Takotsubo syndrome after liver transplantation: An association with intraoperatively administered epinephrine and fentanyl.

Takotsubo syndrome (TTS) can develop after liver transplant (LT), but its predisposing factors are poorly understood. In this study, we aimed to determine if perioperative factors were associated with posttransplant TTS. Adult patients who underwent primary LT between 2006 and 2018 were included. Patients with and without TTS were identified and matched by propensity scores. Of 2181 LT patients, 38 developed postoperative TTS with a mean left ventricular ejection fraction of 25.5% (±7.8%). Multivariable logistic regression revealed two preoperative risk factors (alcoholic cirrhosis and model for end-stage liver disease-sodium scores) for TTS. Post-propensity match analyses showed that TTS patients had significantly higher doses of epinephrine and lower doses of fentanyl during LT compared with non-TTS patients. A higher dose of epinephrine and a lower dose of fentanyl was associated with a higher predicted probability of TTS. All TTS patients had full recovery of cardiac function and had comparable 1-year survival. In conclusion, TTS occurred at a rate of 1.7% after LT and was associated with two pretransplant risk factors. The higher doses of epinephrine and lower doses of fentanyl administered during LT were associated with posttransplant TTS. More studies on the relationship between intraoperative medications and TTS are warranted.

Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits.

Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.

Preoperative beta blockade and severe intraoperative bradycardia in liver transplantation.

Nonselective Beta blockade (NSBB) is commonly prescribed for liver transplantation (LT) candidates, but its impact on intraoperative hemodynamics is not well understood. In this study, we investigated if preoperative NSBB was associated with severe bradycardia during LT and if severe intraoperative bradycardia was associated with 30-day mortality. Adult patients undergoing LT between 2005 and 2014 were included. Propensity matching was used to control selection bias. Intraoperative hemodynamics were compared between patients with and without preoperative NSBB. Univariate and multivariate methods were used in statistical analysis. Of 1452 patients, 370 who received preoperative NSBB were matched in a 1:1 ratio with those who did not. Propensity matching eliminated all significant differences between the two groups. Patients who received preoperative NSBB had a significantly higher incidence of severe intraoperative bradycardia compared with the non-BB group (9.6% vs 3.2%, P = 0.001, OR 2.95, 95% CI 1.42-6.12, P = 0.004). Intraoperative hypotension and postreperfusion syndrome were not significantly different between the two groups. Severe intraoperative bradycardia was associated with increased 30-day mortality. In conclusion, preoperative NSBB was associated with severe intraoperative bradycardia in LT. In patients who receive preoperative NSBB, severe intraoperative bradycardia should be closely monitored in LT. Further studies assessing safety of preoperative NSBB and intraoperative bradycardia in LT are warranted.

Venovenous Bypass Is Associated With a Lower Incidence of Acute Kidney Injury After Liver Transplantation in Patients With Compromised Pretransplant Renal Function.

BACKGROUND: Although the hemodynamic benefits of venovenous bypass (VVB) during liver transplantation (LT) are well appreciated, the impact of VVB on posttransplant renal function is uncertain. The aim of this study was to determine if VVB was associated with a lower incidence of posttransplant acute kidney injury (AKI). METHODS: Medical records of adult (≥18 years) patients who underwent primary LT between 2004 and 2014 at a tertiary hospital were reviewed. Patients who required pretransplant renal replacement therapy and intraoperative piggyback technique were excluded. Patients were divided into 2 groups, VVB and non-VVB. AKI, determined by the Acute Kidney Injury Network criteria, was compared between the 2 groups. Propensity match was used to control selection bias that occurred before VVB and multivariable logistic regression was used to control confounding factors during and after VVB. RESULTS: Of 1037 adult patients who met the study inclusion criteria, 247 (23.8%) received VVB. A total of 442 patients (221 patients in each group) were matched. Aftermatch patients were further divided according to a predicted probability AKI model using preoperative creatinine (Cr), VVB, and intraoperative variables into 2 subgroups: normal and compromised pretransplant renal functions. In patients with compromised pretransplant renal function (Cr ≥1.2 mg/dL), the incidence of AKI was significantly lower in the VVB group compared with the non-VVB group (37.2% vs 50.8%; P = .033). VVB was an independent risk factor negatively associated with AKI (odds ratio, 0.1; 95% confidence interval, 0.1-0.4; P = .001). Renal replacement in 30 days and 1-year recipient mortality were not significantly different between the 2 groups. The incidence of posttransplant AKI was not significantly different between the 2 groups in patients with normal pretransplant renal function (Cr <1.2 mg/dL). CONCLUSIONS: In this large retrospective study, we demonstrated that utilization of intraoperative VVB was associated with a significantly lower incidence of posttransplant AKI in patients with compromised pretransplant renal function. Further studies to assess the role of intraoperative VVB in posttransplant AKI are warranted.

