Perioperative management of adult living donor liver transplantation: Part 1 - recipients.

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients.

Perioperative management of living donor liver transplantation: Part 2 - Donors.

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.

Abdominal Organ Transplantation: Noteworthy Literature in 2020.

In 2020, we identified and screened over 490 peer-reviewed publications on pancreatic transplantation, over 500 on intestinal transplantation, and over 5000 on kidney transplantation. The liver transplantation section specially focused on clinical trials and systematic reviews published in 2020 and featured selected articles. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a wide range of topics, including COVID-19 and organ transplantation, risk factors and outcomes, pain management, artificial intelligence, robotic donor surgery, and machine perfusion.

Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States.

BACKGROUND: Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS: Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS: ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS: We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

Abdominal Organ Transplantation: Noteworthy Literature in 2019.

In the year 2019, we identified and screened over 400 peer-reviewed publications on pancreatic transplantation, over 200 on intestinal transplantation, and over 1900 on kidney transplantation. The liver transplantation section focuses on and features selected articles among 70 clinical trials published in 2019. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a broad range of topics, including risks for and prediction of perioperative complications, updated indications for transplantation, recommendations on perioperative management, including Enhanced Recovery After Surgery programs, and topics relevant to optimization of patient and graft outcomes and survival.

Nonopioid Modalities for Acute Postoperative Pain in Abdominal Transplant Recipients.

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.

Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations.

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.

Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery.

Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.

Incidence, outcome, and risk factors for postoperative pulmonary complications in head and neck cancer surgery patients with free flap reconstructions.

STUDY OBJECTIVE: Postoperative pulmonary complications (PPCs) are significant problems in patients undergoing radical head and neck cancer surgery with free flap reconstruction. The objective of the study was to identify the incidence, outcome, and risk factors for PPCs We hypothesized that preoperative pulmonary disease and amount of fluid administered during the surgery would be associated with PPCs. DESIGN: A retrospective clinical observational study. SETTING: A large academic institution. SUBJECTS: A total of 110 patients who underwent head and neck cancer surgery with microvascular free flap reconstruction between January 1, 2005 and December 31, 2011. INTERVENTIONS: No study interventions were performed. MEASUREMENTS: PPCs including pulmonary edema, pneumonia, and acute respiratory distress syndrome were clinically diagnosed. Perioperative parameters and outcomes among patients with and without PPCs were compared. Factors predictive of PPCs were identified with univariate and multiple logistic regression analyses. MAIN RESULTS: The incidence of PPCs was 32.7% (36 patients): pulmonary edema in 23.6% (26) and pneumonia in 9.1% (10). No acute respiratory distress syndrome was found. Inhospital mortality was 1.8% (2). No difference was found in survival between the patients with PPCs and those without (1 year survival was 69.4% vs 78.4%; P=.85). The patients with PPCs required longer ventilation support (median, 4 vs 2days; P=.002) and more frequent intensive care unit readmissions (30.3% vs 5.7%; P=.001) and stayed longer in the hospital (median, 17 vs 12days; P=.014). None of the preoperative parameters or intraoperative parameters including pulmonary comorbidity or the amounts of intraoperative fluid/blood administration was found as the factor to predict postoperative pulmonary compilations. CONCLUSION: The incidence of PPCs in patients undergoing radical head and neck surgery was 32.7% in 110 patients. Preoperative pulmonary disease or the amount of fluid administered during the surgery was not associated with PPCs.

Inadvertent Endobronchial Intubation in a Patient With a Short Neck Length.

