An evaluation of the safety and preliminary efficacy of peri- and post-operative treprostinil in preventing ischemia and reperfusion injury in adult orthotopic liver transplant recipients.

BACKGROUND: Orthotopic liver transplantation (OLT) is the only treatment option for various end-stage liver diseases. Ischemia and reperfusion (I/R) injury is one of the unavoidable complications/conditions in OLT. In 2019, a total of 8896 livers were transplanted of which >94% organs were procured from deceased donors. An increase in the use of extended criteria donor (ECD) livers for transplantation further unraveled the role of hepatic I/R injury on short-term and long-term graft outcomes. Despite promising outcomes with the use of antioxidants, free radical scavengers, and vasodilators; I/R-mediated liver injury persists and significantly influences the overall clinical outcomes. Treprostinil, a synthetic prostacyclin I2  (PGI2 ) analog, due to its vasodilatory property, antiplatelet activity, and its ability to downregulate pro-inflammatory cytokines can potentially minimize I/R injury. AIM: We investigated the safety and preliminary efficacy of continuous intravenous infusion of treprostinil in liver transplant recipients in a prospective, single-center, non-randomized, interventional study. MATERIAL AND METHODS: This was a dose escalation (3 + 3 design) phase 1/2 study. Deceased donor liver transplant recipients received 5 ng/kg/min for two days, or 2.5, 5, and 7.5 ng/min/kg for 5 days as a continuous infusion. Multiple blood samples were collected for biochemical parameter assessment and for measuring treprostinil levels. Indocyanine green plasma disappearance rate was used as a measure of hepatic functional capacity. RESULTS: Subjects tolerated continuous infusion of treprostinil up to 5 ng/kg/min for 120 h with no occurrence of primary graft non-function (PNF), minimized need for ventilation support, reduced hospitalization time, 100% graft and patient survival, and improved hepatobiliary excretory function comparable to normal healthy adults. DISCUSSION: Treprostinil can be administered to liver transplant patients safely during the perioperative period. CONCLUSION: Based on this phase 1/2 study, further efficacy studies of treprostinil in preventing I/R injury of liver should be conducted to potentially increase the number of livers available for transplantation.

Blood product utilization in human upper-extremity transplantation: challenges, complications, considerations, and transfusion protocol conception.

BACKGROUND: Upper-extremity transplantation (UET) is a reality. Immunologic, functional, and graft survival outcomes have been encouraging. However, these complex reconstructions have unique considerations that pose distinct challenges. Transplant programs have reported morbidity and mortality due to significant intraoperative blood losses, but similar data are scant during other phases of recovery. We report experience from two centers on complete blood component demands and utilization with UET. STUDY DESIGN AND METHODS: Inpatient medical records of UET recipients from intraoperative (time from initiation of transplant surgery to exit from the operative suite) and postoperative (exit from the operative suite to discharge from the hospital) phases were retrospectively reviewed. RESULTS: Six patients received various UETs and mean (±SD) postoperative hospital stay was 46 (±14.4) days. Mean (±SD) intraoperative blood unit utilization was 14.8 (±10.2) red blood cells (RBCs), 10.5 (±11.8) plasma, 0.8 (±1.2) platelets (PLTs), and 0.3 (±0.8) cryoprecipitate units. Mean postoperative blood unit utilization was 9.3 (±10.4) RBCs, 5.3 (±6.7) plasma, 1.2 (±2.0) PLTs, and 0.7 (±1.6) cryoprecipitate units. Both intraoperative and postoperative blood utilization for unilateral versus bilateral transplant were different, but not significantly so. However, total inpatient blood use in bilateral transplants was significantly greater than in unilateral transplants. CONCLUSION: Substantial blood loss may occur in UET and require transfusion of many blood components, primarily RBCs and plasma. We propose an UET transfusion protocol and suggest that centers preparing to perform these transplants should actively engage the transfusion medicine service to ensure availability and access to appropriate blood components for the entire hospitalizations of these unique patients.

