Perioperative Efficiency of Sugammadex Following Laparoscopic Cholecystectomy in Clinical Practice.

Background: Studies have proposed that the routine use of the modified gamma-cyclodextrin, sugammadex, could provide perioperative time savings. However, these investigations have been limited to small group analyses. The purpose of this study was to test the effectiveness of sugammadex on perioperative times when compared to neostigmine under general clinical practice conditions following rocuronium-induced neuromuscular blockade for laparoscopic cholecystectomy. Methods: Following institutional review board approval, data from 1,611 consecutive surgical records for laparoscopic cholecystectomy were reviewed. Patient characteristics, type of primary neuromuscular blocking reversal agent, operating room (OR) discharge times, and postanesthesia care unit (PACU) recovery times were the measures of interest. Equivalence testing was used to determine the between-group differences of the reversal agents in the two perioperative time periods of interest. Results: OR discharge times averaged 10.9 (95% CI, 10-11.8) minutes for patients administered sugammadex and 8.9 (95% CI, 8.2-9.7) minutes for patients administered neostigmine. PACU recovery times averaged 77.6 (95% CI, 74.1-81.1) minutes for sugammadex and 68.6 (95% CI, 65.9-71.3) minutes for neostigmine. Equivalence testing demonstrated no improvement in the two perioperative times with sugammadex. Conclusion: These results suggest no perioperative time savings with sugammadex when compared to neostigmine following laparoscopic cholecystectomy under general clinical practice conditions.

Acute Esophageal Necrosis Following Orthotopic Liver Transplantation.

Acute esophageal necrosis (AEN) is a rare syndrome characterized by circumferential blackening of the esophageal mucosa extending from the gastroesophageal (GE) junction and affecting variable length of the organ. Its etiology is largely multifactorial including ischemic compromise, massive reflux of gastric secretions, and decreased mucosal defense. Endoscopy is diagnostic. Clinical management requires treatment of underlying condition, nil-per-os restriction, and anti-acids. Esophageal stricture or stenosis may be seen as late complication, managed symptomatically with dilatation. Mortality is high and related to associated medical conditions. We present the first case of AEN following orthotopic liver transplantation.

Long-Term Cardiac Morbidity and Mortality in Patients With Aortic Valve Disease Following Liver Transplantation: A Case Matching Study.

INTRODUCTION: This retrospective study examined the role of aortic valve (AV) disease in patients who underwent orthotopic liver transplantation (OLT) to determine the incidence of postoperative cardiac morbidity and mortality when compared with a matched control group without AV disease. METHODS: Patients were included in the AV group if diagnosed with aortic stenosis (AS) or aortic regurgitation or had received AV replacement prior to OLT. The AV group (n = 53) was matched to a control group (n = 212) with the following preoperative variables: type of organ transplanted, age, gender, race, body mass index, MELD, redo-transplantation, preoperative renal replacement therapy, nonalcoholic steatohepatitis, viral hepatitis, diabetes, and coronary artery disease. A 1:4 ratio was utilized to improve the efficiency and power of the analysis. RESULTS: No significant difference in survival or posttransplant cardiac complications (acute coronary syndrome, heart failure, or dysrhythmia) was observed between groups. However, statistically significantly more patients-11% (6/53)-required coronary intervention following OLT in the AV group, whereas 3% (7/212) required coronary intervention (χ2 = 5.8; P = .0156) in the control group. Following OLT, 9% (5/53) in the AV group required surgical or nonsurgical AV intervention, whereas no valvular events were observed in the control group. Event-free survival in the AV group, with an end point defined as AV intervention (n = 5) and death (n = 10), was 92% (49/53) at 1 year, 83% (44/53) at 3 years, and 72% (38/53) at 5 years. CONCLUSIONS: Patients with pretransplant AV replacement or AS have significant cardiac complications (myocardial infarction, AV replacement, or cardiac death) in 1 to 3 years post-OLT.

Thromboprophylaxis With Heparin During Orthotopic Liver Transplantation: Comparison of Hepcon HMS Plus and Anti-Xa Assays for Low-Range Heparin.

OBJECTIVES: The purpose of this study was to compare the agreement between two heparin assays, Hepcon HMS plus/Kaolin-ACT and Anti-Xa, and their predictive power in detecting circulating heparin levels post-reperfusion of the liver graft when compared with thromboelastogram (TEG) r time ratio in patients undergoing orthotopic liver transplantation (OLT). DESIGN: Prospective, observational cohort study design. SETTING: Single center, university hospital. PARTICIPANTS: Thirty-eight consecutive adults who had undergone liver transplant. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Paired arterial blood samples were collected before surgical incision, 5 minutes after administration of an average dose of 2,054±771 units of intravenous unfractionated heparin before caval cross-clamping, 5 minutes after portal reperfusion, 5 minutes after hepatic artery reperfusion, and 1 hour after hepatic artery reperfusion. The observations that heparin assay measurements were within the predetermined limits of agreement, strongly suggested the two heparin assays (Hepcon HMS plus and Anti-Xa assay) are interchangeable during prophylactic heparin dose therapy during OLT. Post-reperfusion, receiver operating characteristic curve analysis revealed high accuracy in measuring circulating heparin levels with both Anti-Xa and Hepcon HMS assays when compared with the TEG r time ratio assay. CONCLUSIONS: The point-of-care Hepcon HMS plus/Kaolin-ACT (activated clotting time) assay appeared to be a reliable alternative to the more expensive and laboratory-required Anti-Xa assay in monitoring the response to intravenous heparin in patients undergoing OLT.

