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.

Role of Intrathecal Morphine for Acute Postoperative Pain Management in Patients Undergoing Kidney Transplant: A Randomized Controlled Study.

OBJECTIVES: Postoperative pain after a major surgery continues to be a challenge. Regional anesthetic techniques make up a substantial part of interventions to decrease postoperative pain and the use of opioids. In this study, we aimed to evaluate the effectiveness of intrathecal morphine in patients undergoing kidney transplant, in terms of both duration and quality of postoperative analgesia. MATERIALS AND METHODS: We conducted a prospective randomized double-blind study and analyzed 60 patients divided into 2 groups of 30 each who were scheduled for elective living-related (first-degree donor) kidney transplant. One group received intrathecal morphine, and the other group received intrathecal normal saline. We used the numeric rating scale to assess the postoperative pain score. We also recorded the postoperative consumption of fentanyl, time of first analgesia requirement, total rescue analgesia, catheter-related bladder discomfort, and related complications for 48 hours postoperatively. RESULTS: Patients in the intrathecal morphine group had significantly lower pain scores both at rest and while coughing and less consumption of total fentanyl (P < .05). When we compared patient groups, patients in the intrathecal morphine group had significantly lower total rescue analgesia (P < .05) and significantly lower catheter-related bladder discomfort but significantly higher pruritus (P = .01). CONCLUSIONS: Intrathecal morphine significantly reduces postoperative opioid consumption and can result in fewer incidences of catheter-related bladder discomfort.

A randomized comparison between pulse pressure variation and central venous pressure in patients undergoing renal transplantation.

Background and Aims: Intraoperative fluid management is important in renal transplant recipients with end-stage renal disease. Conventionally, central venous pressure (CVP) has been used to guide perioperative fluid administration but with high incidence of poor graft outcome. There is a requirement of reliable parameter to guide the fluid therapy in these patients so as to minimize the perioperative complications and improve the outcome. Hence, this study was conducted. Material and Methods: This prospective study included 75 patients of chronic kidney disease undergoing renal transplantation. Patients were divided into two groups. Group A (control group): Intraoperative fluids were guided by CVP; Group B: Intraoperative fluids were guided by pulse pressure variation (PPV). Primary outcome measure of this study was incidence of delayed graft functioning, i.e., need of hemodialysis within 7 days of renal transplant. Secondary outcome measures were incidence of perioperative hypotension, post-transplant pulmonary edema, tissue edema, and lactic acidosis. Results: Total amount of fluid before reperfusion was significantly greater in the control group (P = 0.005). However, the total amount of fluid required at the end of surgery was comparable. Delayed graft functioning was seen only in CVP group, although it was not statistically significant. The postoperative tissue edema was more in CVP group (P = 0.03). The postoperative nausea and vomiting, pulmonary edema, and mechanical ventilation were more in CVP group but not statistically significant. Increase in lactate value was more in CVP group. Conclusion: Perioperative fluid guidance by PPV is better than central venous pressure in renal transplant patients.

[Anesthesia for renal transplantation in patients with dilated cardiomyopathy: a retrospective study of 31 cases]. / Anestesia para transplante renal em pacientes com cardiomiopatia dilatada: estudo retrospectivo de 31 casos.

BACKGROUND AND OBJECTIVES: Dilated cardiomyopathy is a state of progressive enlargement of cardiac chambers mainly left ventricle which leads to decreased cardiac output and ultimately cardiac failure. Although it has multifactorial etiology, it is quite common in patients with end stage renal disease who require renal transplant surgery for their cure. Both conditions go side by side and anesthetic management of such cases poses real challenge to anesthesiologist. Strict monitoring and control of cardiac physiology is of utmost importance besides meticulous fluid management, thus preserving renal blood flow on one hand and preventing cardiac failure on other hand. This is the basis of achieving good outcome of the renal transplant surgery. METHODS: This is a retrospective observational study done by analysing electronic database of 31 patients with dilated cardiomyopathy who underwent renal transplant surgery. Data was studied in terms of demographics, duration of renal disease, comorbidities mainly hypertension, cardiac echo graphic findings including ejection fraction, medications and post-operative outcome. RESULTS: Most common perioperative complication in this patient population was hypotension (51.61%) followed by pulmonary complications postoperative mechanical ventilation (12.9%) and pulmonary edema (6.45%). High incidence of hypotension may be a causative factor to increased rate of delayed graft functioning (12.9%) and acute tubular necrosis (2.23%) in these patients. CONCLUSION: Strict monitoring and control of hemodynamic parameters as well as meticulous fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy undergoing renal transplant surgery.

