An appraisal of neostigmine versus sugammadex for neuromuscular blockade reversal in patients with a prior heart transplant.

INTRODUCTION: Heart transplant recipients present unique perioperative challenges for surgery. Specifically, autonomic system denervation has significant implications for commonly used perioperative drugs. This study investigates neuromuscular blocking antagonists in this population when undergoing subsequent non-cardiac surgery. MATERIAL AND METHODS: A retrospective review was performed for the period 2015-2019 across our health care enterprise. Patients with previous orthotopic heart transplant and subsequent non-cardiac surgery were identified. A total of 185 patients were found, 67 receiving neostigmine (NEO) and 118 receiving sugammadex (SGX). Information of patient characteristics, prior heart transplant, and subsequent non-cardiac surgery was collected. Our primary outcome was the incidence of bradycardia (heart rate < 60 bpm) and/or hypotension (mean blood pressure (MAP) < 65 mmHg) following neuromuscular blockade reversal. Secondary outcomes included need of intra-operative inotropic agents, arrhythmia, cardiac arrest, hospital length of stay (hLOS), ICU admission, and death within 30 postoperative days. RESULTS: In unadjusted analysis, no significant differences were found between the two groups in change in heart rate [0 (-26, 14) vs. 1 (-19, 10), P = 0.59], change in MAP [0 (-22, 28) vs. 0 (-40, 47), P = 0.96], hLOS [2 days (1, 72) vs. 2 (0, 161), P = 0.92], or intraoperative hypotension [4 (6.0%) vs. 5 (4.2%), OR = 0.70, P = 0.60] for NEO and SGX respectively. After multivariable analysis, the results were similar for change in heart rate ( P = 0.59) and MAP ( P = 0.90). CONCLUSIONS: No significant differences in the incidence of bradycardia and hypotension were found in the NEO versus SGX groups. NEO and SGX may have similar safety profiles in patients with prior heart transplant undergoing non-cardiac surgery.

Perioperative Management of Liver Retransplant in an Adult With a History of TRMU Alteration.

Dysfunction of oxidative phosphorylation and the mitochondrial respiratory chain leads to a heterogeneous group of pathogenic mitochondrial variations. The TRMU gene codes for transfer RNA 5- methylaminomethyl-2-thiouridylate methyltransferase and is essential for posttranscriptional modification of the mitochondrial transfer RNA, and alterations in the TRMU gene can lead to infantile liver failure at approximately 6 months of age. Orthotopic liver transplant is a curative option. We present a case of a patient with TRMU alteration who underwent liver transplant at 11 months of age to treat infantile end- stage liver disease. The patient had liver failure due to long-standing allograft rejection and required another liver transplant at age 24 years, and here we discuss the perioperative care of this patient. Coordination of the care team to prevent rhabdomyolysis or alternative negative catabolic effects was the cornerstone of management in addition to evaluation of unusual electrocardiographic findings in the immediate postoperative period. Although the patient's postoperative course was complicated by repair of a bile leak, liver retransplant successfully restored the patient's preoperative quality of life.