Reduced Requirement for Prothrombin Complex Concentrate for the Restoration of Thrombin Generation in Plasma From Liver Transplant Recipients.

BACKGROUND: Plasma transfusion remains the mainstay hemostatic therapy during liver transplantation (LT) in most countries. However, a large volume is required for plasma to achieve clinically relevant factor increases. Prothrombin complex concentrate (PCC) is a low-volume alternative to plasma in warfarin reversal, but its efficacy has not been well studied in LT. METHODS: Blood samples were collected from 28 LT patients at baseline (T0) and 30 minutes after graft reperfusion (T1). Factor X and antithrombin levels were measured. Ex vivo effects of PCC (0.2 and 0.4 IU/mL) and 10% volume replacement with normal plasma were compared in LT and warfarin plasma by measuring lag time, thrombin peak, and endogenous thrombin potential (ETP) using thrombin generation (TG) assay. RESULTS: Coagulation status was worsened at T1 as international normalized ratio increased from 1.7 to 3.0, and factor X was decreased from 49% to 28%. TG measurements showed normal lag time and ETP at T0 and T1, but low-normal peak at T0, and below-normal peak at T1. Both doses of PCC increased peak and ETP, while 10% volume plasma had minimal effects on TG. Thrombin inhibition appears to be very slow after adding 0.4 IU/mL of PCC in LT plasma due to low antithrombin. The same doses of PCC and plasma were insufficient for warfarin reversal. CONCLUSIONS: Reduced TG in LT can be more effectively restored by using PCC rather than plasma. The required doses of PCC for LT patients seem to be lower than warfarin reversal due to slow thrombin inhibition.

Ex vivo evaluation of 4 different viscoelastic assays for detecting moderate to severe coagulopathy during liver transplantation.

Prolonged prothrombin time (PT) and its ratio are routinely used for the assessment of candidates for liver transplantation (LT), but intraoperative coagulation management of transfusion is hindered by its long turnaround time. Abnormal reaction time (R time) on thromboelastography (TEG) or clotting time (CT) of rotational thromboelastometry (ROTEM) are presumably an alternative, but there is a paucity of clinical data on abnormal R time/CT values compared to PT during LT. After receiving institutional review board approval and informed consent, we obtained blood samples from 36 LT patients for international normalized ratio (INR), factor (F) X level, and viscoelastic tests (EXTEM/INTEM and kaolin/rapid TEG) at baseline and 30 minutes after graft reperfusion. Receiver operating characteristic (ROC) curves were calculated for INR > 1.5 and viscoelastic R time/CT thresholds to assess the ability to diagnose FX deficiency at the moderate (<50%) or severe (<35%) level. The FX deficiency data were calculated using cutoff values of INR (>1.5) and abnormal R time/CT for TEG and ROTEM. Tissue factor (TF)-activated INR and EXTEM-CT performed well in diagnosing FX below 50%, but rapid TEG with combined TF and kaolin activators failed. Improved performance of INTEM-CT in diagnosing FX below 35% underlies multifactorial deficiency involving both intrinsic and common pathways. In conclusion, the differences among different viscoelastic tests and clinical situations should be carefully considered when they are used to guide transfusion during LT.

Clinical applicability of rapid thrombelastography and functional fibrinogen thrombelastography to adult liver transplantation.