Effect of Performance Deficiencies on Graduation and Board Certification Rates: A 10-yr Multicenter Study of Anesthesiology Residents.

BACKGROUND: This multicenter, retrospective study was conducted to determine how resident performance deficiencies affect graduation and board certification. METHODS: Primary documents pertaining to resident performance were examined over a 10-yr period at four academic anesthesiology residencies. Residents entering training between 2000 and 2009 were included, with follow-up through February 2016. Residents receiving actions by the programs' Clinical Competency Committee were categorized by the area of deficiency and compared to peers without deficiencies. RESULTS: A total of 865 residents were studied (range: 127 to 275 per program). Of these, 215 residents received a total of 405 actions from their respective Clinical Competency Committee. Among those who received an action compared to those who did not, the proportion graduating differed (93 vs. 99%, respectively, P < 0.001), as did the proportion achieving board certification (89 vs. 99%, respectively, P < 0.001). When a single deficiency in an Essential Attribute (e.g., ethical, honest, respectful behavior; absence of impairment) was identified, the proportion graduating dropped to 55%. When more than three Accreditation Council for Graduate Medical Education Core Competencies were deficient, the proportion graduating also dropped significantly. CONCLUSIONS: Overall graduation and board certification rates were consistently high in residents with no, or isolated, deficiencies. Residents deficient in an Essential Attribute, or multiple competencies, are at high risk of not graduating or achieving board certification. More research is needed on the effectiveness and selective deployment of remediation efforts, particularly for high-risk groups.

Myocardial injury in patients with hemodynamic derangements during and/or after liver transplantation.

Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30 days after LT between 2006 and 2013 were studied. Of 502 patients, 203 (40.4%) met the diagnostic criteria (cTn I ≥0.1 ng/mL) of myocardial injury. The majority of myocardial injury occurred within the first three postoperative days and presented without clinical signs or symptoms of myocardial infarction. Thirty-day mortality in patients with myocardial injury was 11.4%, significantly higher compared with that in patients without myocardial injury (3.4%, P<.01). Cox analysis indicated the peak cTn was significantly associated with 30-day mortality. Multivariable logistic analysis identified three independent risk factors: requirement of ventilation before transplant (odds ratios (OR) 1.6, P=.006), RBC≥15 units (OR 1.7, P=.006), and the presence of PRS (OR 2.0, P=.028). We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted.

Practice improvements based on participation in simulation for the maintenance of certification in anesthesiology program.

