Association Between Single-Injection Regional Analgesia and Postoperative Pain in Cardiac Surgery Patients: A Single-Center Retrospective Cohort Study.

OBJECTIVES: Effective pain control after cardiac surgery may facilitate recovery. This study aimed to assess the use and association of ultrasound-guided single-injection chest wall blocks with liposomal bupivacaine on postoperative pain scores and short-term opioid requirements after cardiothoracic surgery at a single institution. DESIGN: Retrospective cohort study. SETTING: Midwestern academic hospital. PARTICIPANTS: Adult patients who underwent cardiothoracic surgery between July 1, 2020, and June 30, 2022. INTERVENTIONS: Ultrasound-guided single-injection chest wall block with liposomal bupivacaine. MEASUREMENTS AND MAIN RESULTS: Of the 1,038 patients included in this study, 301 (29%) received a perioperative nerve block for postoperative sternotomy pain, and 737 (71%) did not. Most of the single-shot blocks were bilateral parasternal intercostal plane blocks (n = 294 [98%]) performed after induction and before surgical incision (n = 280 [93%]). After adjusting for age, gender, American Society of Anesthesiologists status, select comorbidities, and surgical procedure type, mean postoperative pain scores were not significantly different between groups in the immediate postoperative period at all time points assessed (12 ± 2 hours, 24 ± 4 hours, 48 ± 8 hours, and 72 ± 12 hours). Similarly, there was no difference in mean opioid requirements (milligram morphine equivalents) at 72 hours between groups (68.6 [95% confidence interval, 56.3-83.4] vs 62.9 [95% confidence interval, 52.8-74.9], p = 0.195). CONCLUSIONS: In this retrospective study, the implementation of single-shot chest wall nerve blocks with liposomal bupivacaine was not associated with decreased postoperative pain scores or opioid consumption at 72 hours in select cardiac surgical patients at one institution.

Successful lung transplantation with graft recovered after thoracoabdominal normothermic perfusion from donor after circulatory death.

Lung transplantation with lungs procured from donors after circulatory death (DCD) has been established as an alternative technique to traditional donation after brain death (DBD) with comparable outcomes. Recently, in situ thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a novel technique employed in the procurement of cardiac allografts after circulatory death. TA-NRP, in contrast to ex situ machine perfusion, has the advantage of allowing in situ assessment of donor organs prior to final acceptance. However, there are some concerns that this technique may adversely impact the quality of lung allografts. Here, we present a case of a successful bilateral sequential lung transplantation in a patient with postinflammatory pulmonary fibrosis due to acute respiratory distress syndrome (ARDS), with lungs procured after normothermic in situ lung perfusion. Apart from the lungs, heart, liver, and kidneys were also successfully transplanted from this donor.

2020 Clinical Update in Liver Transplantation.

The gold standard treatment of end-stage liver disease continues to be liver transplantation (LT). The challenges of LT require skilled anesthesiologists to anticipate physiologic changes associated with end-stage liver disease and surgical considerations that affect multiple organ systems. While on the waiting list, patients may be placed on new anticoagulation medications that can confound already complex coagulopathy in LT patients. Pain management often is an afterthought for such a complex procedure, but appropriate medications can help control pain while limiting opioid medications. Surgical stress and medications for immunosuppression can affect perioperative glucose management in ways that have implications for patient and graft survival. The coronavirus disease 2019 pandemic in 2020 provided a new challenge for anesthesiologists. The uncertainty of the novel respiratory virus challenged providers beyond just LT patients.

2019 Clinical Update in Liver Transplantation.

Liver transplantation continues be the standard for treatment of end-stage liver disease, and even with recent advances in organ preservation, the anesthetic management continues to require understanding of multiple organ systems beyond the liver. Multiple factors contribute to hemodynamic changes after reperfusion of the liver graft that anesthesiologists should be aware of before unclamping. Concomitant renal dysfunction in end-stage liver disease is not uncommon, and preparation for continuous renal replacement therapy may need to be considered in certain cases. Cardiac evaluation of liver transplantation patients with an emphasis on arrhythmias, including atrial fibrillation, can help prevent both intraoperative and postoperative complications detrimental to the patient and graft. Finally, combined liver and thoracic organ transplantations may be indicated for certain disease processes that affect multiple organs. These cases require an understanding of the surgical technique and acknowledgment that some goals of the procedures may be in direct opposition to each other.

Assessment of Resident Performance During the Cardiac Anesthesia Rotation: Application of the House Officer Clinical Assessment in Cardiac Anesthesiology.

OBJECTIVE: The assessment of clinical skills was created that evaluates House Officer performance within 13 clinical domains during the Cardiac Anesthesiology rotation to provide an assessment and evaluation process for residents while performing a cardiac anesthetic. DESIGN: A retrospective evaluation of performance assessments over a 33-month period. SETTING: University hospital-based Accreditation Council for Graduate Medical Education accredited Residency Training program. PARTICIPANTS: Anesthesiology house officers within the Department Residency Program. INTERVENTIONS: This House Officer Clinical Assessment was created and implemented as residents rotated through the cardiac anesthesia service. Scores in 13 domain-specific components from this assessment were collected after the attending-resident debrief. MEASUREMENTS AND MAIN RESULTS: Most scores were found to be sufficient to suggest competency, and the evaluation allowed for a more detailed approach to assessment and feedback. The most common aspects of the case in which the residents showed reduced performance and proficiency were the transition off cardiopulmonary bypass and the performance of the transesophageal echocardiogram. Overall, the resident survey showed a positive response to the assessment and the feedback provided during the post-examination debrief. CONCLUSION: The House Officer Clinical Assessment in Cardiac Anesthesiology allows for a more objective assessment of performance for specific portions of the case and allows for improved feedback on performance. Aspects of the evaluation tool and where residents correlate with the Anesthesiology Milestones for residency are discussed, as well as the ability to determine sufficient proficiency with knowledge and skills over the use of subjective rank to determine competency.

