Occurrence and outcome of blood-contaminated percutaneous injuries among anesthesia practitioners: a cross-sectional study.

BACKGROUND: Anesthesia practitioners are at risk for percutaneous injuries by blood-contaminated needles and sharp objects that may result in the transmission of human immunodeficiency virus and hepatitis viruses. Reporting these injuries is important for the early prevention and management of blood-borne infections. OBJECTIVE: To investigate the occurrence, reporting, characteristics and outcome of contaminated percutaneous injuries (CPIs) in anesthesia residents, fellows and faculty. METHOD: A cross-sectional anonymous survey electronically distributed to all 214 anesthesia practitioners at a large academic multihospital-based anesthesia practice in Florida, USA. RESULTS: The overall response rate was 51% (110/214) (60% (50/83) for residents, 50% (8/16) for fellows and 45% (52/115) for anesthesia faculty). Fifty-nine percent (65/110) (95% confidence interval (95% CI): 5068) of participants reported having one or more CPIs during their years of anesthesia practice (residents 42% (95% CI: 2955), fellows 50% and faculty 77% (95% CI: 6688)). The number of CPIs per anesthesia practitioner who answered the survey was 0.58 for residents, 0.75 for fellows and 1.5 for faculty. Within the last 5 years, 35% (95% CI: 2644) of participants had one or more CPIs (39% of residents, 50% of fellows and 29% of faculty). CPIs in the last 5 years in faculty older than 45 years of age were 12% (3/25) compared to 44% (12/27) in faculty younger than 45 years of age.Analyzing data from practitioners who had one CPI revealed that 70% (95% CI: 5585) reported the incident at the time of injury (residents 85%, fellows 100% and faculty 58%). Hollow-bore needles constituted 73.5% (95% CI: 5988) of injuries. As per participants' responses, 17% (18/103) of CPIs received postexposure prophylaxis and there were zero seroconversions. CONCLUSION: Based on our study results, most anesthesia practitioners will sustain a CPI during their years of practice. Despite some improvements compared to historic figures, the occurrence of CPIs continues to be high and reporting of percutaneous injuries remains suboptimal among anesthesia residents. A fifth of injuries in the perioperative setting is from an infected source and requires postexposure prophylaxis. Although no infections were reported due to CPI exposure in this study, findings underscore the need for more education and interventions to reduce occupational blood exposures in anesthesia practitioners and improve reporting.

En-Bloc Simultaneous Heart-Liver Transplantation in Adult Patients.

INTRODUCTION: Complexity of combined heart-liver transplantation has resulted in low adoption rates. We report a case series of adult patients receiving en-bloc heart-liver transplantation (HLTx), describe technical aspects, and discuss benefits of the technique. METHODS: Retrospective review of patients receiving en-bloc HLTx over 18 months, with clinical follow up to 1 year. Primary outcomes included postoperative mortality and major complications. Secondary outcomes included 1-year survival, cardiac or hepatic allograft rejection, and infection. RESULTS: Five patients received en-bloc HLTx. Mean recipient age was 43 years (26-63), and 3 patients were male. Total operative time was 430 minutes (393-480), cold and warm ischemic times of 85 (32-136) and 37.5 (31-47) minutes. Hospital survival was 80%. One patient died on postoperative day 55 due to fungal sepsis. Major postoperative complications included prolonged mechanical ventilation in 2 of 5 patients (40%), and renal insufficiency requiring hemodialysis in 2 of 5 patients (40%). Among patients discharged from hospital 1-year survival was 100%, with no evidence of rejection or infectious complications. CONCLUSION: En-bloc HLTx technique is a safe and effective strategy, decreasing operative times, and allograft ischemic times, whereas offering protection of implanted allografts during early stages of reperfusion while patient is hemodynamically supported on cardiopulmonary bypass.

Thrombotic and hemorrhagic complications during visceral transplantation: risk factors, and association with intraoperative disseminated intravascular coagulation-like thromboelastographic qualities: a single-center retrospective study.