Unlike kaolin thrombelastography (k-TEG), the clinical utility of rapid thrombelastography (r-TEG) and functional fibrinogen thrombelastography (FF-TEG) has not been tested in liver transplantation (LT). These thrombelastography techniques were simultaneously performed at the time of the skin incision (the baseline) and 30 minutes after graft reperfusion (III + 30) for 27 consecutive adult LT patients. k-TEG and r-TEG parameters [alpha angle (α) and maximum amplitude of the clot (MA)] were compared in addition to the assay time. Estimated FF-TEG fibrinogen levels were compared with plasma fibrinogen measurements. At the baseline, the values of Spearman's correlation coefficient (r) between k-TEG and r-TEG were moderate for α (r = 0.40, P = 0.06) and strong for MA (r = 0.90, P < 0.01). At III + 30, r was 0.46 (P < 0.05) for α and 0.80 (P < 0.01) for MA. The average time required to measure MA via r-TEG was decreased in comparison with k-TEG [from 29.7 to 21.6 minutes at the baseline (a 22% reduction) and from 29.6 to 22.9 minutes at III + 30 (a 23% reduction)]. FF-TEG correlated strongly with the plasma fibrinogen level at the baseline (r = 0.90, P < 0.01); however, FF-TEG overestimated the fibrinogen level at III + 30 (r = 0.58, P = 0.01). In conclusion, in adult LT, r-TEG correlates with k-TEG strongly for MA but only moderately for α. FF-TEG estimates the plasma fibrinogen level well at the baseline; however, it must be interpreted with caution because of its overestimation after graft reperfusion when the plasma fibrinogen level often decreases to less than 100 mg/dL.

Cardiac arrest during adult liver transplantation: a single institution's experience with 1238 deceased donor transplants.

Liver transplantation (LT) is one of the highest risk noncardiac surgeries. We reviewed the incidence, etiologies, and outcomes of intraoperative cardiac arrest (ICA) during LT. Adult cadaveric LT recipients from January 1, 2001 through December 31, 2009 were reviewed. ICA was defined as an event requiring either closed chest compression or open cardiac massage. Cardiac arrest patients who recovered with only pharmacological interventions were excluded. Data included etiologies and outcomes of ICA, intraoperative deaths (IDs) and hospital deaths (HDs), and potential ICA risk factors. ICA occurred in 68 of 1238 LT recipients (5.5%). It occurred most frequently during the neohepatic phase (60 cases or 90%), and 39 of these cases (65.0%) experienced ICA within 5 minutes after graft reperfusion. The causes of ICA included postreperfusion syndrome (PRS; 26 cases or 38.2%) and pulmonary thromboembolism (PTE; 24 cases or 35.3%). A higher Model for End-Stage Liver Disease (MELD) score was found to be the most significant risk factor for ICA. The ID rate after ICA was 29.4% (20 cases), and the HD rate was 50.0% (34 cases). The 30-day patient survival rate after ICA was 55.9%, and the 1-year survival rate was 45.6%: these rates were significantly lower (P < 0.001) than those for non-ICA patients (97.4% and 85.1%, respectively). In conclusion, the incidence of ICA in adult cadaveric LT was 5.5% with an intraoperative mortality rate of 29.4%. ICA most frequently occurred within 5 minutes after reperfusion and resulted mainly from PRS and PTE. A higher MELD score was identified as a risk factor.

Complications related to invasive hemodynamic monitors during adult liver transplantation.

The rate of complications directly related to invasive monitors during liver transplantation (LT) was reviewed in 1206 consecutive adult LTs performed over 8.6 yr (1/1/2004-7/31/2012). The designated anesthesiologists placed intra-operative monitors, including two arterial catheters (via the radial and the right femoral arteries), central venous catheters (a 9 Fr. catheter and an 18 Fr. veno-venous bypass [VVB] return cannula in an internal jugular vein), a pulmonary artery catheter, and a transesophageal echocardiography (TEE) probe. A 17 Fr. VVB drainage cannula was placed via the left femoral vein. No Clavien-Dindo Grade V (death) or Grade IV (organ dysfunction) complication was identified. Nine Grade III complications (requiring surgical intervention) and 15 Grade II complications (conservative treatment) were noted. Seven (0.58% in 1206 cases) were related to a femoral arterial line with Grade III of four; seven (0.58%) were due to VVB return cannula in the femoral vein with Grade III of one; four (0.33%) were related to central venous catheters with Grade III of two; four (0.33%) were due to a TEE probe with Grade III of two; and two minor complications (0.17%) that were related to a radial arterial line. No complication was observed with a pulmonary arterial catheter. Current invasive monitors placed during LT have an acceptable risk.

