Comparison of continuous intravenous lidocaine versus transversus abdominis plane block for kidney transplant surgery: a randomized, non-inferiority trial.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane (TAP) blocks are associated with an improvement in postoperative analgesia following kidney transplant surgery. However, these blocks carry inherent risk and require a degree of expertise to perform successfully. Continuous intravenous lidocaine may be an effective alternative. In this randomized, non-inferiority study, we hypothesized that a continuous lidocaine infusion provides similar postoperative analgesia to a TAP block. METHODS: Subjects presenting for kidney transplant surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection TAP block (TAP group) or a continuous infusion of lidocaine (Lido group). The primary outcome of this non-inferiority study was opioid consumption within the first 24 hours following surgery. Secondary outcomes included pain scores, patient satisfaction, opioid-related adverse events, time to regular diet, and persistent opioid use. RESULTS: One hundred and twenty subjects, 59 from the TAP group and 61 from the Lido group, completed the study per protocol. Analysis of the primary outcome showed a cumulative geometric mean intravenous morphine equivalent difference between the TAP (14.6±3.2 mg) and Lido (15.9±2.4 mg) groups of 1.27 mg (95% CI -4.25 to 6.79; p<0.001), demonstrating non-inferiority of the continuous lidocaine infusion. No secondary outcomes showed clinically meaningful differences between groups. CONCLUSIONS: This study demonstrates that a continuous infusion of lidocaine offers non-inferior postoperative analgesia compared with an ultrasound-guided unilateral, single-injection TAP block in the first 24 hours following kidney transplant surgery. TRIAL REGISTRATION NUMBER: NCT03843879.

Surgical solution to an intracorporeal nickel allergy.

A previously healthy 30-year-old man with a symptomatic varicocele underwent gonadal vein embolization using nickel vascular plugs. He developed a painful hypersensitivity to his nickel plugs and elected to pursue laparoscopic excision and proximal gonadal vein ligation. In the operating room, the gonadal vein was isolated from the ureter, and ligated proximal to the cephalad plug and distal to the caudal coil. His pain is completely resolved 5 months after surgery. Metal allergies are well documented in orthopedics and cardiology implants, but there are a limited number of case reports of metal allergies after varicocele embolization. Interestingly, nickel is the most common type of metal hypersensitivity.

Ureteral stent duration and the risk of BK polyomavirus viremia or bacteriuria after kidney transplantation.

OBJECTIVES: Ureteral stents are used in kidney transplantation (KTX) to decrease post-operative complications, but they are associated with BK polyomavirus viremia (BKV). Our primary outcome was to determine the association between ureteral stent duration and BKV. Secondary outcome measures were the association between bacteriuria and stent duration or use of ureteral stent strings. METHODS: Between January 2010 and January 2015, 403 patients underwent KTX at the Virginia Mason Medical Center and met inclusion criteria. Stent duration was classified as short (<3 weeks) or long (>3 weeks). Multivariate logistic regression models were created to assess for factors associated with BKV. The covariates in the BKV model were chosen a priori based on stent duration and risk factors previously described in the literature. RESULTS: Ureteral stents were placed in 304 (75.4%) transplants. Stent strings were left attached in 166 (54.6%) patients. On multivariate analyses, long stent duration was significantly associated with increased risk of BKV compared with no stent (odds ratio [OR] 1.92, P=.044, 95% confidence interval [CI] 1.04-3.74). Short stent duration was not associated with BKV. Sixty-two (15.4%) patients had bacteriuria. Bacteriuria was associated with female gender (OR 2.77, P<.001, 95% CI 1.58-4.95), and there was a dose-dependent effect with stent duration compared with no stent-short duration (OR 2.46, P=.049, 95% CI 1.05-6.49) and long duration (OR 3.58, P=.004, 95% CI 1.58-9.25). Stent strings were not associated with either complication. CONCLUSIONS: The association between ureteral stents and BKV may be dose dependent.

A randomized clinical trial testing the anti-inflammatory effects of preemptive inhaled nitric oxide in human liver transplantation.

Decreases in endothelial nitric oxide synthase derived nitric oxide (NO) production during liver transplantation promotes injury. We hypothesized that preemptive inhaled NO (iNO) would improve allograft function (primary) and reduce complications post-transplantation (secondary). Patients at two university centers (Center A and B) were randomized to receive placebo (n = 20/center) or iNO (80 ppm, n = 20/center) during the operative phase of liver transplantation. Data were analyzed at set intervals for up to 9-months post-transplantation and compared between groups. Patient characteristics and outcomes were examined with the Mann-Whitney U test, Student t-test, logistic regression, repeated measures ANOVA, and Cox proportional hazards models. Combined and site stratified analyses were performed. MELD scores were significantly higher at Center B (22.5 vs. 19.5, p<0.0001), surgical times were greater at Center B (7.7 vs. 4.5 hrs, p<0.001) and warm ischemia times were greater at Center B (95.4 vs. 69.7 min, p<0.0001). No adverse metabolic or hematologic effects from iNO occurred. iNO enhanced allograft function indexed by liver function tests (Center B, p<0.05; and p<0.03 for ALT with center data combined) and reduced complications at 9-months (Center A and B, p = 0.0062, OR = 0.15, 95% CI (0.04, 0.59)). ICU (p = 0.47) and hospital length of stay (p = 0.49) were not decreased. iNO increased concentrations of nitrate (p<0.001), nitrite (p<0.001) and nitrosylhemoglobin (p<0.001), with nitrite being postulated as a protective mechanism. Mean costs of iNO were $1,020 per transplant. iNO was safe and improved allograft function at one center and trended toward improving allograft function at the other. ClinicalTrials.gov with registry number 00582010 and the following URL:http://clinicaltrials.gov/show/NCT00582010.