Epsilon-Aminocaproic Acid Has No Association With Thromboembolic Complications, Renal Failure, or Mortality After Liver Transplantation.

OBJECTIVES: To examine the role of epsilon-aminocaproic acid (EACA) administered after reperfusion of the donor liver in the incidences of thromboembolic events and acute kidney injury within 30 days after orthotopic liver transplantation. One-year survival rates between the EACA-treated and EACA-nontreated groups also were examined. DESIGN: Retrospective, observational, cohort study design. SETTING: Single-center, university hospital. PARTICIPANTS: The study included 708 adult liver transplantations performed from 2008 to 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: EACA administration was not associated with incidences of intracardiac thrombosis/pulmonary embolism (1.3%) or intraoperative death (0.6%). Logistic regression (n = 708) revealed 2 independent risk factors associated with myocardial ischemia (age and pre-transplant vasopressor use) and 8 risk factors associated with the need for post-transplant dialysis (age, female sex, redo orthotopic liver transplantation, preoperative sodium level, pre-transplant acute kidney injury or dialysis, platelet transfusion, and re-exploration within the first week after transplant); EACA was not identified as a risk factor for either outcome. One-year survival rates were similar between groups: 92% in EACA-treated group versus 93% in the EACA-nontreated group. CONCLUSIONS: The antifibrinolytic, EACA, was not associated with an increased incidence of thromboembolic complications or postoperative acute kidney injury, and it did not alter 1-year survival after liver transplantation.

Critical airway management: a suggested modification to the rigid fiber-optic stylet based on 301 novice intubations.

BACKGROUND: Emergent airways in critically ill patients outside the operating room (critical airways) are often difficult airways frequently managed by intensivists. Current advanced airway management tools have not been adequately evaluated for critical airways and are not specifically designed for intensivists. The rigid fiber-optic stylet has the potential to fill this niche as it is an established difficult intubation technique very similar to bronchoscopy. The purpose of this study was to evaluate the rigid fiber-optic stylet and identify characteristics that would affect its use for critical airway management by intensivists. METHODS: A retrospective, single-center, observational study was performed in the setting of a tertiary care university teaching hospital. A total of 301 consecutive elective surgery patients underwent endotracheal intubation attempted by a novice using a rigid fiber-optic stylet. RESULTS: Novices could successfully intubate >95% patients using the rigid fiber-optic stylet. Most patients were intubated within 2 attempts (93%) in a median time of 73 seconds. In all the cases of intubation failure by novices, the staff anesthesiologist could successfully intubate the patient in his first attempt with an average time of 32 seconds. By studying unsuccessful attempts, we identified an important barrier to the adaptation of this tool for critical airway management-the absence of working channels, which does not allow suctioning, oxygenation, or instillation of lidocaine. CONCLUSIONS: A multilumen sheath designed with 2 working channels has the potential to overcome all identified barriers to the use of rigid fiber-optic stylet as a critical airway management device by intensivists. This modification should be evaluated in a clinical study.

A new endotracheal tube designed to enable a single operator to perform percutaneous dilatational tracheostomy while maintaining the airway, providing continuous bronchoscopic guidance, and minimizing procedural complications: demonstration of feasibility on a mannequin and a cadaver.

BACKGROUND: : We designed a double-lumen endotracheal tube (the EZ [Easy] Tracheostomy [EZT]) to enable a single operator to safely perform percutaneous dilatational tracheostomy (PDT) at the bedside while providing continuous bronchoscopic guidance. The EZT design also aims to ensure uninterrupted mechanical ventilation during most of the PDT procedure via a secure airway. It aims to significantly minimize hypoxia, hypoventilation, auto-positive end-expiratory pressure, airway loss, posterior wall laceration, and damage to the endoscope related to the current methodology. METHOD: : We demonstrated the feasibility of our method on a mannequin model and a cadaver. RESULTS: : Single operators successfully performed the modified PDT on their first attempt with excellent visualization and no obvious complications. The potential for minimal interruption in ventilation, low risk of airway loss or malpositioning, and significant reduction in other PDT-related complications were clearly demonstrated. The procedure was found to be easier to perform when compared with conventional PDT. CONCLUSIONS: : It is feasible for a single operator to perform PDT with continuous bronchoscopic guidance when using the EZT on cadaver and mannequin models. Clinical studies are warranted to evaluate this new tool.

Management of the difficult pediatric airway with Shikani Optical Stylet.

The airways of children with many craniofacial and mandibulofacial malformations often present unique challenges to the anesthesiologists. We report the application of Shikani Optical Stylet (SOS) in facilitating the tracheal intubation of four children with history of difficult airway management. The SOS combines the benefits of the lightwand and fiberoptic bronchoscope.