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.

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.

Anesthesia-related cardiac arrest.

BACKGROUND: Much is still unknown about the actual incidence of anesthesia-related cardiac arrest in the United States. METHODS: The authors identified all of the cases of cardiac arrest from their quality improvement database from 1999 to 2009 and submitted them for review by an independent study commission to give them the best estimate of anesthesia-related cardiac arrest at their institution. One hundred sixty perioperative cardiac arrests within 24 h of surgery were identified from an anesthesia database of 217,365 anesthetics. An independent study commission reviewed all case abstracts to determine which cardiac arrests were anesthesia-attributable or anesthesia-contributory. Anesthesia-attributable cardiac arrests were those cases in which anesthesia was determined to be the primary cause of cardiac arrest. Anesthesia-contributory cardiac arrests were those cases where anesthesia was determined to have contributed to the cardiac arrest. RESULTS: Fourteen cardiac arrests were anesthesia-attributable, resulting in an incidence of 0.6 per 10,000 anesthetics (95% CI, 0.4 to 1.1). Twenty-three cardiac arrests were found to be anesthesia-contributory resulting in an incidence of 1.1 per 10,000 anesthetics (95% CI, 0.7 to 1.6). Sixty-four percent of anesthesia-attributable cardiac arrests were caused by airway complications that occurred primarily with induction, emergence, or in the postanesthesia care unit, and mortality was 29%. Anesthesia-contributory cardiac arrest occurred during all phases of the anesthesia, and mortality was 70%. CONCLUSION: As judged by an independent study commission, anesthesia-related cardiac arrest occurred in 37 of 160 cardiac arrests within the 24-h perioperative period.

The use of bovine hemoglobin glutamer-250 (Hemopure) in surgical patients: results of a multicenter, randomized, single-blinded trial.

UNLABELLED: Hemoglobin-based oxygen carrier-201 (HBOC-201, hemoglobin glutamer-250 [bovine], Hemopure; Biopure Corporation, Cambridge, MA) is polymerized hemoglobin of bovine origin being developed as an oxygen therapeutic. In this study, we evaluated the tolerability of a single intraoperative dose of HBOC-201 in surgical patients. In a single-blinded, multicenter study, 81 patients were randomized to receive either a single infusion of HBOC-201 (55 patients) or an equivalent volume of lactated Ringer's solution (26 patients). Forty-two patients originally assigned to the HBOC-201 group received the entire planned treatment of only one of the following doses: 0.6, 0.9, 1.2, 1.5, 2.0, or 2.5 g/kg of body weight. Thirteen of the 55 patients in the HBOC-201-assigned group did not reach the trigger point for transfusion administration, and they were not included in the analysis. We studied clinical outcomes and compared hematologic findings, blood chemistry values, and blood use in the two treatment groups. There were no patient deaths in this study. No pattern of clinically significant laboratory abnormalities could be attributed to exposure to HBOC-201. In the HBOC-201 group, 2 patients had a transient increased concentration of serum transaminases and 6 had transient skin discoloration. One patient in the HBOC-201 group had mast cell degranulation with hypotension. Postoperatively, methemoglobin plasma concentrations increased in the HBOC-201 group in a dose-dependent manner, reaching maximal values of 3.7% +/- 3.2% (average of all doses given) on postoperative day 3. There was no difference in the mean number of allogeneic blood units transfused in the 2 groups (3.3 +/- 1.8 and 3.7 +/- 4.1 for the lactated Ringer's solution and HBOC-201 groups, respectively) over the course of hospitalization. The intraoperative administration of HBOC-201, up to a maximum of 245 g, was generally well tolerated. There was no relationship between HBOC-201 use and the number of allogeneic blood units transfused over the entire hospitalization course. The administration of HBOC-201 was associated with a delayed (third postoperative day) dose-dependent increase in the plasma methemoglobin concentration. We conclude that the intraoperative use of HBOC-201 was generally well tolerated. IMPLICATIONS: The intraoperative use of hemoglobin glutamer-250 (bovine) (HBOC-201, Hemopure was generally well tolerated. The administration of HBOC-201 was associated with a delayed increase in the plasma methemoglobin concentrations.