Inadvertent placement of the endotracheal tube into the right bronchus during intubation for general anesthesia is a fairly common occurrence. Many precautions should be taken by the anesthesia provider in order to minimize the incidence of endobronchial intubation, including bilateral auscultation of the lungs, use of the 21/23 rule, and palpation of the inflated endotracheal cuff at the sternal notch. These provisions, however, are not foolproof; anesthesia providers should realize that endobronchial intubation may occur from time to time because of variations in patient anatomy, changes in patient positioning, and cephalad pressures exerted during surgery. A 58-year-old man with chronic obstructive pulmonary disease received general endotracheal anesthesia for a laparoscopic cholecystectomy. His height was 165 cm (5 ft, 5 in) and the endotracheal tube was secured at his incisors at 21 cm after placement with a rigid laryngoscope. Bilateral breath sounds were confirmed with auscultation, although they were distant because of his chronic obstructive pulmonary disease. After radiographic examination in the postanesthesia care unit, a right main-stem intubation was revealed to have taken place, resulting in complete atelectasis of the left lung. After repositioning of the endotracheal tube, radiography confirmed that the patient had an anatomically short tracheal length.

Characteristic MRI features of chronic inflammatory demyelinating polyradiculoneuropathy.

We present characteristic magnetic resonance imaging (MRI) features in a pediatric female patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Muscle weakness developed at 8 years old and fluctuated during the clinical course over 7 years. Electrophysiological studies showed a demyelination pattern with moderately delayed nerve conduction velocity, as well as dispersion phenomenon. MRI showed marked changes in thickening of the spinal nerve roots and their peripheral nerves in the lumber and brachial plexuses, as well as in the bilateral trigeminal nerves. It is suggested that these MRI features are characteristic and strongly supportive of the diagnosis of CIDP with a prolonged clinical course.

Fate of abstracts presented at the 2004-2008 International Liver Transplantation Society meetings.

Only 20.5% to 61.6% of abstracts presented at biomedical meetings are subsequently published as full-length articles. The aim of this study was to analyze the abstract-to-publication rate of International Liver Transplantation Society (ILTS) meeting abstracts. Abstracts presented at 5 consecutive annual ILTS meetings (2004-2008) were included to ensure a minimum follow-up period of 4 years. For each abstract, a PubMed Central search was conducted with the first author's name and affiliation along with keywords from the title. The following abstract characteristics were examined and used to obtain the abstract-to-publication rate: (1) the year of presentation, (2) the presentation category (plenary session, concurrent oral presentation, or poster presentation), (3) the type of study (randomized clinical study, case report, other clinical study, or basic science study), (4) the first author's discipline (surgery, medicine, anesthesiology/critical care medicine, pathology, radiology, or pharmacology), and (5) the location of the authors (ie, an English-speaking or non-English-speaking country). A total of 2345 abstracts (469 ± 144 abstracts per meeting) were presented, and 913 of those abstracts (38.9%) were expanded into full-length publications. It took 46 months for 90% of the abstracts to be published as full-length journal articles. The abstract-to-publication rates differed with the year of abstract presentation (50.2% in 2004, 45.9% in 2005, 47.6% in 2006, 30.6% in 2007, and 30.3% in 2008; P < 0.001), with the presentation category (49.6% for plenary sessions, 48.5% for concurrent oral presentations, and 34.8% for poster presentations; P < 0.001), and with the type of study (66.7% for randomized clinical studies, 63.1% for basic science studies, 36.7% for other clinical studies, and 35.0% for case reports; P < 0.001). Abstracts from authors from non-English-speaking countries had a higher publication rate (41.1% versus 33.6%, P < 0.001). No differences were found between first authors' disciplines.

Isolated small bowel transplantation outcomes and the impact of immunosuppressants: Experience of a single transplant center.