Simulation: a teaching tool for liver transplantation anesthesiology.

Anesthesia for liver transplantation (ALT) requires extensive preparation and rapid recognition of changing clinical conditions. Owing to the proliferation of transplant centers, greater number of anesthesia providers need training in specific skills required to treat these patients. These cases are no longer limited to few transplant centers; therefore, reduction of cases in individual centers has created a need for simulation training to prepare and supplement clinical experience. We have developed an ALT simulation course for senior anesthesia residents which combines didactic sessions with live-patient-based and mannequin-based simulation. Outcomes have been measured using pre- and post-simulation course quizzes as well as a survey given at the end of the month-long ALT rotation. Twenty-four senior anesthesiology residents (n = 24) have completed the ALT simulation course. Residents had an average score of 75% ± 10% on the pre-simulation quiz, which increased to 92% ± 6.5% on the post-simulation quiz (p < 0.001). Furthermore, survey scores indicated that residents noted that the course provided an improvement in their preparedness, confidence, anticipation, and understanding of the importance of communication skills in the care of this patient population. The ALT simulation course provided a standardized in-depth exposure to clinical issues involved in the perioperative care of liver transplant patients.

Anesthetic management in upper extremity transplantation: the Pittsburgh experience.

BACKGROUND: Hand/forearm/arm transplants are vascularized composite allografts, which, unlike solid organs, are composed of multiple tissues including skin, muscle, tendons, vessels, nerves, lymph nodes, bone, and bone marrow. Over the past decade, 26 upper extremity transplantations were performed in the United States. The University of Pittsburgh Medical Center has the largest single center experience with 8 hand/forearm transplantations performed in 5 recipients between January 2008 and September 2010. Anesthetic management in the emerging field of upper extremity transplants must address protocol and procedure-specific considerations related to the role of regional blocks, effects of immunosuppressive drugs during transplant surgery, fluid and hemodynamic management in the microsurgical setting, and rigorous intraoperative monitoring during these often protracted procedures. METHODS: For the first time, we outline salient aspects of upper extremity transplant anesthesia based on our experience with 5 patients. We highlight the importance of minimizing intraoperative vasopressors and improving fluid management and blood product use. RESULTS: Our approach reduced the incidence of perioperative bleeding requiring re-exploration or hemostasis and shortened in-hospital and intensive care unit stay. Functional, immunologic and graft survival outcomes have been highly encouraging in all patients. CONCLUSIONS: Further experience is required for validation or standardization of specific anesthetic protocols. Meanwhile, our recommendations are intended as pertinent guidelines for centers performing these novel procedures.

Auricular field nerve stimulation using the NSS-2 BRIDGE® device as an alternative to opioids following kidney donor surgery.

OBJECTIVES: The purpose of this study was to investigate the role that the NSS-2 BRIDGE® device, an auricular field nerve stimulator, may play in reducing opioid requirement and pain in kidney donor surgery. It was not a randomized study. Electrophysiologic studies have demonstrated that the stimulation of the cranial nerves produced by the NSS-2 BRIDGE® device modulates the ascending/descending spinal pain pathways, especially at the level of the limbic system. METHODS: The design compared the effects of the NSS-2 BRIDGE® device (NSS 2-BRIDGE® device group; n=10) to a control group (n=10). In both groups, the surgery was performed using the same standard enhanced recovery after surgery protocol based on the use of a multimodal analgesic approach. For the active treatment group, the NSS-2 BRIDGE® device was placed in the post anesthesia care unit. The primary endpoint was opioid requirement (oral morphine equivalent, OME in mg) at 24 h post-surgery. Secondary endpoints included pain (0-10), at 24 and 48 h, time to discharge from the recovery room, incidence of post-operative nausea and vomiting at 24 h, time to oral intake, time to ambulation, and time to discharge from the hospital. Data was analyzed using unpaired t-test and presented as mean ± standard deviation. RESULTS: Compared to control, the use of the NSS-2 BRIDGE® was associated with a 75.4% reduction in OME (33.6 vs. 8.3 mg; p=0.03) and 41.5% reduction in pain (5 vs. 3.28; p=0.06) at 24 h and a 73.3% difference in pain at 48 h (1.6 ± 1.6 vs. 6.0 ± 2.8; p=0.0004). There was no difference in non-opioid analgesics administration between groups. CONCLUSIONS: The tolerability of NSS-2 BRIDGE® device was reported by most to be excellent. This study suggests that the NSS-2 BRIDGE® device may represent a complementary approach for controlling postoperative opioid consumption and pain in patients undergoing kidney donation.