BACKGROUND: This study describes anesthesiologists' practice improvements undertaken during the first 3 yr of simulation activities for the Maintenance of Certification in Anesthesiology Program. METHODS: A stratified sampling of 3 yr (2010-2012) of participants' practice improvement plans was coded, categorized, and analyzed. RESULTS: Using the sampling scheme, 634 of 1,275 participants in Maintenance of Certification in Anesthesiology Program simulation courses were evaluated from the following practice settings: 41% (262) academic, 54% (339) community, and 5% (33) military/other. A total of 1,982 plans were analyzed for completion, target audience, and topic. On follow-up, 79% (1,558) were fully completed, 16% (310) were partially completed, and 6% (114) were not completed within the 90-day reporting period. Plans targeted the reporting individual (89% of plans) and others (78% of plans): anesthesia providers (50%), non-anesthesia physicians (16%), and non-anesthesia non-physician providers (26%). From the plans, 2,453 improvements were categorized as work environment or systems changes (33% of improvements), teamwork skills (30%), personal knowledge (29%), handoff (4%), procedural skills (3%), or patient communication (1%). The median word count was 63 (interquartile range, 30 to 126) for each participant's combined plans and 147 (interquartile range, 52 to 257) for improvement follow-up reports. CONCLUSIONS: After making a commitment to change, 94% of anesthesiologists participating in a Maintenance of Certification in Anesthesiology Program simulation course successfully implemented some or all of their planned practice improvements. This compares favorably to rates in other studies. Simulation experiences stimulate active learning and motivate personal and collaborative practice improvement changes. Further evaluation will assess the impact of the improvements and further refine the program.

Gastroesophageal and hemorrhagic complications associated with intraoperative transesophageal echocardiography in patients with model for end-stage liver disease score 25 or higher.

OBJECTIVE: To investigate major gastroesophageal and hemorrhagic complications that may be related to intraoperative transesophageal echocardiography (TEE) in liver transplant (LT) patients with high model for end-stage liver disease (MELD) score 25 or higher. DESIGN: Retrospective. SETTING: Single institution university setting. PARTICIPANTS: Of 906 transplant recipients, 656 who had MELD score 25 or higher were included for analysis. INTERVENTIONS: Patient demographics, pre- and intraoperative characteristics, and major gastroesophageal and hemorrhagic complications were compared between patients with and without TEE. MEASUREMENTS AND MAIN RESULTS: Sixty-six percent (433 patients) had intraoperative TEE and 34% (223 patients) did not. One patient in the TEE group had a major gastroesophageal complication (Mallory-Weiss tear). Eleven patients required postoperative gastrointestinal consultation. These patients were distributed evenly between the TEE and non-TEE groups. Eighteen (2.8%) had major hemorrhagic complication (defined as bloody nasogastric output>500 mL in 24 hours postoperatively). Multivariate analysis showed alcoholic cirrhosis had 5.3 higher odds of post-transplant gastroesophageal hemorrhage compared with other indications for transplant (95% confidence interval 1.8-15.8, p<0.001). TEE was not associated with an increased likelihood of major hemorrhagic complication after LT. CONCLUSIONS: The authors demonstrated that the incidence of major gastroesophageal and hemorrhagic complications following intraoperative TEE in LT patients with MELD score 25 or higher was low.

Perioperative complications in liver transplantation using donation after cardiac death grafts: a propensity-matched study.

Donation after cardiac death (DCD) is an important source for expanding the donor pool for liver transplantation (LT). Although the long-term outcomes of LT using DCD grafts have been extensively studied, perioperative complications related to DCD grafts are rarely reported. The aim of this study was to determine whether DCD grafts were associated with a higher incidence of postreperfusion complications and worse outcomes in adult LT patients. After institutional review board approval, the medical records of all adult patients who underwent LT at our medical center between 2004 and 2011 were reviewed. Postreperfusion complications and posttransplant outcomes were compared between patients receiving DCD grafts and patients receiving donation after brain death (DBD) grafts. In all, 74 patients received DCD grafts during the study period, and 1369 patients received DBD grafts. An initial comparison showed that many preoperative, prereperfusion, and donor variables in the DCD group differed significantly from those in the DBD group. Propensity matching was chosen so that adjustments could be made for the differences. A postmatching analysis showed that the preoperative, prereperfusion, and donor variables no longer differed between the 2 groups. The postreperfusion requirements for blood products and vasopressors, the posttransplant ventilation times, the incidence of posttransplant acute renal injury, and the 30-day and 1-year patient and graft survival rates were comparable between the 2 groups. However, patients receiving DCD grafts experienced significantly higher rates of hyperkalemia (33.8% versus 18.9%, P < 0.05) and postreperfusion syndrome (PRS; 25.7% versus 12.3%, P < 0.05). In conclusion, after adjustments for preoperative and prereperfusion risks via propensity matching, DCD grafts remained a risk factor for postreperfusion hyperkalemia and PRS. A prophylactic regimen aimed at decreasing postreperfusion hyperkalemia and PRS is recommended for the management of LT using DCD grafts.