This study describes the risk of thrombotic and hemorrhagic complications, both intraoperatively, and up to 1 month following visceral transplantation. Data from 48 adult visceral transplants performed between 2010 and 2017 were retrospectively studied [32 multivisceral (MVTx); 10 isolated intestine; six modified-MVTx]. Intraoperatively, intracardiac thrombosis (ICT)/pulmonary embolism (PE) occurred in 25%, 0% and 0% of MVTx, isolated intestine and modified MVTx, respectively, and was associated with 50% (4/8) mortality. Preoperative portal vein thrombosis (PVT) was a significant risk factor for ICT/PE (P = 0.0073). Thromboelastography resembling disseminated intravascular coagulation (DIC) (r time <4 mm combined with fibrinolysis or flat-line) was statistically associated with occurrence of ICT/PE (P < 0.0001). Compared to subgroup without ICT/PE, occurrence of ICT/PE was associated with an increased demand for all blood product components both overall, and each surgical stage. Hyperfibrinolysis (56%) was identified as cause of bleeding in MVTx. Incidence of postoperative thrombotic event at 1 month was 25%, 30% and 17% for MVTx, isolated intestine and modified MVTx, respectively. Incidence of postoperative bleeding complications at 1 month was 11%, 20% and 17% for MVTx, isolated intestine and modified MVTx. In conclusion, MVTx recipients with preoperative PVT are at an increased risk of developing intraoperative life-threatening ICT/PE events associated with DIC-like coagulopathy.

Perianesthetic Management of Laparoscopic Kidney Surgery.

PURPOSE OF REVIEW: Laparoscopic kidney surgery is commonly used for living donor, partial, and total tumor nephrectomy. The successful emergence of laparoscopic technique was justified by the many benefits offered such as reduced blood loss, tissue trauma, pain, and hospital stay. However, this comes at the expense of physiologic changes and complications secondary to pneumoperitoneum, surgical technique, and patient positioning with significant challenges in anesthetic management. RECENT FINDINGS: A variety of laparoscopic approaches (transperitoneal, retroperitoneal, hand-assisted, robotic) are used with some having advantages over others. The kidneys are particularly sensitive to hemodynamic changes and pneumoperitoneum. Controversies in perioperative fluid administration exist. New modalities for postoperative pain control have been suggested. Laparoscopic kidney surgery is associated with multiple physiologic changes and adverse events but offers advantages of reduced postoperative pain, faster recovery, and shorter hospital stay. Understanding these physiologic changes and related anesthetic considerations is key for safe patient outcome.

Survey of anesthesiologists' practices related to steep Trendelenburg positioning in the USA.

BACKGROUND: Steep Trendelenburg during surgery has been associated with many position-related injuries. The American Society of Anesthesiology practice advisory recommends documentation, frequent position checks, avoiding shoulder braces, and limiting abduction of upper extremities to avoid brachial plexopathy. We conducted a web-based survey to assess anesthesiologists' practices, institutional policies, and complications encountered when using steep Trendelenburg. METHODS: Two thousand fifty randomly selected active members of the American Society of Anesthesiology were invited via email to participate in a 9-item web-based survey. Results are reported as absolute numbers and proportions with 95% confidence interval (CI). RESULTS: Survey response rate was 290 of 2050 (14.1%). 44.6% (95% CI, 38.9-50.3) of the respondents documented anesthesia start and finish, 73.9% (95% CI, 68.8-79) frequently checked positioning during surgery, 30.8% (95% CI, 25.4-36.2) reported using shoulder braces, 66.9% (95% CI, 61.5-72.3) tucked patients' arms to the side, 54.0% (95% CI, 48.2-59.8) limited fluid administration, and more than two-thirds did not limit the duration or inclination angle. Notably, 63/290 (21.7%) reported a complication and only 6/289 (2.1%) had an institutional policy. The most common complication was airway and face edema, second was brachial plexus injury, and third was corneal abrasions. Most institutional policies, when present, focused on limiting duration of steep Trendelenburg and communication with surgical team. Only 1/6 policies required avoiding use of shoulder braces. CONCLUSION: Based on survey results, practices related to steep Trendelenburg varied among USA anesthesiologists. Differences included protective measures, documentation, positioning techniques, fluid management, and institutional guidelines. The singular commonality found among all respondents was lack of institutional policies. Survey results highlighted the need for institutional policies and more education.

Perioperative Concerns in the Patient with History of Alcohol Use.

Alcohol use is common in patients presenting for surgery and can result in significant physiologic changes and postoperative complications. Anesthesia providers must be aware of the potential risks associated with alcohol consumption and take steps to minimize them. Perioperative management includes assessing patients for alcohol use, providing alcohol cessation interventions, adjusting the anesthetic plan according to the patient's alcohol use history, providing appropriate pain management strategies, and closely monitoring patients during and after surgery for signs of alcohol withdrawal.