2018 Clinical Update in Liver Transplantation.

Liver transplantation (LT) continues to be the gold standard for treating end-stage liver disease, and challenges that are posed to the anesthesiologist during transplantation are well known. Successful liver transplantation requires knowledge, recognition, and treatment of hemodynamic and metabolic disturbances by the anesthesiologist. End-stage liver disease causes unique derangements to the clotting cascade, increasing risk both for hemorrhagic and thrombotic events. Cirrhotic cardiomyopathy may be masked for years because of low systemic vascular resistance in cirrhosis, and overt heart failure can be precipitated by LT. Surveys of high-volume transplant centers show an overall transesophageal echocardiography (TEE) use rate of 95%. Guidelines on the use of TEE in LT have mirrored safety findings in several studies and suggest TEE may be used for patients with esophageal varices if the benefit outweighs the risk. This review will cover organ system dysfunction in liver cirrhosis and the implications for liver cirrhosis patients and review recent advances in pathophysiology and treatments. In addition, the authors will highlight the concept of enhanced recovery after surgery and how it pertains to the LT patient population. Lastly, the authors review recent advances in organ preservation and optimization.

The Implementation of a Preoperative Transthoracic Echocardiography Consult Service by Anesthesiologists.

We describe a preoperative transthoracic echocardiography consult service led by anesthesiologists. The implementation process and the patient cohort are described. Preoperative transthoracic echocardiographic examinations were mostly performed in patients undergoing intermediate- or high-risk noncardiac surgery and in patients with a higher calculated mortality risk. All transthoracic echocardiographic examinations were interpreted by anesthesiologists.

The safety of transesophageal echocardiography in patients undergoing orthotopic liver transplantation.

OBJECTIVE: To evaluate the safety of transesophageal echocardiography for the evaluation and intraoperative monitoring of patients during orthotopic liver transplantation. DESIGN: Retrospective observational study. SETTING: Tertiary care, university teaching hospital. PARTICIPANTS: Patients (n = 116) who underwent intraoperative transesophageal echocardiography during liver transplantation. INTERVENTIONS: Intraoperative transesophageal echocardiography during liver transplantation. MEASUREMENTS AND MAIN RESULTS: The authors evaluated the safety of intraoperative transesophageal echocardiography in patients undergoing liver transplantation through a retrospective chart review. Complications associated with transesophageal echocardiography use were divided into minor and major complications. Out of 116 patients who underwent intraoperative transesophageal echocardiography, there was one minor and one major complication. The major complication rate was 0.86% (1/116) and the overall complication rate was 1.7% (2/116). There was no statistically significant correlation between pre-transplant sclerotherapy for treatment of varices and intraoperative transesophageal echocardiography-related gastrointestinal bleeding. Although the reported complication rate is higher than what has been quoted in the cardiac literature, intraoperative transesophageal echocardiography during liver transplantation has a low complication rate. CONCLUSIONS: Intraoperative transesophageal echocardiography is a relatively safe method of monitoring cardiac performance in liver transplant patients.

A review of 364 perioperative rescue echocardiograms: findings of an anesthesiologist-staffed perioperative echocardiography service.

OBJECTIVE: Review the findings and use of rescue echocardiography performed by the Division of Perioperative Echocardiography and its impact on patient management. DESIGN: Retrospective observational study. SETTING: Single institution, tertiary care hospital. PARTICIPANTS: Three hundred sixty-four consecutive rescue echocardiograms in the perioperative setting. INTERVENTIONS: Rescue transesophageal or rescue transthoracic echocardiography. MEASUREMENTS AND MAIN RESULTS: Of a total of 1,675 perioperative echocardiograms performed in a 28-month period, 364 (21.8%) were rescue studies. Of these, 95.9% were transesophageal and 4.1% were transthoracic. Location at time of rescue echocardiography was intraoperative (55.5%), postoperative (44.2%), and preoperative (0.3%). No single diagnosis predominated the intraoperative or postoperative environment, and the frequency of common etiologies did not allow for assumption. There was a change in management for 214 patients (59%) as the result of findings. The methods used in performing rescue echocardiography at the authors' institution are reported. CONCLUSIONS: The heterogeneity of diagnoses and the frequency with which rescue echocardiography changed management further supports the growing body of evidence that the hemodynamically unstable perioperative patient benefits from its use.

Considerations for the use of porcine organ donation models in preclinical organ donor intervention research.

Use of animal models in preclinical transplant research is essential to the optimization of human allografts for clinical transplantation. Animal models of organ donation and preservation help to advance and improve technical elements of solid organ recovery and facilitate research of ischemia-reperfusion injury, organ preservation strategies, and future donor-based interventions. Important considerations include cost, public opinion regarding the conduct of animal research, translational value, and relevance of the animal model for clinical practice. We present an overview of two porcine models of organ donation: donation following brain death (DBD) and donation following circulatory death (DCD). The cardiovascular anatomy and physiology of pigs closely resembles those of humans, making this species the most appropriate for pre-clinical research. Pigs are also considered a potential source of organs for human heart and kidney xenotransplantation. It is imperative to minimize animal loss during procedures that are surgically complex. We present our experience with these models and describe in detail the use cases, procedural approach, challenges, alternatives, and limitations of each model.