Liver Transplantation in a Patient With Antiphospholipid Syndrome: A Case Report.

Antiphospholipid syndrome (APS) is an acquired thrombophilic disorder characterized by autoantibodies to cell membrane phospholipids. While altered coagulation can complicate end-stage liver disease, there are few reports describing the perioperative management for liver transplantation in recipients with a preexisting hypercoagulable disorder, such as APS. We present a patient with a history of APS, Budd-Chiari syndrome with cirrhosis, hepatopulmonary syndrome, and heparin-induced thrombocytopenia who underwent liver transplantation complicated by hepatic artery thrombosis. Management included postoperative anticoagulation with a factor Xa inhibitor and, after repeat transplantation, transition to long-term anticoagulation therapy with eventual recovery.

Adherence to a Multimodal Analgesic Clinical Pathway: A Within-Group Comparison of Staged Bilateral Knee Arthroplasty Patients.

BACKGROUND AND OBJECTIVES: Multimodal analgesic clinical pathways for joint replacement patients often include perineural catheters, but long-term adherence to these pathways has not yet been investigated. Our primary aim was to determine adherence rate to a knee arthroplasty clinical pathway for patients undergoing staged bilateral procedures. METHODS: This study was performed at a hospital with a Perioperative Surgical Home program and knee arthroplasty clinical pathway using multimodal analgesia and adductor canal catheters. Data were examined for all orthopedic surgery patients over a 4-year period. We included patients who had staged bilateral knee arthroplasty electively scheduled on 2 separate dates. The primary outcome was rate of adductor canal catheter utilization as a measure of adherence to the clinical pathway. Other outcomes included rates of neuraxial anesthesia and minor and major perioperative complications. RESULTS: We analyzed data for 103 unique patients. The interval between surgeries was a median of 261 days (10th-90th percentile, 138-534 days). All 103 patients had adductor canal catheters for both the first and second surgeries (P > 0.999). Forty-one percent of patients had the same surgeon for both surgeries, but only 2% had the same anesthesiologist (P < 0.001). From the first to the second surgery, utilization of neuraxial anesthesia increased from 51% to 68%, respectively (P = 0.005). There were no differences in minor or major complications. CONCLUSIONS: For staged bilateral knee arthroplasty patients, 100% clinical pathway adherence including perineural catheters and multimodal analgesia is feasible despite multiple variables. We believe that patient-centered acute pain management requires consistent and reliable delivery of care.

Incidence and 1-Year Outcomes of Perioperative Atrial Arrhythmia in Elderly Adults After Hip Fracture Surgery.

OBJECTIVES: To determine the incidence and 1-year outcomes of an elderly population with perioperative atrial arrhythmia (PAA) within 7 days of hip fracture surgery. DESIGN: Retrospective cohort study. SETTING: The Rochester Epidemiology Project (REP). PARTICIPANTS: Elderly adults consecutive undergoing hip fracture repair from 1988 to 2002 in Olmsted County, Minnesota (N = 1,088, mean age 84.0 ± 7.4, 80.2% female). MEASUREMENTS: Baseline clinical variables were analyzed in relation to survival using Cox proportional hazards methods for comparison. RESULTS: Sixty-one participants (5.6%) developed PAA within the first 7 days. During 1 year of follow-up, 239 (22%) participants died. PAA was associated with greater mortality (45% vs 21%; hazard ratio (HR) = 2.8, 95% confidence interval (CI) = 1.9-4.2). Other mortality risk factors were male sex (HR = 2.0, 95% CI = 1.5-2.6), congestive heart failure (HR = 2.1, 95% CI = 1.7-2.8), chronic renal insufficiency (HR = 2.0, 95% CI = 1.5-2.8), dementia (HR = 2.9, 95% CI = 2.2-3.7), and American Society of Anesthesiologists risk Class III, IV, or V (HR = 3.3, 95% CI = 1.9-5.9). CONCLUSION: Elderly adults undergoing hip fracture surgery who develop PAA within 7 days have significantly higher 1-year mortality than those who do not. Further studies are indicated to determine whether prevention of PAA will reduce mortality in this population.

Acute vocal fold dystonic reaction to propofol: a case report.

A 67-year old male underwent uneventful robotic-assisted thoracoscopic resection of a solitary pulmonary fibrous tumor. Immediately following extubation at the completion of the surgical procedure, the patient developed respiratory distress that did not resolve with treatment. Benadryl provided only temporary relief. Midazolam and hydromorphone were given for anxiolysis and analgesia respectively, which provided transient relief of symptoms. Propofol was given to decrease upper airway reflexes. Adequate reversal from nondepolarizing neuromuscular blockade was confirmed with nerve stimulator. A flexible laryngoscope was introduced nasally to visualize the vocal cords, which revealed intermittent tremulousness of the vocal cords, adduction of bilateral vocal cords to the midline, and minimal to absent opening with inspiration, without any apparent injury or blood, saliva, or vomit noted in or around the glottic opening. The patient was then given diazepam and reintubated. Given the patient's history of difficulty breathing after previous surgery and the lack of vocal cord movement, dystonic reaction to propofol was suspected. The patient remained intubated for two hours in the post-anesthesia care unit before being extubated uneventfully.

Derivation of mean pulmonary artery pressure from noninvasive parameters.

BACKGROUND: The assessment of pulmonary pressure is important for the diagnosis and management of patients with pulmonary hypertension. Mean pulmonary artery pressure (MPAP) has been used in the current definition of pulmonary hypertension. However, invasive derivation by Doppler echocardiography provides the peak pulmonary artery systolic pressure (PASP). The aim of this study was to derive a method to predict MPAP from PASP. METHODS: Invasive hemodynamic pressures in 307 patients who underwent right heart catheterization were examined. Simple regression techniques were used to determine the relationship between MPAP and PASP in a derivation cohort (n = 198) and a validation sample (n = 109). Bland-Altman analysis was performed to examine predicted versus observed values of MPAP. RESULTS: MPAP and PASP at catheterization were strongly related over a range of pressures (R(2) = 0.89, n = 198; SE, 4.04; P < .0001). The relation of MPAP to PASP in the derivation cohort (MPAP = 0.61 × PASP + 1.95 mm Hg) was validated in the test sample, with an R(2) value of 0.94 for predicted versus observed MPAP (SE, 2.87; P < .0001). The relationship of predicted versus observed MPAP was constant across different degrees of pressure elevation, as well as different etiologies of pulmonary hypertension. Applying the equation to Doppler-derived pulmonary pressures, there was excellent correlation of predicted MPAP from echocardiography and invasively measured MPAP (R(2) = 0.78, P < .0001). CONCLUSIONS: MPAP can be accurately predicted from PASP over a wide pressure range for different etiologies of pulmonary hypertension. This finding may help define MPAP noninvasively.