European association of cardiothoracic anesthesiology and intensive care pediatric cardiac anesthesia fellowship curriculum: first edition

ABSTRACT: Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First Edition.

Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

The validity of central venous to arterial carbon dioxide difference to predict adequate fluid management during living donor liver transplantation. A prospective observational study.

BACKGROUND: To assess the validity of central and pulmonary veno-arterial CO2 gradients to predict fluid responsiveness and to guide fluid management during liver transplantation. METHODS: In adult recipients (ASA III to IV) scheduled for liver transplantation, intraoperative fluid management was guided by pulse pressure variations (PPV). PPV of ≥15% (Fluid Responding Status-FRS) indicated fluid resuscitation with 250 ml albumin 5% boluses repeated as required to restore PPV to < 15% (Fluid non-Responding Status-FnRS). Simultaneous blood samples from central venous and pulmonary artery catheters (PAC) were sent to calculate central venous to arterial CO2 gap [C(v-a) CO2 gap] and pulmonary venous to arterial CO2 gap [Pulm(p-a) CO2 gap]. CO and lactate were also measured. RESULTS: Sixty seven data points were recorded (20 FRS and 47 FnRS). The discriminative ability of central and pulmonary CO2 gaps between the two states (FRS and FnRS) was poor with AUC of ROC of 0.698 and 0.570 respectively. Central CO2 gap was significantly higher in FRS than FnRS (P = 0.016), with no difference in the pulmonary CO2 gap between both states. The central and Pulmonary CO2 gaps are weakly correlated to PPV [r = 0.291, (P = 0.017) and r = 0.367, (P = 0.002) respectively]. There was no correlation between both CO2 gaps and both CO and lactate. CONCLUSION: Central and the Pulmonary CO2 gaps cannot be used as valid tools to predict fluid responsiveness or to guide fluid management during liver transplantation. CO2 gaps also do not correlate well with the changes in PPV or CO. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03123172 . Registered on 31-march-2017.

The use of terlipressin during living donor liver transplantation: Effects on systemic and splanchnic hemodynamics and renal function.

OBJECTIVES: To assess the effect of the intraoperative use of terlipressin on splanchnic hemodynamics and postoperative renal function in patients undergoing liver transplantation. DESIGN: Open-label, prospective, randomized study. SETTING: Single-center study. PATIENTS: Thirty patients who underwent elective, living-donor liver transplantation with portal pressure >20 mm Hg. INTERVENTIONS: Patients were assigned randomly to one of two equal groups. The control group received saline, whereas the treatment group (TP group) received an initial bolus dose of terlipressin (1 mg over 30 mins) followed immediately by a continuous infusion of 2 µg·kg(-1)·h(-1) for 48 hrs. MEASUREMENTS AND MAIN RESULTS: Portal pressure and gas exchange (radial artery, portal vein, and hepatic vein, blood gas analyses, and lactate concentration) were assessed at baseline (after ligation of the hepatic artery) and 2 hrs after drug administration. Systemic hemodynamic data and calculated tissue oxygenation parameters were compared throughout the procedure. Renal function was assessed by measurement of serum cystatin C after induction of anesthesia and on the first 2 days postoperatively. After the infusion of terlipressin, portal venous pressure decreased significantly from 26.3 ± 3.3 to 21.3 ± 3.6 mm Hg (p < .001). The mean arterial pressure and systemic vascular resistance were significantly higher in the TP group than in the control group, whereas heart rate and cardiac index were comparable between the groups. Portal and hepatic base excess, and the level of serum lactate, did not differ between the two groups. The serum levels of both cystatin C and creatinine were significantly higher in the control group than in the TP group on postoperative day 2. CONCLUSION: Perioperative use of terlipressin abrogates the early postoperative decline in renal function of patients who have chronic liver disease and undergo liver transplantation without any detrimental effect on hepatosplanchnic gas exchange and lactate metabolism.

The safety of modern hydroxyethyl starch in living donor liver transplantation: a comparison with human albumin.

BACKGROUND: Intravascular volume replacement therapy is an important issue in the perioperative management of liver transplantation. There is paucity of data on the safety of hydroxyethyl starch (HES) in patients undergoing liver transplantation. We evaluated the safety of a new HES 130/0.4 in the perioperative management of liver transplantation, with a special emphasis on renal function. METHODS: Forty patients undergoing living donor liver transplantation were prospectively randomized into two groups. Patients in the ALB group (n = 20) received 5% human albumin. Patients in the HES group (n = 20) received third generation HES (6% HES 130/0.4). Total colloid administration was limited to 50 mL x kg(-1) x d(-1). The volume was given to maintain pulmonary artery occlusion pressure or central venous pressure between 5 and 7 mm Hg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Serum creatinine and cystatin C plasma levels were measured from arterial blood samples after induction of anesthesia, at the end of surgery, and on the first 4 postoperative days. RESULTS: All 40 enrolled patients completed the study. Demographic and intraoperative variables were comparable in both groups. Postoperatively, the mean +/- sd volume was 6229 +/- 1140 mL and 4636 +/- 1153 mL in HES and ALB groups, respectively (P = 0.003). There was significantly greater [corrected] net cumulative fluid balance in the HES [corrected] group 3047 +/- 2000 [corrected] mL compared with the ALB group 1100 +/- 900 [corrected] mL, P = 0.029. Serum creatinine, creatinine clearance, and cystatin C plasma levels showed no significant differences between the two groups. One patient in each group developed acute renal failure requiring renal replacement therapy. CONCLUSION: The use of HES 130/0.4 as an alternative to human albumin resulted in equivalent renal outcome after liver transplantation.