Preoperative Comorbidity and Mortality in Pediatric Liver Transplantation Recipients: A Population-Based Cohort Study.

OBJECTIVE: The purpose of this large, population-based study was to investigate preoperative comorbidities as risk factors of mortality in pediatric liver transplant recipients. METHODS: A total of 2,938 patients who underwent liver transplantation (LT) surgery from 1998 through 2012 in Taiwan were enrolled in this study. Based on the International Classification of Disease, 9th Revision, Clinical Modifi cation (ICD-9-CM) codes, basic information regarding medical comorbidities was extracted from the National Health Insurance Research Database (NHIRD). RESULTS: All patients were followed to the endpoint of the study or until death. The study enrolled 2,597 adult (≥ 18 years old) and 341 pediatric (< 18 years old) liver transplant recipients. The median age for the pediatric cohort was 1.88 years (interquartile range = 0.92-5.42 years). Four hundred and twenty-eight deaths occurred after LT in the total population, including 41 children. The median follow-up period was 6.1 years (interquartile range = 2.5-9.7 years) in pediatric liver transplant recipients. Pediatric patients with heart disease exhibited the highest risk of mortality. Further, during the entire study period of 14.5 years, patient survival rates were signifi cantly different (log-rank p = 0.002) for patients younger than 18 years and those older than 18 years. CONCLUSION: Cardiac disease is an important risk of mortality in pediatric LT. These fi ndings confi rm that the survival rate of LT is higher in pediatric patients than in adult patients.

Nationwide population-based study reveals increased malignancy risk in taiwanese liver transplant recipients.

Post-transplant malignancy is a major cause of late mortality for liver transplant recipients (LTRs). This nationwide population-based cohort study investigated the cancer type, incidence, and risk factors associated with post-transplant malignancies in 2938 Taiwanese LTRs who underwent transplantation between 1998 and 2012. Data from the National Health Insurance Research Database were extracted on the basis of the International Classification of Disease, Ninth Revision, Clinical Modification codes. Among these patients, 284 post-transplant malignancies were diagnosed. These included 99 de novo malignancies among 98 patients, yielding a standardized incidence ratio of 2.17 (95% CI, 1.76 to 2.64) compared to the general population. The most common malignancies were infection related liver cancer (19.39%), oropharyngeal cancer (19.39%), non-Hodgkin's lymphoma (9.18%), and esophageal cancer (5.10%), as well as non-infection-related prostate cancer (6.12%). Patients with recurrent malignancies had the highest mortality. Furthermore, 186 recurrent malignancies relapsed, and the commonly affected organs were the liver (83.33%), lung (4.84%), bone and bone marrow (4.30%), and intrahepatic bile ducts (2.69%). Old age, the male sex, liver cirrhosis, hepatitis B, peptic ulcer, diabetes mellitus, and pre-existing cancer were all risk factors associated with post-transplant malignancies. Recipients with biliary atresia or urea cycle metabolism disorders were protected from post-transplant malignancies. Our data revealed a significantly increased risk of malignancies in Taiwanese LTRs and suggest implementation of a careful malignancy-surveillance program and immunosuppression-minimizing strategy for high-risk patients.

Effects of Interscalene Nerve Block for Postoperative Pain Management in Patients after Shoulder Surgery.

OBJECTIVES: Shoulder surgery can produce severe postoperative pain and movement limitations. Evidence has shown that regional nerve block is an effective management for postoperative shoulder pain. The purpose of this study was to investigate the postoperative analgesic effect of intravenous patient-controlled analgesia (PCA) combined with interscalene nerve block in comparison to PCA alone after shoulder surgery. METHODS: In this study, 103 patients receiving PCA combined with interscalene nerve block (PCAIB) and 48 patients receiving PCA alone after shoulder surgery were included. Patients' characteristics, preoperative shoulder score and range of motion, surgical and anesthetic condition in addition to visual analog scale (VAS) pain score, postoperative PCA consumption, and adverse outcomes were evaluated. RESULTS: The results showed that PCA combined with interscalene nerve block (PCAIB) group required less volume of analgesics than PCA alone group in 24 hours (57.76 ± 23.29 mL versus 87.29 ± 33.73 mL, p < 0.001) and 48 hours (114.86 ± 40.97 mL versus 183.63 ± 44.83 mL, p < 0.001) postoperatively. The incidence of dizziness in PCAIB group was significantly lower than PCA group (resp., 1.9% and 14.6%, p = 0.005). VAS, nausea, and vomiting were less in group PCAIB, but in the absence of significant statistical correlation. CONCLUSION: Interscalene nerve block is effective postoperatively in reducing the demand for PCA analgesics and decreasing opioids-induced adverse events following shoulder surgery.

Comparison of sevoflurane versus propofol under auditory evoked potential monitoring in female patients undergoing breast surgery.

BACKGROUND: General anesthesia is used for most major surgeries, and the most common side effects include headache, nausea, vomiting, and sore throat. Major breast surgery is associated with a high incidence of postoperative nausea and vomiting (PONV). We compared the postoperative nausea and vomiting of propofol-based total intravenous anesthesia (TIVA) and sevoflurane (SEVO) anesthesia under auditory evoked potential (AEP) monitoring in female patients undergoing breast surgery. METHODS: A total of 84 patients scheduled to undergo elective breast surgery from 1 to 4 h in duration from March 2011 to December 2011 were prospectively included in the study. All participants were randomly assigned to TIVA or SEVO group. The AEP index was maintained at 15-25. After completing the surgery, the duration of surgery, emergence time, and the side effects of PONV were recorded. RESULTS: Patient characteristics, intraoperative and postoperative data, and the amounts of intraoperative analgesic drugs used were not significantly different between the TIVA and SEVO groups. The incidence of PONV was significantly higher in the SEVO group than in the TIVA group (50% and 14.3%, respectively; p < 0.001), and the total cost was significantly lower in the TIVA group than in the SEVO group (648 ± 185 and 850 ± 197, respectively). CONCLUSION: We observed that when compared with sevoflurane, propofol given for the maintenance of general anesthesia improves the postoperative patient well-being and reduces the incidence of PONV. Furthermore, total intravenous anesthesia with propofol resulted in significant cost reductions.

Anesthetic management of a repeat cesarean section in a parturient with severe peripartum cardiomyopathy requiring ECMO in a previous pregnancy: a case report.

The number of pregnant women with cardiac disease is increasing with improvements in technology. In addition, more people are part of the national health insurance plan. However, there are few reports concerning the best method for anesthesia and mode of delivery in these high-risk patients. We report a 29-year-old woman scheduled for a planned caesarean section, who had a history of severe peripartum cardiomyopathy requiring extracorporeal membrane oxygenation in a previous pregnancy. The patient had regular prenatal care in our obstetric clinic. At 29 weeks' gestation, she developed severe dyspnea. A chest radiograph revealed bilateral pulmonary edema and 2-dimensional echocardiography showed a global hypokinesis and severe valve regurgitation with left ventricular ejection fraction of 41.2%. She had an emergency caesarean section and a cardiovascular surgeon was consulted to stand-by. Anesthesia was induced by ketamine 25 mg, midazolam 2.5 mg and rocuronium 50 mg for rapid intubation. The patient tolerated the procedure well and was extubated on postoperative day 1. She was discharged one week after surgery. Postoperatively, the patient was followed in the obstetric and cardiovascular surgery outpatient departments and at 5 months after surgery she was in good condition without any complaints.