Anesthesia for renal transplantation in patients with dilated cardiomyopathy: a retrospective study of 31 cases / Anestesia para transplante renal em pacientes com cardiomiopatia dilatada: estudo retrospectivo de 31 casos

Abstract Background and objectives: Dilated cardiomyopathy is a state of progressive enlargement of cardiac chambers mainly left ventricle which leads to decreased cardiac output and ultimately cardiac failure. Although it has multifactorial etiology, it is quite common in patients with end stage renal disease who require renal transplant surgery for their cure. Both conditions go side by side and anesthetic management of such cases poses real challenge to anesthesiologist. Strict monitoring and control of cardiac physiology is of utmost importance besides meticulous fluid management, thus preserving renal blood flow on one hand and preventing cardiac failure on other hand. This is the basis of achieving good outcome of the renal transplant surgery. Methods: This is a retrospective observational study done by analysing electronic database of 31 patients with dilated cardiomyopathy who underwent renal transplant surgery. Data was studied in terms of demographics, duration of renal disease, comorbidities mainly hypertension, cardiac echo graphic findings including ejection fraction, medications and post-operative outcome. Results: Most common perioperative complication in this patient population was hypotension (51.61%) followed by pulmonary complications postoperative mechanical ventilation (12.9%) and pulmonary edema (6.45%). High incidence of hypotension may be a causative factor to increased rate of delayed graft functioning (12.9%) and acute tubular necrosis (2.23%) in these patients. Conclusion: Strict monitoring and control of hemodynamic parameters as well as meticulous fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy undergoing renal transplant surgery.

Resumo Justificativa e objetivos A cardiomiopatia dilatada é um estado de aumento progressivo das câmaras cardíacas, principalmente do ventrículo esquerdo, que leva à diminuição do débito cardíaco e, por fim, à insuficiência cardíaca. Embora tenha etiologia multifatorial, é bastante comum em pacientes com doença renal terminal que precisam de transplante renal para sua cura. Ambas as condições andam lado a lado e o manejo anestésico de tais casos é um verdadeiro desafio para o anestesiologista. A monitoração e o controle rigoroso da fisiologia cardíaca são de extrema importância, além de um meticuloso manejo dos líquidos, o que por um lado preserva o fluxo sanguíneo renal, por outro previne a insuficiência cardíaca. Essa é a base para alcançar o bom resultado da cirurgia de transplante renal. Métodos Este estudo observacional retrospectivo foi feito mediante a análise de prontuários eletrônicos de 31 pacientes com cardiomiopatia dilatada submetidos à cirurgia de transplante renal. Os dados foram avaliados em termos demográficos, duração da doença renal, comorbidades (principalmente hipertensão), achados ecocardiográficos (inclusive fração de ejeção), medicamentos e resultados no pós-operatório. Resultados A complicação perioperatória mais comum nessa população de pacientes foi hipotensão (51,61%), seguida de complicações pulmonares, como ventilação mecânica pós-operatória (12,9%) e edema pulmonar (6,45%). A alta incidência de hipotensão pode ser um fator causador do aumento da incidência de atraso no funcionamento do enxerto (12,9%) e necrose tubular aguda (2,23%) nesses pacientes. Conclusão A monitoração rigorosa e o controle dos parâmetros hemodinâmicos, bem como a fluidoterapia criteriosa, são a pedra angular na melhoria dos resultados em pacientes com cardiomiopatia dilatada submetidos à cirurgia de transplante renal.

