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.

Regional anesthesia in patients with Charcot-Marie-Tooth disease: a historical cohort study of 53 patients.

PURPOSE: Anesthetic management for patients with Charcot-Marie-Tooth disease (CMT) is controversial. Description of the use of regional anesthesia (RA) in patients with CMT is limited. Regional anesthesia has traditionally been avoided because of risk of nerve injury. We retrospectively reviewed patients with CMT who received RA at our institution. METHODS: We performed a historical cohort study of all patients with CMT who received RA from 30 April 2010 to 30 April 2020 within our institution. Charts were reviewed for information on demographics, RA procedures, perioperative variables, evidence of neurologic complications, post-RA neurology consults, and perioperative electromyography (EMG) results. Electromyographs were reviewed by a neurologist who was blinded to the surgical and RA details. RESULTS: Fifty-three patients received a total of 132 regional anesthetics during the study period. Twenty-five patients received RA on more than one occasion. Fifty-five EMGs and 14 postoperative neurology consults were performed. Two patients had neurology consults with peripheral nerve block (PNB) distribution complaints years later. Neither attributed the complaints to the PNB. The other neurology consults were for unrelated complaints. No EMG results suggested injury related to PNB. CONCLUSION: This study found no evidence of documented neurologic complications or an increased risk of nerve injury related to RA in CMT patients.

RéSUMé: OBJECTIF: La prise en charge anesthésique des patients atteints de la maladie de Charcot-Marie-Tooth (CMT) est controversée. Les descriptions de l'utilisation de l'anesthésie régionale (AR) chez les patients atteints de CMT sont limitées. L'anesthésie régionale est traditionnellement évitée en raison du risque de lésion nerveuse. Nous avons rétrospectivement passé en revue les dossiers des patients atteints de CMT ayant reçu une AR dans notre établissement. MéTHODE: Nous avons réalisé une étude de cohorte historique de tous les patients atteints de CMT ayant reçu une AR entre le 30 avril 2010 et le 30 avril 2020 au sein de notre établissement. Les dossiers ont été passés en revue pour en tirer des renseignements sur les données démographiques, les interventions d'AR, les variables périopératoires, les signes de complications neurologiques, les consultations en neurologie post-AR et les résultats de l'électromyographie (EMG) périopératoire. Les électromyographes ont été examinés par un neurologue qui n'avait pas accès aux détails concernant la chirurgie et l'AR. RéSULTATS: Cinquante-trois patients ont reçu un total de 132 anesthésies régionales au cours de la période d'étude. Vingt-cinq patients ont reçu une AR à plus d'une occasion. Cinquante-cinq EMG et 14 consultations postopératoires en neurologie ont été effectuées. Deux patients ont consulté en neurologie après s'être plaints de la distribution du bloc nerveux périphérique (BNP) des années plus tard. Ni l'un ni l'autre n'a attribué ces problèmes au BNP. Les autres consultations en neurologie concernaient des plaintes non liées au BNP. Aucun résultat d'EMG n'a suggéré de lésion liée au BNP. CONCLUSION: Cette étude n'a trouvé aucune preuve de complications neurologiques documentées ou d'un risque accru de lésion nerveuse liée à l'AR chez les patients atteints de CMT.

Paravertebral block for radiologically inserted gastrostomy tube placement in amyotrophic lateral sclerosis.

INTRODUCTION: Radiologically inserted gastrostomy (RIG) placement in patients with amyotrophic lateral sclerosis (ALS) carries risks related to periprocedural sedation and analgesia. To minimize these risks, we used a paravertebral block (PVB) technique for RIG placement. METHODS: We retrospectively reviewed patients with ALS undergoing RIG placement under PVB between 2013 and 2017. RESULTS: Ninety-nine patients with ALS underwent RIG placement under PVB. Median (range) age was 66 (28 to 86) years, ALS Functional Rating Scale-Revised score was 27 (6 to 45), and forced vital capacity was 47% (8%-79%) at time of RIG placement. Eighty-five (85.9%) patients underwent RIG placement as outpatients, with a mean postanesthesia care unit stay of 2.3 hours. The readmission rate was 4% at both 1 and 30 days postprocedure. DISCUSSION: PVB for RIG placement has a low rate of adverse events and provides effective periprocedural analgesia in patients with ALS, the majority of whom can be treated as outpatients.

Peripheral Nerve Blocks and Immediate Postoperative Recovery: A Single-Institution Survey of Perianesthesia Nurses' Preferences and Opinions.