Characteristics, Risk Factors, and Outcome of New-onset Systolic Heart Failure After Liver Transplantation: A Single-center Cohort.

New-onset systolic heart failure (HF) after liver transplantation (LT) is a significant cause of morbidity and mortality; however, its characteristics are still insufficiently delineated. HF may involve the left ventricle (LV), right ventricle (RV), or both ventricles. We explored the incidence, characteristics, etiologies, risks, involved cardiac chambers, and outcomes of HF after LT. Methods: This study included 528 adult patients with preoperative LV ejection fraction ≥ 55% who underwent LT between 2016 and 2020. The primary outcome was new-onset systolic HF, defined by the presence of clinical signs, symptoms, and echocardiographic evidence of reduced LVejection fraction <50% and RV dysfunction within the first year after LT. Results: Thirty-one patients (6%) developed systolic HF within a median of 9 d (1-364). Of those, 23% of patients had ischemic HF, whereas 77% had nonischemic HF. Nonischemic HF was caused by stress (11), sepsis (8), or other factors (5). Nonischemic HF was secondary to isolated LV failure in 58% of patients or RV ± LV failure in 42% of patients. Recursive partitioning identified subgroups with varying risks and uncovered interaction between variables. HF risk increased from 4.2% to 13% when epinephrine and/or norepinephrine drips were used intraoperatively (P < 0.01). When no epinephrine and/or norepinephrine were used, HF risk increased from 3.1% to 38.5% if baseline hemoglobin was <7.2 g/dL (P < 0.01). When baseline hemoglobin was ≥7.2 g/dL, HF risk increased from 0% to 5.2% when ≥3500 mL crystalloid was used intraoperatively (P < 0.01). Posttransplant first-year survival and reversibility of HF depended on the etiology (stress, sepsis, ischemia, etc) and cardiac chamber involvement (isolated LV or RV ± LV). RV dysfunction was associated with inferior recovery of cardiac function and poorer survival than nonischemic isolated LV dysfunction (50% versus 70%, respectively). Conclusions: Posttransplant new-onset HF is mostly nonischemic in nature and is associated with increased morbidity and mortality.

Efficacy and Ease of Use of a Newly Designed Pencil-Point Epidural Needle Compared to Conventional Tuohy Epidural Needle: A Randomized Single-Blind Pilot Study.

Background and objective Accidental dural puncture (ADP) and consequent post-dural puncture headache (PDPH) related to epidural needle use have prompted the design of a pencil-point epidural needle. The aim of this prospective, randomized, single-blind pilot study was to assess the efficacy, ease of use, patient satisfaction, and adverse events associated with this newly designed pencil-point epidural needle compared to a Tuohy conventional epidural needle in parturients receiving combined spinal-epidural (CSE) anesthesia for labor. Methods After obtaining the Institutional Research Board approval, 100 parturients were randomized to receive CSE anesthesia with either the new pencil-point epidural needle (Gertie Marx, IMD Inc., Huntsville, UT) (P group) or Tuohy needle (T group). We documented patients' height, weight, loss of resistance (LOR), number of attempts required, onset time of spinal anesthesia, difficulties with insertion of spinal needle, difficulties with insertion of the epidural needle and catheter, duration of the procedure, overall satisfaction of the provider and patient, ADP, PDPH, paresthesia, and pain. Results There was no difference in body mass index (BMI), LOR, number of attempts, and onset time of spinal anesthetic between the study groups. Success in obtaining cerebrospinal fluid (CSF) on the first attempt was 50/51 (98%) in the T group vs. 44/49 (89.8%) in the P group (p=0.108). The need for subsequent epidural needle readjustment to obtain CSF was higher in the P group (16/49, 32.7%) vs. the T group (3/51, 5.9%, p<0.001). Success on the first attempt with epidural catheter threading was lower with the pencil-point epidural needle compared to the Tuohy needle (69% vs. 98%, p<0.001). The anesthesiologist switched from the assigned pencil-point epidural needle to the Tuohy needle due to technical difficulties in 8/49 (16.3%) cases. The duration of the procedure was longer in the P group (16.43 ±6.33 minutes) compared to the T group (11.49 ±1.87 minutes) (p<0.001). User satisfaction was lower in the P group compared to the T group (34.7% vs. 90.2%, p<0.001). Patient satisfaction was lower with the pencil-point epidural needle compared to the Tuohy needle (75.5% vs. 92.2%, p=0.03). There was no difference in complication rates from the CSE procedure between groups (pain, paresthesia, ADP, and PDPH). Conclusion In this pilot study, the use of the pencil-point epidural needle for CSE was associated with less successful epidural catheter placement as well as low user and patient satisfaction compared to the Tuohy epidural needle. Modifications in the pencil-point epidural needle design are needed to improve efficacy and enhance user acceptance before a larger study can be conducted to evaluate the rates of ADP and PDPH.