Portopulmonary hypertension as an indication for combined heart, lung, and liver or lung and liver transplantation: literature review and case presentation.

End-stage liver disease with severe portopulmonary hypertension (PPHTN), which is refractory to vasodilator therapies, is a contraindication for isolated liver transplantation (LT) because of the high mortality rate. Combined heart, lung, and liver transplantation (CHLLT) and combined lung and liver transplantation (CLLT) can be lifesaving options for these patients; however, these procedures have rarely been performed. A 52-year-old man had end-stage liver disease due to hepatitis C and PPHTN; the latter showed a suboptimal response to pulmonary vasodilator therapy with continuous intravenous treprostinil sodium and oral sildenafil citrate and was considered a contraindication to isolated LT. His preoperative left ventricular function was normal, and he had mild to moderate right ventricular dysfunction. He underwent CLLT, which consisted of sequential double-lung transplantation under cardiopulmonary bypass followed by standard LT under venovenous bypass. Re-exploration of the chest cavity was necessary because of bleeding, and respiratory failure developed; however, the patient recovered, was discharged home on day 26, and remained well 1 year after CLLT with the standard immunosuppressants (similar to those used for heart and lung transplantation). For PPHTN, combined thoracic organ and liver transplantation has been reported in only 10 patients. Six of these patients, including our case, underwent CLLT, whereas 4 patients underwent CHLLT. Notably, 2 of the 6 CLLT patients expired within 24 hours of transplantation because of acute right heart failure. CHLLT should be considered for patients with refractory PPHTN. The assessment of preoperative cardiac function is a vital part of the decision to include heart transplantation in CLLT.

Persistent Left Superior Vena Cava-When a Left-Sided Central Line Does Not Make the Turn: A Case Report.

A 59-year-old male presenting for a living nonrelated kidney transplant has an intraoperative left internal jugular central venous catheter placed for operative access and monitoring. Post-anesthesia care unit postoperative chest X-ray shows possible aortic placement as read by radiology. The catheter is confirmed venous on insertion, with monitoring during the operation, and with repeat transduction and venous blood gas results postoperatively. A follow-up computed tomography scan shows findings consistent with persistent left superior vena cava. This can be associated with other cardiac abnormalities and an increased risk of complications, both mechanical and physiological. Care should be taken in patients identified with persistent left superior vena cava to prevent complications in future procedures.

Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists.

BACKGROUND: Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients. METHODS: Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence. RESULTS: Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status. CONCLUSIONS: These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.

N-acetylcysteine does not prevent hepatorenal ischaemia-reperfusion injury in patients undergoing orthotopic liver transplantation.