PURPOSE: To ascertain the preferences of perianesthesia nurses regarding peripheral nerve blocks (PNBs) and their impact on patient recovery after total joint replacement (TJR). DESIGN: Survey of perianesthesia nurses at a single medical center. METHODS: Fifty-nine perianesthesia nurses completed a 23-question survey on PNBs for TJR. FINDINGS: Most agreed PNBs improved patients' pain after knee, hip, and shoulder TJR (35 [92.1%], 35 [92.1%], and 34 [91.9%], respectively). Most felt lower extremity PNBs increased risk of falling (26 [70.3%]), whereas 7 of 35 (20.0%) felt patients fell more after spinal anesthesia than after general anesthesia. Respondents preferred a block to opioid-based analgesia if they were to have lower extremity TJR or total shoulder replacement (100% [30/30 and 33/33]). CONCLUSIONS: The perianesthesia nurses surveyed felt PNBs improved pain control and patient recovery despite a perceived risk of falling for lower extremity TJR, and they preferred PNB when considering TJR surgery for themselves.

Intraoperative evaluation of cervical nerve root avulsion using ultra-high-frequency ultrasound system.

Avulsion of C5 and C7 nerve roots was confirmed intraoperatively in a 21 year old male presenting after motor vehicle accident with confirmed absence of somatosensory evoked potentials upon stimulation via ultra-high-frequency ultrasound (70 MHz). Ultra-high-frequency ultrasound can be used as a reliable tool to directly visualise nerve injury.

Peripheral nerve blocks and postoperative physical therapy: a single-institution survey of physical therapists' preferences and opinions.

BACKGROUND AND AIMS: Our aim was to ascertain the opinions and preferences of physical therapists with regard to use of peripheral nerve blocks and their impact on the recovery of patients undergoing total joint replacement. METHODS: We conducted an anonymous 24-question survey of 20 full-time inpatient physical therapists at a single tertiary care medical center. RESULTS: One respondent indicated they never work with patients who have undergone total joint replacement surgery. Nineteen questionnaires were included in the final analysis. Questions omitted by respondents or with write-in answers were not included in the analysis. A majority of respondents (15 [78.9%]) agreed nerve blocks somewhat to greatly improve a patient's pain after total joint replacement surgery. Most respondents answered that nerve blocks somewhat to greatly impede a patient's ability to participate in physical therapy (14 [73.6%]) and make therapy somewhat to very difficult for them as physical therapists (16 [84.2%]). When asked about specific surgeries, (17/18 [94.4%]) and (14/18 [77.8%]) of respondents would prefer that their patients receive periarticular infiltration or no block at all after total knee arthroplasty or total hip arthroplasty, respectively. All respondents (19 [100%]) answered that they thought lower extremity nerve blocks increased a patient's risk of falling after surgery. CONCLUSIONS: According to the physical therapists we surveyed, nerve blocks impede patient recovery and increase the risk of falls, despite their positive impact on pain control. When considering surgery for themselves, therapists indicated they would not want a nerve block.

Perioperative ketamine for acute postoperative analgesia: the Mayo Clinic-Florida experience.

Many common elective surgeries are associated with moderate-to-severe postoperative pain. These common surgeries include total knee and total hip arthroplasty, thoracotomy, and multilevel lumbar spine surgery. Unfortunately, many patients requiring these surgeries are already in moderate-to-severe pain, necessitating high doses of oral or transdermal opioids preoperatively. This is an established risk factor for difficult-to-control postoperative pain.(1,2) Opioid-sparing interventions are important elements in these patients to promote convalescence and reduce common opioid side effects such as constipation, confusion, pruritus, nausea, vomiting, and urinary retention. Potential interventions to reduce postoperative pain can include nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, and even invasive therapies such as epidural or peripheral nerve blockade. Ketamine is a well-known anesthetic agent that has opioid-sparing analgesic properties, is noninvasive, and in analgesic doses, has few contraindications. This article will review the basic science behind ketamine, some of the evidence supporting its perioperative use, and the logistics of how the Department of Anesthesia at Mayo Clinic in Jacksonville, Florida rolled out a hospital-wide ketamine infusion protocol.

Anesthetic pharmacology and perioperative considerations for the end stage liver disease patient.

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.

Acute aortic occlusion presenting as paraplegia: a catastrophic complication in an elective surgical patient.

Acute aortic occlusion by massive thoracoabdominal thrombi has been reported as a serious complication in patients undergoing major vascular or cardiac surgical procedures. However, this complication occurs rarely after ambulatory procedures. In this case report, we describe a patient who experienced paraplegia after an elective laparoscopic cholecystectomy in whom acute aortic thromboembolic occlusion was subsequently diagnosed. We emphasize the importance of accurate neurologic and cardiovascular history taking and examination throughout the perioperative period along with the appropriate diagnostic studies to expeditiously arrive at a diagnosis of such a rare complication.