Foot drop: an iatrogenic complication of spinal anesthesia / Pé caído: uma complicação iatrogênica da anestesia espinhal

Abstract Background and objectives Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. Case report A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). Conclusions Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention.

Resumo Justificativa e objetivos Pé caído no período pós-operatório é muito raro após a anestesia espinhal. Avaliação clínica e intervenções diagnósticas precoces são de primordial importância para estabelecer a etiologia e iniciar o tratamento adequado. Um acompanhamento atento é justificado no pós-operatório imediato nos casos em que o paciente se queixa de parestesia ou dor durante a inserção da agulha ou da injeção de fármacos. Relato de caso Paciente do sexo masculino, 22 anos, submetido a cirurgia ortopédica de membros inferiores sob anestesia espinhal. Durante a transferência para a sala de recuperação pós-operatória, houve suspeita de pé caído durante a avaliação rotineira da regressão do nível espinhal. O paciente foi imediatamente enviado ao neurologista e uma ressonância magnética foi feita, mas não foi conclusiva. O manejo conservador foi iniciado e o estudo de condução nervosa foi feito no 4° dia de pós-operatório, o que confirmou a neuropatia motora pura do nervo fibular direito. O paciente foi dispensado com imobilizador de tornozelo e fisioterapia após ligeira melhoria da força motora (2/5). Conclusões Pé caído é muito raro após a anestesia espinhal. Qualquer paciente suspeito deve ser submetido à consulta neurológica de emergência e ressonância magnética para excluir o principal achado e a necessidade de intervenção cirúrgica precoce.

Pulmonary hypertension and post-operative outcome in renal transplant: A retrospective analysis of 170 patients.

BACKGROUND AND AIMS: Renal transplant is the best possible treatment for patients suffering with end-stage renal disease (ESRD). Cardiovascular events are the commonest factors contributing to perioperative morbidity and mortality in this population. These patients have a high incidence (up to 60%) of pulmonary hypertension (PH) and that may affect the perioperative outcome. METHODS: In this study, we aimed to study the impact of PH on perioperative outcome after renal transplant. PH was defined as patients with pulmonary artery systolic pressure ≥35 mmHg on pre-operative echocardiography. Medical records of 170 patients who had undergone renal transplantation in the past 3 years were reviewed. Primary outcome was delayed graft functioning and secondary outcomes were perioperative complications such as hypotension, arrhythmias, need of post-operative mechanical ventilation, atelectasis and pulmonary oedema. RESULTS: We observed 46.5% incidence of PH in ESRD patients. Compared to patients without PH, more patients with PH had postoperative hypotension (26.58% vs. 9.89%, P = 0.004) and delayed graft functioning (8.8% vs. 1.1%, P = 0.026). On multivariate analysis, however, PH was not an independent predictor of delayed graft functioning. CONCLUSION: In ESRD patients, although PH is not an independent predictor of delayed graft functioning, patients having PH are more prone for perioperative hypotension and delayed graft functioning after renal transplant.

[Foot drop: an iatrogenic complication of spinal anesthesia]. / Pé caído: uma complicação iatrogênica da anestesia espinhal.

BACKGROUND AND OBJECTIVES: Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. CASE REPORT: A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). CONCLUSIONS: Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention.

Effect of preoperative incentive spirometry on fentanyl-induced cough: a prospective, randomized, controlled study.

BACKGROUND: Fentanyl-induced cough (FIC) has a reported incidence of 13-65% on induction of anesthesia. Incentive spirometry (IS) creates forceful inspiration, while stretching pulmonary receptors. We postulated that spirometry just before the fentanyl (F) bolus would decrease the incidence and severity of FIC. METHODS: This study enrolled 200 patients aged 18-60 years and with American Society of Anesthesiologists status I or II. The patients were allocated to two groups of 100 patients each depending on whether they received preoperative incentive spirometry before fentanyl administration. Patients in the F+IS group performed incentive spirometry 10 times just before an intravenous bolus of 3 µg/kg fentanyl in the operating room. The onset time and number of coughs after fentanyl injection were recorded as primary outcomes. Any significant changes in blood pressure, heart rate, or adverse effects of the drug were recorded as secondary outcomes. RESULTS: Patients in the F+IS group had a significantly lower incidence of FIC than in the F group (6% vs. 26%) (P < 0.05). The severity of cough in the F+IS group was also significantly lower than that in group F (mild, 5 vs. 17; moderate 1 vs. 7; severe, 0 vs. 2) (P < 0.05). The median onset time was comparable in both groups (9 s [range: 6-12 s] in both groups). CONCLUSIONS: Preoperative incentive spirometry significantly reduces the incidence and severity of FIC when performed just before fentanyl administration.