BACKGROUND: Glutathione (GSH) acts as a free radical scavenger that may be helpful in preventing reperfusion injury. N-acetylcysteine (NAC) replenishes GSH stores. The aims of this study were to evaluate the efficacy of NAC in improving liver graft performance and reducing the incidence of post-operative acute kidney injury (AKI). METHODS: Our study was a randomized, double-blind, placebo-controlled trial of 100 patients; 50 received placebo and 50 received a loading dose of 140 mg/kg of intravenous (IV) NAC over 1 h followed by 70 mg/kg IV repeated every 4 h for a total of 12 doses. Both groups were followed up for 1 year post-orthotopic liver transplant (OLT). We recorded liver function tests, renal function tests, graft survival, patient survival, plasma GSH and duration of hospital and ICU stay. In addition to serum creatinine (SCr) levels, we analysed cystatin C and beta-trace as independent measures of glomerular filtration. All clinical data were recorded daily for the first week after the surgery, then on Days 14, 21, 30, 90 and 180 and at the end of the first year. RESULTS: IV NAC did not affect survival, graft function or risk of AKI. However, GSH levels were highly variable with only 50% of patients receiving NAC exhibiting increased levels and fewer patients developed AKI when GSH levels were increased. Additional risk factors for AKI in the post-transplant period were female gender (P = 0.05), increased baseline serum bilirubin (P = 0.004) and increased baseline SCr levels (P = 0.02). CONCLUSIONS: IV NAC was not effective in reducing renal or hepatic injury in the setting of liver transplantation. The dose and duration of NAC used, though higher than most renal protection studies, may have been ineffective for raising GSH levels in some patients.

Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists.

Surgical advances using the retrohepatic caval preservation technique in liver transplantation (LT) has significantly decreased the need for veno-venous bypass (VVB). However, VVB still remains a viable adjunct of LT. The venous return cannula has traditionally been inserted using a cut-down technique via the axillary vein, but this technique carries significant risks for lymphorrhea, infection, or nerve damage. Since 2001, our institution has routinely used VVB in adult LT surgery. Percutaneous insertion of an internal jugular venous return cannula is performed by the attending anesthesiologist. The aim of this report is to describe the method of insertion and management of a percutaneous veno-venous return cannula in the internal jugular vein during LT. In-depth detail as well as video clips will provide a reference for LT centers wishing to apply this method in their practice.

Comparison of surgical methods in liver transplantation: retrohepatic caval resection with venovenous bypass (VVB) versus piggyback (PB) with VVB versus PB without VVB.

Use of piggyback technique (PB) and elimination of venovenous bypass (VVB) have been advocated in adult liver transplantation (LT). However, individual contribution of these two modifications on clinical outcomes has not been fully investigated. We performed a retrospective review of 426 LTs within a 3-year period, when three different surgical techniques were employed per the surgeons' preference: retrohepatic caval resection with VVB (RCR+VVB) in 104 patients, PB with VVB (PB+VVB) in 148, and PB without VVB (PB-Only) in 174. The primary outcomes were intraoperative blood transfusion and the patient and graft survivals. Demographic profiles were similar, except younger recipient age in RCR+VVB and fewer number of grafts with cold ischemic time over 16 h in PB-Only. PB-Only required lesser intraoperative red blood cells (P=0.006), fresh frozen plasma (P=0.005), and cell saver return (P=0.007); had less incidence of acute renal failure (P=0.001), better patient survival (P=0.039), and graft survival (P=0.003). The benefits of PB+VVB were only found in shortened total surgical time (P=0.0001) and warm ischemic time (P=0.0001), and less incidence of acute renal failure (P=0.001) than RCR+VVB. PB-Only method seemed to provide the best clinical outcome. The benefit of PB was not fully achieved when it was used with VVB.

The impact of postreperfusion syndrome on short-term patient and liver allograft outcome in patients undergoing orthotopic liver transplantation.

