Multimodal temperature management during donor hepatectomy under combined general anaesthesia and neuraxial analgesia: Retrospective analysis.

BACKGROUND AND AIMS: Unintended hypothermia (UIH) during surgery under general anaesthesia has adverse implications. A retrospective analysis of the perioperative temperature records of healthy voluntary liver donors was done to evaluate the efficacy of a multimodal protocol for temperature management. METHODS: Records of 50 American Society of Anesthesiologists physical status Class 1 patients operated for Donor Hepatectomy lasting >2 h under combined general and epidural anaesthesia were analysed. Ambient temperature was maintained 24°C-27°C before induction of GA and during insertion of epidural catheter. Active warming was done using warming mattress set to temperature 38°C, hot air blanket with temperature set to 38°C and fluid warming device (Hotline™) with preset temperature of 41°C. Nasopharyngeal temperature was continuously monitored. After induction of GA and draping of the patient, ambient temperature was decreased and maintained at 21°C-24°C and was again increased to 24°C-27°C at the conclusion of surgery. During surgery, for every 0.1°C above 37°C, one heating device was switched off such that at 37.3°C all the 3 devices were switched off. Irrigation fluid was pre-warmed to 39°C. RESULTS: Baseline temperature was 35.9°C ± 0.4°C. Minimum temperature recorded was 35.7°C ± 0.4°C. Mean decrease in temperature below the baseline temperature was 0.2°C ± 0.2°C. Temperature at the end of surgery was 37.4°C ± 0.5°C. CONCLUSION: Protocol-based temperature management with simultaneous use of resistive heating mattress, forced-air warming blanket, and fluid warmer along with ambient temperature management is an effective method to prevent unintended perioperative variation in body temperature.

Use of ultrasound-guided preoperative diaphragmatic thickness as a predictor of postoperative weaning failure in recipients and donors scheduled for living donor liver transplant surgery.

BACKGROUND AND OBJECTIVES: The present study was designed to explore the utility of ultrasound-guided diaphragmatic thickness in the preoperative period in healthy controls scheduled for live-related donor hepatectomy and patients suffering from chronic liver disease scheduled for liver transplantation (LT) and its use as a predictor of postoperative weaning failure. MATERIALS AND METHODS: This prospective observational study was conducted in a tertiary health care center and 65 adult (18-70 years) participants (30 healthy liver donors and 35 liver transplant recipients) were enrolled for this study. Right diaphragmatic thickness of both donors and recipients was measured by B-mode ultrasound using a 10 MHz linear array transducer in the supine position in the operation theater just before induction of anesthesia. For subgroup analysis of the recipients, we further divided them into two groups - Group 1 (diaphragmatic thickness < 2 mm) and Group 2 (diaphragmatic thickness > 2 mm), and comparison was done for duration of mechanical ventilation. Intergroup comparison was made for duration of mechanical ventilation and various other parameters. RESULTS: The sonographic measurement of diaphragm revealed that its thickness is decreased in patients with chronic liver disease patients (2.12 ± 0.54 mm) as compared to healthy donors (3.70 ± 0. 58 mm). On multiple logistic regression, higher duration of mechanical ventilation was associated with diaphragmatic thickness < 2 mm (Group 1 of recipients) (adjusted odds ratio 0.86; 95% confidence interval: 0.75-0.99; P = 0.013) after adjusting for age, gender, and body mass index. CONCLUSIONS: Diaphragmatic thickness is decreased in patients with chronic liver disease as compared to healthy liver donors. Preoperative measurement of ultrasound-guided right hemidiaphragm thickness can be used to predict weaning failure in patients undergoing LT. Other studies are needed to confirm these finding on different group of patients.

Diagnostic and therapeutic challenge of heart failure after liver transplant: Case series.

Heart failure (HF) following liver transplant (LT) surgery is a distinct clinical entity with high mortality. It is known to occur in absence of obvious risk factors. No preoperative workup including electrocardiogram, echocardiography at rest and on stress, reasonably prognosticates the risk. In patients of chronic liver disease, cirrhotic cardiomyopathy, alcoholic cardiomyopathy, and stress induced cardiomyopathy have each been implicated as a cause for HF after LT. However distinguishing one etiology from another not only is difficult, several etiologies may possibly coexist in a given patient. Diagnostic dilemma is further compounded by the fact that presentation and management of HF irrespective of the possible underlying cause, remains the same. In this case series, 6 cases are presented and in the light of existing literature modification in the preoperative workup are suggested.

Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue.

Operative hysteroscopy has emerged as an effective alternative to hysterectomy and has become standard surgical treatment for varied gynaecological conditions like abnormal uterine bleeding and uterine myomas. This procedure requires distention of the uterine cavity for adequate visualization of the operative field. 1.5% glycine is a widely used distention medium because it has good optical properties and is non-conductive. However, the intraoperative absorption of this electrolyte-free fluid can cause hyponatraemia, hypoosmolality, hyperglycinaemia and volume overload, including pulmonary oedema. We report a case of operative hysteroscopy intravascular absorption (OHIA) syndrome, presenting abruptly during hysteroscopic myomectomy, employing 1.5% glycine as the fluid distention medium. Successful management of the case and prevention strategies are discussed.