Assessment of fluid responsiveness after tidal volume challenge in renal transplant recipients: a nonrandomized prospective interventional study.

Background: When applying lung-protective ventilation, fluid responsiveness cannot be predicted by pulse pressure variation (PPV) or stroke volume variation (SVV). Functional hemodynamic testing may help address this limitation. This study examined whether changes in dynamic indices such as PPV and SVV, induced by tidal volume challenge (TVC), can reliably predict fluid responsiveness in patients undergoing renal transplantation who receive lung-protective ventilation. Methods: This nonrandomized interventional study included renal transplant recipients with end-stage renal disease. Patients received ventilation with a 6 mL/kg tidal volume (TV), and the FloTrac system was attached for continuous hemodynamic monitoring. Participants were classified as responders or nonresponders based on whether fluid challenge increased the stroke volume index by more than 10%. Results: The analysis included 36 patients, of whom 19 (52.8%) were responders and 17 (47.2%) were nonresponders. Among responders, the mean ΔPPV6-8 (calculated as PPV at a TV of 8 mL/kg predicted body weight [PBW] minus that at 6 mL/kg PBW) was 3.32±0.75 and ΔSVV6-8 was 2.58±0.77, compared to 0.82±0.53 and 0.70±0.92 for nonresponders, respectively. ΔPPV6-8 exhibited an area under the curve (AUC) of 0.97 (95% confidence interval [CI], 0.93-1.00; P≤0.001), with an optimal cutoff value of 1.5, sensitivity of 94.7%, and specificity of 94.1%. ΔSVV6-8 displayed an AUC of 0.93 (95% CI, 0.84-1.00; P≤0.001) at the same cutoff value of 1.5, with a sensitivity of 94.7% and a specificity of 76.5%. Conclusions: TVC-induced changes in PPV and SVV are predictive of fluid responsiveness in renal transplant recipients who receive intraoperative lung-protective ventilation.

Perioperative care in acute liver failure: An anaesthesiologist perspective in the operating theatre.

Acute liver failure (ALF) is a life-threatening condition characterized by rapid liver function deterioration, necessitating a multidisciplinary approach for optimal perioperative care. This comprehensive review focuses on the critical role of the anaesthesiologist throughout the preoperative, intraoperative, and postoperative phases, addressing the unique challenges posed by ALF. The article begins with an exploration of ALF, underlining the urgency of timely referral to specialized hepatology centres. Liver transplantation emerges as a life-saving intervention, and the complex decision-making process is discussed, emphasizing the need for a multidisciplinary team to assess transplantation candidacy based on established prognostic criteria. In the preoperative phase, the review stresses the importance of early engagement with tertiary liver centres for timely referrals and identifies patients suitable for transplantation. Safe transport protocols are detailed, highlighting the meticulous planning required for the secure transfer of ALF patients between healthcare facilities. The intraoperative management section delves into the anaesthesiologist's key concerns, including neurological status, sepsis, acute kidney injury, body mass index, and preoperative fasting. Hemodynamic stability, fluid management, and coagulation balance during surgery are emphasized, with insights into anaesthesia techniques, vascular access, monitoring, and hemodynamic management tailored to the challenges posed by ALF patients. The postoperative care is thoroughly examined covering neurological, hemodynamic, metabolic, renal, and nutritional aspects. Management of ALF involves multidisciplinary team, including nephrology for continuous renal replacement therapy, transfusion medicine for plasma exchange, critical care for overall patient care, nutritionists for ensuring adequate nutrition, and hepatologists as the primary guides. In conclusion, the review recognizes the anaesthesiologist as a linchpin in the perioperative care of ALF patients. The integration of safe transport protocols and multidisciplinary approach is deemed crucial for navigating complexities of ALF, contributing to improved patient outcomes. This article serves as an invaluable resource for gastroenterologist and intensivists, enhancing their understanding of the anaesthesiologist's indispensable role in the holistic care of ALF patients in an ever-evolving healthcare landscape.

An overview of unresolved issues in the perioperative management of liver transplant patients.

Over the past decade, the field of solid organ transplantation has undergone significant changes, with some of the most notable advancements occurring in liver transplantation. Recent years have seen substantial progress in preoperative patient optimization protocols, anesthesia monitoring, coagulation management, and fluid management, among other areas. These improvements have led to excellent perioperative outcomes for all surgical patients, including those undergoing liver transplantation. In the last few decades, there have been numerous publications in the field of liver transplantation, but controversies related to perioperative management of liver transplant recipients persist. In this review article, we address the unresolved issues surrounding the anesthetic management of patients scheduled for liver transplantation.

Perioperative management of a severely thrombocytopenic kidney transplant recipient using thromboelastography.

Perioperative transfusion of blood and blood products can be avoided or reduced with bedside real time monitoring of coagulation in patients at risk. Thromboelastography (TEG), is a point of care coagulation monitor to assess dynamic progress of clot formation. We report a case of 26 years old female patient with end-stage kidney disease (ESKD) who underwent living donor kidney transplantation at our institute. On preoperative work-up, her complete blood count revealed severe thrombocytopenia. Etiology of thrombocytopenia could not be established except past history of hemolysis, elevated liver enzymes, and low platelets syndrome in her last pregnancy. Perioperative transfusion of blood and blood products was guided with TEG and transplant was conducted successfully without any transfusion. In conclusion, severe thrombocytopenia in patients with ESKD enhances the risk of perioperative bleeding and related complications in already compromised coagulation system. Kidney transplant without pre-emptive transfusion could be possible with perioperative use of TEG.