Recommendations From the Society for the Advancement of Transplant Anesthesiology Fellowship Committee: Core Competencies and Milestones for the Kidney/Pancreas Component of Abdominal Organ Transplant Anesthesia Fellowship.

The Society for the Advancement of Transplant Anesthesia (SATA) is dedicated to improving patient care in all facets of transplant anesthesia. The anesthesia fellowship training recommendations for thoracic transplantation (heart and lungs) and part of the abdominal organ transplantation (liver) have been presented in previous publications. The SATA Fellowship Committee has completed the remaining component of abdominal transplant anesthesia (kidney/pancreas) and has assembled core competencies and milestones derived from expert consensus to guide the education and overall preparation of trainees providing care for kidney/pancreas transplant recipients. These recommendations provide a comprehensive approach to pre-operative evaluation, vascular access procedures, advanced hemodynamic monitoring, assessment of coagulation and metabolic abnormalities, operative techniques, and post-operative pain control. As such, this document supplements the current liver/hepatic transplant anesthesia fellowship training programs to include all aspects of "Abdominal Organ Transplant Anesthesia" recommended knowledge.

Perioperative risk factors associated with delayed graft function following deceased donor kidney transplantation: A retrospective, single center study.

BACKGROUND: There is an abundant need to increase the availability of deceased donor kidney transplantation (DDKT) to address the high incidence of kidney failure. Challenges exist in the utilization of higher risk donor organs into what appears to be increasingly complex recipients; thus the identification of modifiable risk factors associated with poor outcomes is paramount. AIM: To identify risk factors associated with delayed graft function (DGF). METHODS: Consecutive adults undergoing DDKT between January 2016 and July 2017 were identified with a study population of 294 patients. The primary outcome was the occurrence of DGF. RESULTS: The incidence of DGF was 27%. Under logistic regression, eight independent risk factors for DGF were identified including recipient body mass index ≥ 30 kg/m2, baseline mean arterial pressure < 110 mmHg, intraoperative phenylephrine administration, cold storage time ≥ 16 h, donation after cardiac death, donor history of coronary artery disease, donor terminal creatinine ≥ 1.9 mg/dL, and a hypothermic machine perfusion (HMP) pump resistance ≥ 0.23 mmHg/mL/min. CONCLUSION: We delineate the association between DGF and recipient characteristics of pre-induction mean arterial pressure below 110 mmHg, metabolic syndrome, donor-specific risk factors, HMP pump parameters, and intraoperative use of phenylephrine.

Anaesthetic management of a parturient with spondylothoracic dysostosis.

Spondylothoracic dysostosis is a rare congenital disorder characterised by multiple vertebral malformations, shortening of the spine and fusion of the ribs at the costovertebral junction. These abnormalities create anaesthetic challenges due to difficult airway, severe restrictive lung disease and spine deformity necessitating a multidisciplinary approach and careful perioperative planning. We present the perianaesthetic management of a parturient with spondylothoracic dysostosis who successfully underwent preterm caesarean delivery under general anaesthesia with awake videolaryngoscopy-assisted tracheal intubation.

The effect of low-dose remifentanil on responses to the endotracheal tube during emergence from general anesthesia.

BACKGROUND: Emergence from general anesthesia can be associated with coughing, agitation, and hemodynamic disturbances. Remifentanil may attenuate these responses. METHODS: In a prospective, double-blind, randomized trial, we enrolled 60 adult patients undergoing nasal surgery using remifentanil-based anesthesia. During the emergence phase, the remifentanil group had remifentanil reduced to one tenth of the maintenance rate, whereas the control group had remifentanil discontinued. RESULTS: Times to awakening and tracheal extubation were similar between the two groups. During emergence, the remifentanil group (infusion rate 0.014 +/- 0.011 microg x kg(-1) x min(-1)) had a significantly lower incidence (40% vs 80%, P = 0.002) and less severe coughing compared with the control group, as well as a lower incidence of nonpurposeful movement (3.3% vs 30%, P = 0.006) and slower heart rates. CONCLUSIONS: Low-dose remifentanil during emergence did not prolong wake-up but reduced the incidence and severity of coughing from the endotracheal tube.

