RESUMEN
With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.
RESUMEN
Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field. METHODS: An institutional "FT Anesthesia Protocol" was developed and applied to 2 face transplants. A systematic review of 3 databases captured FTs in the peer-reviewed literature up to February 2020. Two reviewers independently screened titles and abstracts to include all clinical articles with FT recipient and/or donor-specific preoperative, intraoperative, and relevant postoperative anesthetic variables. Data charting guided a narrative synthesis, and quantitative synthesis reported variables as median (range). RESULTS: Our institutional experience emphasizes the importance of on-site rehearsals, anticipation of patient-specific anesthetic and resuscitative requirements, and long-term pain management. Systematic search identified 1092 unique records, and 129 met inclusion criteria. Reports of 37 FTs in the literature informed the following anesthetic axes: donor pre- and intraoperative management during facial allograft procurement, recipient perioperative care, immunotherapy, antimicrobial prophylaxis, and pain management. Quantitative synthesis of 30 articles showed a median operative time of 18 hours (range, 9-28) and fluid replacement with 13 L (5-18) of crystalloids, 13 units (0-66) of packed red blood cells, 10 units (0-63) of fresh frozen plasma, and 1 unit (0-9) of platelets. CONCLUSIONS: Anesthetic considerations in FT span the continuum of care. Future efforts should guide standard reporting to establish evidence-based strategies that promote quality improvement and patient safety.
RESUMEN
OBJECTIVES/HYPOTHESIS: Cochlear implantation (CI) is effective in the treatment of childhood sensorineural hearing loss and is associated with minimal surgical complications. We investigated the incidence of anesthetic complications in young patients undergoing general anesthesia for CI. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review of 123 patients younger than 18 years, who underwent CI between 2007 and 2008, was conducted for identification of intra- and postoperative anesthesia-related complications. The relation of collected variable to the complication events was analyzed using logistic regression. RESULTS: Of the 123 CI procedures, eight patients had nine anesthesia-related complications, yielding a complication rate of 6.5% and included the following: postoperative wheezing/stridor (5 cases), laryngospasm (3 cases), and emesis during inhalational induction (1 case). Divided by age group, 12 patients were <12 months with one complication (8%), 18 patients were between 1 and 2 years with one complication (5.6%), 35 patients were between 2 and 5 years with one complication (3%), 39 patients were between 5 and 12 years with five complications (13%), and 19 patients were older than 12 years with no complication (0%). Logistic regression failed to identify a significant association of any collected variable(s) with the observed complications. The incidence of complications is similar to that previously reported in elderly patients (4.3%) (Pearson χ(2) , P = .523). CONCLUSIONS: General anesthesia is well tolerated by pediatric patients undergoing CI, even under 1 year of age. Significant perioperative complications are primarily respiratory, are usually free of long-term sequelae, and occur with an incidence similar to other reported age groups.