AIM: To investigate patient and graft outcomes in isolated small bowel transplant (SBTx) recipients and immunosuppressant induction agent impact on outcomes. METHODS: A retrospective review of the perioperative data of patients who underwent SBTx transplant during an 8-year period was conducted. The intraoperative data were: patient demographics, etiology of short gut syndrome, hemodynamic parameters, coagulation profiles, intraoperative fluid and blood products transfused, and development of post-reperfusion. The postoperative data were: hospital/intensive care unit stays, duration of mechanical ventilation, postoperative incidence of acute kidney injury, and 1-year patient and graft outcomes. The effects of the three immunosuppressant induction agents (Zenapax, Thymoglobulin, Campath) on patient and graft outcomes were reviewed. RESULTS: During the 8-year period there were 77 patients; 1-year patient and graft survival were 95% and 86% respectively. Sixteen patients received Zenapax, 22 received Thymoglobulin, and 39 received Campath without effects on patient or graft survival (P = 0.90, P = 0.14, respectively). The use of different immune induction agents did not affect the incidence of rejection and infection during the first 90 postoperative days (P = 0.072, P = 0.29, respectively). The Zenapax group received more intraoperative fluid and blood products and were coagulopathic at the end of surgery. Zenapax and Thymoglobulin significantly increased serum creatinine at 48 h (P = 0.023) and 1 wk (P = 0.001) post-transplant, but none developed renal failure or required dialysis at the end of the first year. CONCLUSION: One-year patient and graft survival were 95% and 86%, respectively. The use of different immunosuppressant induction agents may affect the intraoperative course and short-term postoperative morbidities, but not 1-year patient and graft outcomes.

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.

High mortality associated with intracardiac and intrapulmonary thromboses after cardiopulmonary bypass.

PURPOSE: Intrapulmonary or intracardiac thrombosis is a rare but catastrophic event following complex cardiothoracic surgery. Although there have been multiple cases reported in the literature, the causes of these events are largely unknown. In this retrospective review, we attempt to identify risk factors and propose possible mechanisms of thromboses after cardiopulmonary bypass (CPB). METHODS: A literature search was conducted using the MEDLINE and EMBASE with these keywords: (intra)pulmonary thrombosis, pulmonary embolism, pulmonary infarction, lung embolism, (intra)cardiac thrombosis, cardiac thrombi, in combination with CPB, extracorporeal membrane oxygenation, deep hypothermic circulatory arrest, or cardiac surgery. Putative risk factors were compiled from reported cases. RESULTS: We identified 34 cases of massive intrapulmonary and/or intracardiac thromboses. All but 2 cases (94.1%) were fatal. Clinical presentations were systemic hypotension and/or pulmonary hypertension, right ventricular failure, and cardiogenic shock in 32 (94.1%) cases. The timing was immediate (<10 min) following hemostatic intervention in 16 cases (47.1%), within 45 min in 8 cases (23.5%), and not reported in the rest. Putative risk factors included antifibrinolytic use (88.2%), congestive heart failure (55.9%), prolonged CPB use (>2 h) (41.1%), and low activated clotting time (<400 s) after initial heparinization (20.6%). The administration of tissue plasminogen activator in 5 cases was ineffective. CONCLUSIONS: Massive thrombosis following cardiac surgery is a highly lethal event with limited treatment options. Particular attention should be paid to the status of thrombin regulatory proteins before protamine and other hemostatic interventions in patients undergoing complex cardiac surgery with antifibrinolytic agents.

Stem cells decreased neuronal cell death after hypoxic stress in primary fetal rat neurons in vitro.

To explore stem cell-mediated neuronal protection through extracellular signaling pathways by transplanted stem cells, we sought to identify potential candidate molecules responsible for neuronal protection using an in vitro coculture system. Primary fetal rat hippocampal neurons underwent hypoxia (≤1% oxygen) for 96 h nad then were returned to a normoxic condition. The study group then received rat umbilical cord matrix-derived stem cells, while the control group received fresh media only. The experimental group showed decreased neuronal apoptosis compared to the control group [44.5 ± 1.6% vs. 71.0 ± 4.2% (mean ± SD, p = 0.0005) on day 5] and higher neuronal survival (4.9 ± 1.2 cells/100× field vs. 2.2 ± 0.3, p = 0.02 on day 5). Among 90 proteins evaluated using a protein array, stem cell coculture media showed increased protein secretion of TIMP-1 (5.61-fold), TIMP-2 (4.88), CNTF-Rα (3.42), activin A (2.20), fractalkine (2.04), CCR4 (2.02), and decreased secretion in MIP-2 (0.30-fold), AMPK α1 (0.43), TROY (0.48), and TIMP-3 (0.50). This study demonstrated that coculturing stem cells with primary neurons in vitro decreased neuronal cell death after hypoxia with significantly altered protein secretion. The results suggest that stem cells may offer neuronal protection through extracellular signaling.