Storage age of transfused red blood cells during liver transplantation and its intraoperative and postoperative effects.

BACKGROUND: Recent studies suggest that the storage age of red blood cells (RBCs) may be associated with morbidity and mortality in surgical patients. We studied perioperative effects of RBC storage age in patients undergoing orthotopic liver transplant (OLT). METHODS: Adult patients who received ≥ 5 U of RBCs during OLT between January 2004 and June 2009 were studied. The subjects were divided into two groups according to the mean storage age of RBCs they received: new or old RBCs (stored ≤ 14 or >14 days, respectively). Effects of storage age of transfused RBCs during OLT on intraoperative potassium (K(+)) concentrations, incidence of hyperkalemia (K(+) ≥ 5.5 mmol/L), postoperative morbidity, and patient and graft survival were studied. RESULTS: The mean serum K(+) concentrations and the incidence of hyperkalemia during OLT were significantly associated with storage age of the RBCs. Logistic analysis showed that storage age of RBCs was an independent risk factor for intraoperative hyperkalemia (odds ratios 1.067-1.085, p < 0.001) in addition to baseline K(+) concentration and units of RBCs transfused. Patient and graft survival and postoperative morbidity including postoperative ventilation, reoperation, acute renal dysfunction defined by the RIFLE criteria was not associated with old RBCs. CONCLUSIONS: Transfusion of RBCs stored for a longer time was associated with intraoperative hyperkalemia but not with postoperative adverse outcomes in adult OLT. Prevention and treatment of potentially harmful hyperkalemia should be considered when old RBCs are administered.

Impact of the COVID-19 pandemic on American College of Surgeons-Accredited Education Institutes & American Society of Anesthesiologists-Simulation Education Network: Opportunities for interdisciplinary collaboration.

BACKGROUND: The COVID-19 pandemic presented challenges for simulation programs including American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network. American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network leadership were surveyed to identify opportunities to enhance patient safety through simulation. METHODS: Between January and June 2021, surveys consisting of 3 targeted domains: (I) Changing practice; (II) Contributions and recognition; and (III) Moving ahead were distributed to 100 American College of Surgeons Accredited Education Institutes and 54 American Society of Anesthesiologists Simulation Education Network centers. Responses were combined and percent frequencies reported. RESULTS: Ninety-six respondents, representing 51 (51%) American College of Surgeons Accredited Education Institutes, 17 (31.5%) American Society of Anesthesiologists Simulation Education Network, and 28 dually accredited centers, completed the survey. Change of practice. Although 20.3% of centers stayed fully operational at the COVID-19 onset, 82% of all centers closed: 32% were closed less than 3 months, 28% were closed 3 to 6 months, 8% were closed 7 to 9 months, and 32% remained closed as of June 6, 2021. Most impacted activities were large-group instruction and team training. Sixty-nine percent of programs converted in-person to virtual programs. Contributions. The top reported innovative contributions included policies (80%), curricula (80%), and scholarly work (74%), Moving ahead. The respondents' top concerns were returning to high-quality training to best address learners' deficiencies and re-engagement of re-directed training programs. When asked "How the American College of Surgeons/American Society of Anesthesiologists Programs could best assist your simulation center goals?" the top responses were "facilitate collaboration" and "publish best practices from this work." CONCLUSION: The Pandemic presented multiple challenges and opportunities for simulation centers. Opportunities included collaboration between American College of Surgeons Accredited Education Institutes and the American Society of Anesthesiologists Simulation Education Network to identify best practices and resources needed to enhance patient safety through simulation.