The greatest part of liver allograft injury occurs during reperfusion, not during the cold ischemia phase. The aim of this study, therefore, was to investigate how the severity of postreperfusion syndrome (PRS) influences short-term outcome for the patient and for the liver allograft. Over a 2-year period, 338 consecutive patients who presented for orthotopic liver transplantation (OLT) were included in this retrospective study. They were divided into 2 groups according to the severity of the PRS they experienced. The first group comprised 152 patients with mild or no PRS; the second group comprised 186 patients with significant PRS. Perioperative hemodynamic parameters, coagulation profiles, blood product requirements, incidence of infection, incidence of rejection and outcome data for both groups were collected and analyzed. There was no demographic difference between the groups except for age; group 2 had older patients than group 1 (54.94 +/- 9.07 versus 51.52 +/- 9.91, P = 0.001). Compared to group 1, group 2 patients required more red blood cell transfusions (11.31 +/- 10.90 versus 8.08 +/- 7.89 units, P = 0.002), more fresh frozen plasma transfusions (10.25 +/- 10.96 versus 7.03 +/- 7.64 units, P = 0.002), more cryoprecipitate (1.88 +/- 4.72 units versus 0.61 +/- 1.80 units, P = 0.001), and were more likely to suffer from fibrinolysis (52.7% versus 41.4%, P = 0.041). Interestingly, group 2 had a shorter average warm ischemia time than group 1 (33.19 +/- 8.55 versus 36.21 +/- 11.83 minutes, P = 0.01). Group 2 also required longer, on average, mechanical ventilation (14.95 +/- 29.79 versus 8.55 +/- 17.79 days, P = 0.015), remained in the intensive care unit longer (17.65 +/- 31.00 versus 11.49 +/- 18.67 days, P = 0.025), and had a longer hospital stay (27.29 +/- 32.35 versus 20.85 +/- 21.08 days, P = 0.029). Group 2 was more likely to require retransplantation (8.6% versus 3.3%, P = 0.044). In conclusion, the severity of PRS during OLT appears to be related to the outcome of patient and liver allograft.

Recent update on coagulation management and hemostatic therapies in liver transplantation.

Liver transplantation is an ever-evolving field and understanding coagulation management and hemostatic therapies is essential for good outcomes. In this review, we discuss current monitoring tools available in the operating room and the hemostatic agents available to control hemostasis. Multifactorial coagulation defects are discussed and point-of care monitoring is reviewed to guide selection of hemostatic agents when indicated.

Anesthesia and Perioperative Care in Reconstructive Transplantation.

Reconstructive transplantation of vascularized composite allografts (VCAs), such as upper extremity, craniofacial, abdominal, lower extremity, or genitourinary transplants, has emerged as a cutting-edge specialty, with more than 50 programs in the United States and 30 programs across the world performing these procedures. Most VCAs involve complicated technical planning and preparation, protracted surgery, and complex immunosuppressive or immunomodulatory protocols, each associated with unique anesthesiology challenges. This article outlines key procedural, patient, and protocol-related aspects of VCA relevant to anesthesiology management with the goal of ensuring patient safety and optimizing surgical, immunologic, and functional outcomes.

The incidence and outcome of perioperative pulmonary aspiration in a university hospital: a 4-year retrospective analysis.

We evaluated the current incidence and outcome of perioperative pulmonary aspiration (PPA) in the nonobstetric adult population at a tertiary university medical center. A 4-yr retrospective analysis (January 2001-December 2004) was conducted using both quality improvement data and the hospital-wide medical archive recording system. PPA was defined as either detection of nonrespiratory secretions from the tracheobronchial tree or development of new pulmonary symptoms and/or new abnormalities in chest radiographs within 24 hr postoperatively. Of 99,441 anesthetics, 14 cases had confirmed PPA. Seven of them (50%) occurred in connection with gastroesophageal procedures. All patients had one or more predisposing risk factors for PPA. PPA occurred under general anesthesia in 10 patients and under monitored anesthesia care in 4 patients. In general anesthesia cases, the aspiration was recognized immediately after induction in 5 patients and occurred during changing of the endotracheal tubes in 5. The PPA was detected during the surgical procedures in all the monitored anesthesia care cases. Six patients with confirmed PPA developed pulmonary complications, of which, one died. Ten of 14 (70%) cases of PPA were the result of improper anesthesia technique. The current incidence of PPA is 1 of 7103, with morbidity 1 of 16,573 and mortality 1 of 99,441.