Accidental insertion of a percutaneous venovenous cannula into the persistent left superior vena cava of a patient undergoing liver transplantation.

PURPOSE: Persistent left superior vena cava (PLSVC) is a rare congenital vascular abnormality found in 0.3% of the general population. We report herein a rare complication involving the accidental insertion of a large bore cannula into the PLSVC during liver transplantation (LT). CLINICAL FEATURES: A 63-yr-old man with primary sclerosing cholangitis presented for LT. Given the existence of a tunnelled dialysis catheter in the right internal jugular vein (IJV) and a triple lumen catheter via the left IJV, insertion of an 18 French cannula for venovenous bypass (VVB) was performed via the left IJV using the existing triple lumen cannula as a conduit for a guidewire. Upon initiation of VVB, profound systemic hypotension occurred, and liver transplantation was completed without the further use of VVB. A chest x-ray confirmed a malposition of the VVB cannula with a large left hemothorax. A mini-sternotomy was performed for removal of the VVB cannula, which was found to be inserted in the PLSVC. Retrospectively, the presence of PLSVC was not anticipated due to a normal superior vena cava and a left innominate vein, as revealed by the course of a pre-existing left internal jugular vein triple lumen catheter on a preoperative chest x-ray, and due to a normal-sized coronary sinus on preoperative echocardiography. CONCLUSION: Malpositioning of a venous cannula in a PLSVC should be anticipated as one of the potential complications of vascular access via the left internal jugular vein.

The diagnostic challenge of a tracheal tear with a double-lumen endobronchial tube: massive air leak developing from the mouth during mechanical ventilation.

The case of a 78 year-old woman who underwent a right lower lobectomy using a 35-French, left-sided, double-lumen endobronchial tube (DLET) is presented. Multiple adjustments were needed for the DLET's proper placement. At the end of surgery, sudden loss of tidal volume with a large air leak from the patient's mouth was noted. Fiberoptic bronchoscopic examination through the DLET was negative. Rupture of the tracheal cuff was suspected, and the DLET was replaced with a single-lumen tube. In the intensive care unit, the massive air leak from the mouth recurred during mechanical ventilation. Nasal fiberoptic bronchoscopic examination showed a longitudinal laceration of the membranous portion of the trachea extending from the subglottic area to the orifice of the right bronchus. Surgical repair of the tear was performed.

Isolated left-sided pulmonary edema caused by alemtuzumab (Campath) during kidney transplantation.

Alemtuzumab is a novel anti-CD-52 monoclonal antibody for immunosuppression. Although cost effective and efficacious, alemtuzumab is not without risk. Interestingly, intraoperative complications caused by alemtuzumab have rarely been reported. We describe a case of intraoperative pulmonary edema following administration of alemtuzumab. A 22-year-old man underwent kidney transplantation and received alemtuzumab intraoperatively. To provide better surgical exposure for transplantation, the operation table was tilted to the right. At the end of 3.5-h uneventful procedure, a sudden oxygen desaturation was noted after the bed was flattened. The postoperative chest X-ray showed opacification of the entire left lung field. After 4 days of bi-level positive airway pressure treatment, the lung field was cleared. This case is unique in that pulmonary edema developed during surgery after administration of alemtuzumab, and that the edema developed only in the nondependent lung. Transplant anesthesiologists should be aware of the risk of this complication with these novel anti-CD-52 monoclonal antibodies.