Fibrinolytic Shutdown Is Associated With Intraoperative Thrombosis and Hemorrhage During Visceral Transplant.

Background and Objective. End-stage liver disease is characterized by a precarious imbalance of hemostasis. Detrimental consequences of hypofibrinolysis, also known as fibrinolytic shutdown, have been recently demonstrated, and its significance in visceral (ie, an allograft that contains the intestine) transplant remains unknown. Design and Setting. To fill this gap, following institutional review board approval, this retrospective study included 49 adult recipients of visceral allografts (14 "visceral allograft without the liver" and 35 "multivisceral" with the liver) transplanted between 2010 and 2018 in a single university hospital, and for whom pre-incisional thromboelastography was available. Based on percent clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: fibrinolytic shutdown, physiologic fibrinolysis, and hyperfibrinolysis. Results. Fibrinolytic shutdown occurred in 57% of patients, with higher incidence in recipients of multivisceral transplant (69%) compared with visceral allograft without liver (29%) allografts (P = .04). Fibrinolytic shutdown was associated with an increase in both intraoperative thrombosis and hemorrhage. Intraoperative thrombosis (18%) occurred only with multivisceral transplant, and accounted for 36% of in-hospital mortality. A clinically meaningful reduction in incidence of intraoperative thrombosis was noted in recipients who received intravenous heparin thromboprophylaxis. Logistic regression identified pretransplant platelet count as a risk factor for fibrinolytic shutdown (odds ratio = 0.992, 95% confidence interval = [0.984-0.998]; χ2 = 7.8, P = .005). Conclusions. This study highlights fibrinolytic shutdown as a dominant and clinically important feature of the hemostatic imbalance in recipients undergoing visceral transplantation.

Anesthetic Approach for Endoscopic Repair of Acquired Tracheoesophageal Fistula.

Tracheoesophageal fistula develops in 5 % to 15 % of patients with esophageal cancer. Metal stent placement can be used for treatment. Stent placement can result in aspiration, hemorrhage, perforation, migration, and pneumonia. Patients may present for medical attention with unanticipated worsening of the fistula and stent displacement requiring special anesthetic care. We discuss the perianesthetic management of a patient with malignant tracheoesophageal fistula and stent migration who presented for endoscopic esophageal stent replacement.

Transesophageal echocardiography-guided thrombectomy of intracardiac renal cell carcinoma without cardiopulmonary bypass.

Advanced renal cell carcinoma (RCC) resection has important anesthetic management implications, particularly when tumor extends, suprahepatic, into the right atrium. Use of transesophageal echocardiogram (TEE) is essential in identifying tumor extension and guiding resection. Latest surgical approach avoids venovenous and cardiopulmonary bypass yet requires special precautions and interventions on the anesthesiologist's part. We present a case of Level IV RCC resected without cardiopulmonary bypass and salvaged by TEE guidance and detection of residual intracardiac tumor.

Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy.

Lingual tonsils are lymphatic tissues located at the base of the tongue that may hypertrophy causing difficulty and sometimes inability to ventilate or intubate during anesthesia. Routine airway assessment fails to diagnose lingual tonsil hypertrophy. There is limited experience with use of videolaryngoscopy in cases of lingual tonsil hypertrophy. We present a case of difficult airway due to unanticipated lingual tonsil hypertrophy successfully managed by atypical video laryngoscope positioning.

Prolonged respiratory depression after general anesthesia in an adult with congenital rubella syndrome.

Congenital rubella syndrome (CRS) is caused by rubella virus infection of the pregnant mother leading to teratogenic effects on the fetus. Although rare in the developed world, manifestations reach far into adulthood and underscore the importance of careful evaluation before surgery. We present a case of an adult with CRS in whom unexpected prolonged postoperative respiratory depression occurred. Perioperative workup of CRS and investigations pertaining to the patient's respiratory insufficiency are discussed.