Techniques and applications of perioperative therapeutic plasma exchange.

PURPOSE OF REVIEW: Therapeutic plasma exchange (TPE) is a useful adjunct in the management of antibody-mediated disorders. The indications for TPE now include the perioperative setting. This review updates the anesthesiologist on the relevant clinical indications and precautions of plasma exchange. RECENT FINDINGS: Although still considered experimental, TPE for heparin-induced thrombocytopenia for urgent cardiac surgery is the most promising recent advance. SUMMARY: Plasmapheresis, or TPE, removes monoclonal antibodies, immune complexes and paraproteins. The utility of TPE in the perioperative period has recently become more apparent. Antibody-mediated disorders are associated with postoperative morbidity and mortality and are treated with TPE. Indications for TPE for cardiac surgery include heparin-induced thrombocytopenia, thrombotic thrombocytopenia purpura and antiphospholipid syndrome. Other indications for perioperative TPE are typically related to immunomodulation during solid-organ transplant. Immunomodulation, primarily with immunosuppressive medications and TPE, of a previously allosensitized recipient pretransplant increases the likelihood of a successful match. TPE is also useful in the management of intentional and inadvertent ABO incompatible recipients and is essential in the treatment of hyperacute rejection. TPE will likely be more utilized in the future and understanding the essentials of the procedure will facilitate the perioperative management of antibody-mediated disorders.

Anesthesia for tracheal reconstruction and transplantation.

PURPOSE OF REVIEW: Tracheobronchial lesions requiring significant resection of the airway have limited surgical options and present significant obstacles to the anesthesiologist and surgeon. This article will review recent advancements in anesthetic and surgical management. RECENT FINDINGS: Technological advances have introduced novel approaches to the patient with large airway lesions. The use of pump-driven and pumpless extracorporeal life support has rapidly expanded and allow for prolonged periods of apneic airway surgery. Tracheal transplantation has advanced from the cadaveric decellularized scaffolds initially used to true synthetic based structures with autologous stem cell derived epithelium. SUMMARY: Significant leaps in tissue engineered airway transplantation have created curative options for patients previously considered inoperable. These patients pose significant challenges to the anesthesiologist during the entire perioperative period. Close collaboration with surgeons and intensivists and the use of recently developed systems for extracorporeal life support are required.