Major Thromboembolic Complications in Liver Transplantation: The Role of Rotational Thromboelastometry and Cryoprecipitate Transfusion.

BACKGROUND: Although hemorrhage is a major concern during liver transplantation (LT), the risk for thromboembolism is well recognized. Implementation of rotational thromboelastometry (ROTEM) has been associated with the increased use of cryoprecipitate; however, the role of ROTEM-guided transfusion strategy and cryoprecipitate administration in the development of major thromboembolic complications (MTCs) has never been documented. METHODS: We conducted a study on patients undergoing LT before and after the implementation of ROTEM. We defined MTC as intracardiac thrombus, pulmonary embolism, hepatic artery thrombosis, and ischemic stroke in 30 d after LT. We used a propensity score to match patients during the 2 study periods. RESULTS: Among 2330 patients, 119 (4.9%) developed MTC. The implementation of ROTEM was significantly associated with an increase in cryoprecipitate use (1.1 ± 1.1 versus 2.9 ± 2.3 units, P < 0.001) and MTC (4.2% versus 9.5%, P < 0.001). Further analysis demonstrated that the use of cryoprecipitate was an independent risk factor for MTC (odds ratio 1.1, 95% confidence interval 1.04-1.24, P = 0.003). Patients with MTC had significantly lower 1-y survival. CONCLUSIONS: Our study suggests that the implementation of ROTEM and the use of cryoprecipitate play significant roles in the development of MTC in LT. The benefits and risks of cryoprecipitate transfusion should be carefully evaluated before administration.

Screen-Based Simulation for Training and Automated Assessment of Teamwork Skills: Comparing 2 Modes With Different Interactivity.

INTRODUCTION: The need for teamwork training is well documented; however, teaching these skills is challenging given the logistics of assembling individual team members together to train in person. We designed 2 modes of screen-based simulation for training teamwork skills to assess whether interactivity with nonplayer characters was necessary for in-game performance gains or for player satisfaction with the experience. METHODS: Mixed, randomized, repeated measures study with licensed healthcare providers block-stratified and randomized to evaluation-participant observes and evaluates the team player in 3 scenarios-and game play-participant is immersed as the leader in the same 3 scenarios. Teamwork construct scores (leadership, communication, situation monitoring, mutual support) from an ontology-based, Bayesian network assessment model were analyzed using mixed randomized repeated measures analyses of variance to compare performance, across scenarios and modes. Learning was measured by pretest and posttest quiz scores. User experience was evaluated using χ2 analyses. RESULTS: Among 166 recruited and randomized participants, 120 enrolled in the study and 109 had complete data for analysis. Mean composite teamwork Bayesian network scores improved for successive scenarios in both modes, with evaluation scores statistically higher than game play for every teamwork construct and scenario (r = 0.73, P = 0.000). Quiz scores improved from pretest to posttest (P = 0.004), but differences between modes were not significant. CONCLUSIONS: For training teamwork skills using screen-based simulation, interactivity of the player with the nonplayer characters is not necessary for in-game performance gains or for player satisfaction with the experience.

Incidental intracardiac thromboemboli during liver transplantation: incidence, risk factors, and management.

