Complications related to intraoperative transesophageal echocardiography in liver transplantation.

PURPOSE: Intraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation (OLT) out of concern about rupture of esophageal varices. Complications associated with TEE in OLT were evaluated. METHODS: We retrospectively reviewed charts and TEE videos of all OLT cases from January 2003 through December 2013 at Mayo Clinic (Jacksonville, Florida). RESULTS: Of the 1811 OLTs performed, we identified 232 patients who underwent intraoperative TEE. Esophageal variceal status was documented during presurgical esophagogastroduodenoscopy in 230 of the 232 patients. Of these, 69 (30.0 %), had no varices; 113 (49.1 %), 41 (17.8 %), and 7 (3.0 %) had grades I, II, and III varices, respectively. Two patients (0.9 %) had no EGD performed because of acute liver failure. During OLT, 1 variceal rupture (0.4 %) occurred after placement of an oral gastric tube and TEE probe; the patient required intraoperative variceal banding. Most patients had preexisting coagulopathy at the time of probe placement. The mean (SD) laboratory test results were as follows: prothrombin time, 21.7 (6.6) seconds; international normalized ratio, 1.9 (1.3); partial thromboplastin time, 43.8 (13.3) seconds; platelet, 93.7 (60.8) × 1000/µL; and fibrinogen, 237.8 (127.6) mg/dL. CONCLUSION: TEE was a relatively safe procedure with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices and coagulopathy undergoing OLT. It appeared to effectively disclose cardiac information and allowed rapid reaction for proper patient management.

Intracardiac thrombosis during liver transplant: A 17-year single-institution study.

Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right- and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.

Anesthesia for combined cardiac surgery and liver transplant.

OBJECTIVE: To describe aspects of anesthesia for combined cardiac surgery and orthotopic liver transplant (OLT). DESIGN: Retrospective case series. SETTING: Hospital with cardiac surgery and liver transplant programs. PARTICIPANTS: Nine patients between September 1998 and July 2006. INTERVENTION: Combined cardiac surgery and OLT. MEASUREMENT AND MAIN RESULTS: Demographic and outcome data were recorded for each patient. Multiple intraoperative parameters were collected at baseline, after induction of anesthesia, after cardiac surgery, and after OLT. Five patients underwent combined OLT and coronary artery bypass graft (CABG) surgery. Four patients underwent combined OLT and aortic valve replacement (AVR) to relieve aortic stenosis. One of these 4 patients also had a saphenous vein graft to the left anterior descending artery. The CABG/OLT patients had hypertension, diabetes, or both, and multiple coronary arteries were affected although ejection fraction was preserved. The 1 death in this group was unrelated to a coronary event. The AVR/OLT patients had aortic stenosis that met American Heart Association guidelines for AVR. One death, within 24 hours of surgery, was associated with severe pulmonary artery hypertension. The median transfusion volumes were 12 units of packed red blood cells, 22 units of fresh frozen plasma, and 30 units of platelets. Three of the 9 patients required renal replacement therapy postoperatively. The median duration of intubation was 2 days, and length of stay in the intensive care unit was 5.5 days. CONCLUSION: Combined cardiac and OLT surgery is complex and serious morbidity occurs, but successful outcomes are attainable.

Importance of perioperative blood glucose management in cardiac surgical patients.

Tight blood glucose control has become a therapeutic goal for anesthetic management of patients undergoing cardiovascular surgery. We discuss the evidence for a link between blood glucose levels and rates of morbidity and mortality in cardiac surgical patients in the intensive care unit. Hyperglycemia per se has been associated with higher rates of deep wound infection, neurologic, renal, and cardiac complications following surgery, as well as longer intensive care unit stay. We review the specifics of glucose management in patients undergoing cardiac surgery and hypothermic cardiopulmonary bypass, including the role that insulin may play in regulating blood glucose levels intraoperatively and the relationship between insulin and outcome.

Intraoperative management: endovascular stents.

This article discusses the current state of minimally invasive treatment options for a variety of vascular diseases. Advances that have been introduced over the last two decades have dramatically changed the practice of vascular surgery and anesthesia. The ability to treat pathology, using both intraluminal and extraluminal means,has provided vascular surgeons, interventional radiologists, and cardiologists with unique treatment options that were not available less than a decade ago. Peripheral interventions to treat vascular disease have exploded, from 90,000 in 1994 to more than 200,000 in 1997, and endovascular procedures now replace almost 50% of traditional open vascular operations.