A comparative study between propofol and etomidate in patients under general anesthesia / Estudo comparativo entre propofol e etomidato em pacientes sob anestesia geral

ABSTRACT BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2 mg/kg) and etomidate (0.3 mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p > 0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

RESUMO JUSTIFICATIVA E OBJETIVOS: A indução é uma parte crítica da prática de anestesia. Hipotensão súbita, arritmias e colapso cardiovascular são complicações ameaçadoras após a injeção de agente de indução em pacientes hemodinamicamente instáveis. É aconselhável o uso de um agente seguro com menos efeitos adversos para esse propósito. O presente estudo prospectivo, randômico, teve como objetivo comparar propofol e etomidato quanto a seus efeitos sobre a hemodinâmica e aos vários efeitos adversos em pacientes sob anestesia geral. MÉTODOS: Cem pacientes ASA I e II, entre 18-60 anos, programados para procedimento cirúrgico eletivo sob anestesia geral, foram divididos aleatoriamente em dois grupos de 50 cada para receber propofol (2 mg/kg) e etomidato (0,3 mg/kg) como um agente de indução. Os parâmetros vitais na indução, laringoscopia e posteriormente foram registrados para comparação. Efeitos adversos como dor à injeção, apneia e mioclonia foram cuidadosamente monitorados. RESULTADOS: As variáveis demográficas foram comparáveis em ambos os grupos. Os pacientes do grupo etomidato apresentaram pouca alteração da pressão arterial média (PAM) e da frequência cardíaca (FC) em comparação com o grupo propofol (p < 0,05) a partir do valor basal. Houve mais dor à injeção no grupo propofol, enquanto houve mais atividade mioclônica no grupo etomidato. CONCLUSÕES: Este estudo conclui que etomidato é um agente melhor para a indução do que o propofol em relação à estabilidade hemodinâmica e menos dor à injeção.

A comparative study between propofol and etomidate in patients under general anesthesia.

BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2mg/kg) and etomidate (0.3mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p>0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.

[A comparative study between propofol and etomidate in patients under general anesthesia]. / Estudo comparativo entre propofol e etomidato em pacientes sob anestesia geral.

BACKGROUND AND OBJECTIVES: Induction of anesthesia is a critical part of anesthesia practice. Sudden hypotension, arrhythmias, and cardiovascular collapse are threatening complications following injection of induction agent in hemodynamically unstable patients. It is desirable to use a safe agent with fewer adverse effects for this purpose. Present prospective randomized study is designed to compare propofol and etomidate for their effect on hemodynamics and various adverse effects on patients in general anesthesia. METHODS: Hundred ASA I and II patients of age group 18-60 years scheduled for elective surgical procedure under general anesthesia were randomly divided into two groups of 50 each receiving propofol (2mg/kg) and etomidate (0.3mg/kg) as an induction agent. Vital parameters at induction, laryngoscopy and thereafter recorded for comparison. Adverse effect viz. pain on injection, apnea and myoclonus were carefully watched. RESULTS: Demographic variables were comparable in both the groups. Patients in etomidate group showed little change in mean arterial pressure (MAP) and heart rate (HR) compared to propofol (p>0.05) from baseline value. Pain on injection was more in propofol group while myoclonus activity was higher in etomidate group. CONCLUSIONS: This study concludes that etomidate is a better agent for induction than propofol in view of hemodynamic stability and less pain on injection.