Even though numerous cases of massive thromboemboli have been reported in the literature, intracardiac thromboemboli (ICTs) incidentally found during orthotopic liver transplantation (OLT) have not been examined. In this study, we retrospectively examined the incidence, risk factors, and management of incidental ICTs during OLT. After institutional review board approval, adult patients who underwent OLT between January 2004 and December 2008 at our center were reviewed. ICTs were identified and confirmed by the examination of OLT datasheets, anesthesia records, and recorded transesophageal echocardiography (TEE) clips. The clinical presentation, management, and outcomes of the patients with ICTs were reviewed. Risk factors were analyzed by multivariate logistic regression. During the study period, 426 of the 936 adult OLT patients (45.5%) underwent intraoperative TEE monitoring. Incidental ICTs were identified in 8 of these 426 patients (1.9%). Two ICTs occurred before reperfusion, and 6 ICTs occurred after reperfusion. The treatment was at the discretion of the treating physicians; however, none of the patients received an anticoagulant or thrombolytics. Multivariate analysis identified 2 independent risk factors for intraoperative incidental ICTs: the presence of symptomatic or surgically treated portal hypertension (a history of gastrointestinal bleeding, a transjugular intrahepatic portosystemic shunt procedure, or portocaval shunt surgery) before OLT and intraoperative hemodialysis (odds ratios of 4.05 and 7.29, respectively; P < 0.05 for both). In conclusion, incidental ICTs during OLT occurred at a rate of 1.9% and were associated with several preoperative and intraoperative risk factors. The use of TEE allows early identification, which may be important. Our management for incidental ICTs is described; however, no conclusions can be made about the optimal therapy.

Anesthesiology residents' performance of pediatric resuscitation during a simulated hyperkalemic cardiac arrest.

BACKGROUND: Anesthesiologists are responsible for the management of perioperative cardiopulmonary arrest in children. This study used simulation to assess the pediatric resuscitation skills of experienced anesthesia residents. METHODS: Nineteen anesthesia residents were evaluated using a pediatric pulseless electrical activity scenario. The authors used a standardized checklist to evaluate the residents' diagnostic and therapeutic interventions. RESULTS: After the onset of pulseless electrical activity, 79% of residents initiated cardiopulmonary resuscitation within 1 min. Approximately one third (31%) performed chest compressions at the recommended rate. Epinephrine was administered by 95% of residents, but only one third used the correct pediatric dose. All residents administered fluid boluses, but only 16% administered the recommended volume. Only one fourth of the residents considered hyperkalemia as a cause of pulseless electrical activity. None of the residents asked for dosing aids. CONCLUSION: During this simulated pediatric emergency, anesthesia residents demonstrated an acceptable knowledge of general resuscitation maneuvers. However, a subset of resuscitation skills was incorrectly performed, mostly related to age or weight. Importantly, many residents did not consider the full differential diagnosis of pulseless electrical activity. Anesthesia residents may benefit from additional pediatric resuscitation training and practice using cognitive aids to access dosages and complicated diagnostic algorithms.

Insulin therapy in divided doses coupled with blood transfusion versus large bolus doses in patients at high risk for hyperkalemia during liver transplantation.

OBJECTIVE: To assess the effectiveness of an insulin regimen in divided doses designed to target risk factors of hyperkalemia in patients undergoing liver transplantation. DESIGN: Retrospective comparison of the divided insulin dose regimen with a conventional large-bolus insulin method during liver transplantation. SETTING: University-based, academic, tertiary center. PARTICIPANTS: Adult patients whose baseline potassium levels were >/=4.0 mmol/L and received insulin therapy during liver transplantation at the authors' medical center between January 2004 and April 2007. INTERVENTIONS: Insulin was administered either in divided doses (1-2 units) for each unit of red blood cells transfused or in a large-bolus in patients at high risk for hyperkalemia during liver transplantation. MEASUREMENTS AND MAIN RESULTS: Among 717 patients who underwent liver transplantation, 50 patients received insulin in divided doses, and 101 patients received a large-bolus of insulin. Perioperative characteristics were comparable except for higher insulin doses in the large-bolus group. The divided insulin regimen was associated with significantly lower mean potassium levels within 2 hours before reperfusion of the graft compared with the conventional group (p < 0.005). The mean glucose levels in the divided group were significantly lower in both the pre- and postreperfusion periods than in the conventional group (p < 0.05 to <0.001). CONCLUSIONS: The divided insulin dose regimen that specifically targets the risk factors for prereperfusion hyperkalemia is associated with significantly lower prereperfusion potassium and pre- and postreperfusion glucose levels and provides a useful alternative to the conventional large-bolus method in management of intraoperative hyperkalemia during liver transplantation.