, airway management, relatively poor respiratory reservoir and transitional cardiac physiology. Neonate having cyanotic congenital heart disease with abnormal cardiac physiology demands further attention. In children with congenital heart disease, difficult intubation remains a possibility as they are more often associated with airway anomalies. NORA has its own set of anaesthesia challenges related to a lack of adequate anaesthesia equipment and monitoring devices, a limited and unfamiliar workspace, lack of trained support staff along with more medically complex patients. Recently there has been concern regarding the safety of anaesthetic agents in children < 3 years. So, techniques are being developed to promote immobilisation without using anaesthesia in short procedures. One such technique is the "feed and wrap" technique where feeding and swaddling induce natural sleep in infants. Here, we have used the "feed and wrap technique" in a 24-day-old neonate having supracardiac total anomalous pulmonary venous return with incidental stridor posted for contrast-enhanced computed tomography angiography.

Normal Saline Versus Balanced Crystalloids in Renal Transplant Surgery: A Double-Blind Randomized Controlled Study.

Background The importance of optimal acid-base balance during renal transplant surgeries cannot be stressed enough. Optimal preload and electrolyte balance is important in maintaining this. There has been a debate on the choice of perioperative crystalloids in renal transplant surgeries over the past decades. Normal saline (0.9% saline) is more likely to cause hyperchloremic acidosis when compared to balanced salt solutions (BSS) with low chloride content whereas BSS may cause hyperkalemia. We aim to compare the safety and efficacy of normal saline (NS), Ringer's lactate (RL) and Plasmalyte (PL) on acid-base balance and electrolytes during living donor kidney transplantation. Materials and methods Patients were randomized to NS group (n = 60), RL group (n = 60) and Plasmalyte group (n = 60). Arterial blood samples were collected for acid-base analysis after induction of anaesthesia (T0), prior to clamping the iliac vein (T1), 10 minutes after reperfusion of the donated kidney (T2) and at the end of surgery (T3). In addition, serum creatinine and 24-hour urine output were recorded on postoperative days one, two and seven. Results There was a statistically significant difference (p < 0.001) in the pH at the end of surgery between the three groups with the NS group being more acidotic (pH 7.29 ± 0.06, 95% CI 7.27-7.32), although this was not clinically relevant. This was explainable by the parallel increase in chloride in the NS group. Early postoperative graft functions in terms of serum creatinine, urine output and graft failure requiring dialysis were not significantly different between the groups. Conclusion Balanced salt solutions such as Plasmalyte and Ringer's lactate are associated with better pH and chloride levels compared to normal saline when used intraoperatively in renal transplant patients. This difference, however, does not appear to have any bearing on graft function. Plasmalyte seems to maintain a better acid-base and electrolyte balance, especially during the postreperfusion period.

Efficacy of dexmedetomidine as an adjunct to ropivacaine in transversus abdominis plane block for paediatric laparoscopic surgeries: A double-blinded randomised trial.

BACKGROUND AND AIMS: α2 agonists have been utilised in regional blocks, but very little data is available for their use in transversus abdominis plane (TAP) block in paediatric laparoscopic (LAP) surgeries. This study investigated the analgesic effect of ropivacaine alone versus its combination with dexmedetomidine for TAP block in children undergoing LAP surgery. METHODS: A randomised, double-blind trial was conducted in 50 American Society of Anesthesiologists (ASA) 1 and 2 children of 2-8 years undergoing LAP abdominal surgery. Children were randomised to receive a total volume of 0.5 ml/kg of 0.2% ropivacaine (LA group) or 0.2% ropivacaine with 1 µg/kg dexmedetomidine (LAD group) for performing ultrasound-guided bilateral TAP block postoperatively (PO). Patients were monitored PO for vital signs, pain, sedation, time to first rescue analgesic and total analgesic consumption for 24 h. Time to first rescue analgesic was expressed as mean ± standard deviation (SD) and analysed using Kaplan-Meier survival analysis. Pain and sedation scores were expressed as median [interquartile range (IQR)] and analysed using Mann-Whitney U test. RESULTS: First rescue analgesic demand was significantly longer (P = 0.001) in LAD (474.8 min) versus LA group (240.9 min) but total analgesics consumption in first 24 h was comparable. Pain scores were significantly lower (P < 0.05) in LAD compared to LA group at all times PO. Each group had comparable but significantly lower sedation scores up to 24 h PO. CONCLUSION: Addition of dexmedetomidine to ropivacaine in TAP block prolongs the time to first analgesic requirement without a difference in the total analgesic consumption.