Impact of fatigue on neurophysiologic measures of surgical residents.

BACKGROUND: To gain additional insight into the impact of fatigue on surgery resident proficiency, we set out to quantify its impact on behavioral and neurophysiologic measures. STUDY DESIGN: Simulations were first created using a visio-haptic joystick attached to a surgical instrument (tool) that allows realistic interactions. Before baseline (pre-call) and after call, 7 PGY1 surgery residents performed simulation tasks that required varying levels of psychomotor and cognitive skill. Residents completed 3 sessions per week for 4 weeks. Surgical proficiency was established using 5 metrics: hand movement smoothness; instrument movement smoothness; time to task completion; gesture level proficiency and cognitive errors. Data (percent change from baseline, pre-call) were analyzed using repeated measures ANOVA. While performing these tasks, the residents also wore an EEG cap (B-Alert; Advanced Brain Monitoring), the data from which provided second to second insight into the effects of workload, distraction, and attention on task performance. Mean (±SD) pre-call and post-call values for each were analyzed using repeated measures ANOVA. RESULTS: Residents experienced significant (p < 0.014) post-call erosions in surgical proficiency, punctuated by dramatic increases in cognitive errors. EEG-based attention scores showed a significant (p < 0.014) concomitant decrement of 40%; distraction/drowsiness scores increased by 91%; and workload score increased by 51%. CONCLUSIONS: Fatigue adversely affects PGY1 resident surgical proficiency and neurophysiologic performance.

Effects of duty hours and time of day on surgery resident proficiency.

BACKGROUND: Night floats have evolved in the era of limited resident work hours. This study was designed to define the effect of restricted nighttime duty hours on the psychomotor and cognitive skills of surgery residents. METHODS: To quantify the effect of fatigue on the skills of residents on day-shift and night-float rotations, residents were asked to complete visuohaptic simulations before and after 12-hour duty periods and to rate their fatigue level with questionnaires. RESULTS: Both groups showed significant decrements in proficiency measures after their shifts compared with baseline. The night-float group showed more significant declines (P < .05) in all areas assessed than the day-shift group. The night-float group was significantly less proficient in cognitive tasks after their shifts compared with the day-shift group. CONCLUSIONS: The deterioration of surgical proficiency is to a degree dependent on the time of day during which call occurs, not solely on the length of call.

Impact of a patient care pathway protocol on surgical site infection rates in cardiothoracic surgery patients.

BACKGROUND: We hypothesized that implementing a quality care initiative, including peri-incisional antibiotic administration, tight blood glucose control, and hair removal with clippers would reduce surgical site infection (SSI) rates in patients undergoing coronary artery bypass grafting (CABG), with or without valve replacement. METHODS: Patients undergoing CABG were studied retrospectively, before (n = 808) and after (n = 674) instituting a patient care protocol. The pathway included peri-incisional antibiotics, tight glucose control (80 mg/dL-110 mg/dL) throughout intensive care unit (ICU) stays, and hair removal with clippers. RESULTS: SSIs were significantly decreased in the experimental group (1.5%), compared with the control group (3.5%), (P = .001, odds ratio [OR] = .21). Significant independent predictors of infection included diabetes mellitus (P = .001, OR = 4.71), Nosocomial Infection Surveillance System (NNIS) wound class II (P = .044, OR = 2.07), and female gender (P = .001, OR = 2.83). CONCLUSIONS: Protocols implementing timely perioperative antibiotics, tight blood glucose control, and avoidance of shaving decrease SSI rates in CABG patients.

Cargo from tumor-expressed albumin inhibits T-cell activation and responses.

In this study, we show that rodent albumin is expressed by and cell surface localized on at least some murine tumor cells. We have been able to purify this tumor-expressed albumin from in vivo grown tumor masses. The tumor-expressed albumin, unlike normal serum albumin purified from blood, is capable of inhibiting T-cell activation, proliferation, and function in both in vitro and in vivo settings. Tumor-expressed albumin does not appear to affect antigen processing or presentation by professional antigen-presenting cells. The activity appears to lie in relatively small, lipid-like moieties that are presumably cargo for tumor-expressed albumin, and that activity can be removed from the albumin by lipid removal or treatment with lipase. Thus, we herein report of a novel form of tumor-induced immune suppression attributable to lipid-like entities, cloaked by albumin produced by tumors.