Intrathecal Opioid Use in Kidney Transplantation: An Observational Cohort Study.

BACKGROUND: Kidney transplant is the most common transplant operation performed in the United States. Although various approaches to pain management have been described, the optimal analgesic strategy remains undefined. Specifically, the role of intrathecal opioids in this patient population has not been comprehensively evaluated. METHODS: Using a retrospective cohort design, data from kidney transplant operations at a single tertiary care medical center between August 1, 2017, and July 31, 2022, were extracted. Inverse probability of treatment weighting (IPTW) was used to assess differences in clinical outcomes based on the presence or absence of intrathecal opioid administration before surgical incision. The primary outcome was total opioid exposure expressed in milligram morphine equivalents (MME) in the first 72 hours postoperatively, with secondary outcomes including total MME (intraoperative plus postoperative MME, postoperative pain scores, and the presence of postoperative nausea/vomiting [PONV], pruritus, or adverse events). RESULTS: A total of 1014 kidney transplants in 1012 unique patients were included, with 411 (41%) receiving intrathecal opioids preoperatively. Hydromorphone was the intrathecal opioid used in all cases with median dose of 100 µg (interquartile range [IQR], 100, 100; range 50-200). Subjects receiving intrathecal opioids had significantly lower postoperative opioid requirements at 72 hours (30 [0-68] vs 64 [22, 120] MME), with ratio of geometric means in the IPTW analysis (ratio of geometric means 0.34, 95% confidence interval [CI], 0.26-0.43; P < .001). Similar findings were observed for total opioids (45 [30-75] vs 75 [60-90] MME; ratio of geometric means 0.58, 95% CI, 0.54-0.63; P < .001). Maximum reported pain scores in the intrathecal group were lower at 24 hours (4 [2-7] vs 7 [5, 8]; OR, 0.28; 95% CI, 0.21-0.37 for experiencing a higher pain score with intrathecal opioids, P < .001) and 72 hours (6 [4-7] vs 7 [5-8]; OR, 0.41; 95% CI, 0.31-0.54; P < .001). Patients receiving intrathecal opioids were more likely to experience PONV (225 of 411 [55%] vs 232 of 603 [38%]; OR, 2.16; 95% CI, 1.63-2.86; P < .001). CONCLUSIONS: Intrathecal opioid administration was associated with improved pain outcomes in patients undergoing kidney transplantation, including lower opioid requirements and pain scores through 72 hours. However, this was accompanied by an increased risk of PONV.

Fontan-Associated Liver Disease: Screening, Management, and Transplant Considerations.

Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.

The perioperative management of simultaneous bilateral nephrectomy with renal transplantation: a case series.

PURPOSE: Bilateral nephrectomy is performed at times with renal transplantation. Though surgical indications and timing of these two procedures have been described, there are no large case series describing the anesthetic management of these cases. We sought to describe our experience. METHODS: We performed a historical cohort study on 54 consecutive cases of simultaneous bilateral nephrectomy with renal transplantation at a single, tertiary-care medical centre. Descriptive statistics were used. RESULTS: The most common etiology of kidney disease involved was autosomal dominant polycystic kidney disease at 52/54 (96%) cases. All patients received grafts from living donors. An arterial line was placed in 44 (81%) and a central venous catheter in 16 (30%) subjects. At least one vasopressor infusion was used in 44 (81%) cases and 37 (69%) patients required admission to the intensive care unit (ICU). Of this subset, 30 (81%) were admitted for ongoing vasopressor support and six (16%) for hemodynamic monitoring. All patients were extubated in the operating room upon completion of the procedure. Median [interquartile range (IQR)] ICU length of stay (LOS) was 0.9 [0.7-1.4] days and total hospital LOS was 4.4 [4.3-5.4] days. There were no cases of mortality at 30 days or of postoperative dialysis. CONCLUSIONS: Adult patients undergoing simultaneous bilateral nephrectomy with renal transplantation often developed perioperative hypotension requiring vasopressor infusions and postoperative transfer to the ICU. This is possibly due to a temporary loss of the renin-angiotensin system. Despite this, patients most commonly were transferred to the floor on postoperative day 1 and had successful outcomes with no mortality at 30 days.

RéSUMé: OBJECTIF: La néphrectomie bilatérale est parfois réalisée en même temps qu'une transplantation rénale. Bien que les indications chirurgicales et le moment de ces deux interventions aient été décrits, il n'existe aucune grande série de cas décrivant la prise en charge anesthésique de ces procédures. Notre objectif était de décrire notre expérience. MéTHODE: Nous avons réalisé une étude de cohorte historique sur 54 cas consécutifs de néphrectomie bilatérale avec transplantation rénale simultanée dans un seul centre médical de soins tertiaires. Des statistiques descriptives ont été utilisées. RéSULTATS: La maladie polykystique des reins autosomique dominante constituait l'étiologie de la maladie rénale la plus fréquente, représentant 52/54 (96 %) des cas. Tous les patients ont reçu des greffes de donneurs vivants. Une ligne artérielle a été installée chez 44 (81 %) patients et un cathéter veineux central chez 16 (30 %) patients. Au moins une perfusion de vasopresseurs a été utilisée chez 44 (81 %) patients, et 37 (69 %) patients ont dû être admis à l'unité de soins intensifs (USI). De ce sous-ensemble, 30 (81 %) patients ont été admis pour recevoir un soutien continu de vasopresseurs et six (16 %) pour un monitorage hémodynamique. Tous les patients ont été extubés en salle d'opération à la fin de l'intervention. La durée médiane [écart interquartile (ÉIQ)] de séjour aux soins intensifs était de 0,9 [0,7 à 1,4] jour, et la durée totale de séjour à l'hôpital était de 4,4 [4,3 à 5,4] jours. Il n'y a eu aucun cas de mortalité à 30 jours ou de dialyse postopératoire. CONCLUSION: Les patients adultes subissant une néphrectomie bilatérale et une transplantation rénale simultanées ont souvent souffert d'hypotension périopératoire exigeant des perfusions de vasopresseurs et un transfert postopératoire aux soins intensifs. Ceci est probablement dû à une perte temporaire du système rénine-angiotensine. Malgré cela, les patients étaient en général transférés à l'étage au jour postopératoire 1 et ont eu des devenirs favorables sans mortalité à 30 jours.

Reduced Echocardiographic Inotropy Index after Cardiopulmonary Bypass Is Associated With Complications After Cardiac Surgery: An Institutional Outcomes Study.

OBJECTIVE: Despite advances in echocardiography and hemodynamic monitoring, limited progress has been made to effectively quantify left ventricular function during cardiac surgery. Traditional measures, including left ventricular ejection fraction (LVEF) and cardiac index, remain dependent on loading conditions; more complex measures remain impractical in a dynamic surgical setting. However, the Smith-Madigan Inotropy Index (SMII) and potential-to-kinetic energy ratio (PKR) offer promise as measures calculable during cardiac surgery and potentially predictive of outcomes. Using echocardiographic and hemodynamic monitoring data, the authors aimed to calculate SMII and PKR values after cardiopulmonary bypass and understand associations with postoperative outcomes, adjusting for previously identified risk factors. DESIGN: Observational cohort study. SETTING: Tertiary care academic hospital. PATIENTS: The study comprised 189 elective adult cardiac surgical procedures from 2015-2016. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was postoperative mortality or organ system complication (stroke, prolonged ventilation, reintubation, cardiac arrest, acute kidney injury, new-onset atrial fibrillation). After adjustment, SMII <0.83 W/m2 independently predicted the primary outcome (adjusted odds ratio 2.19, 95% confidence interval 1.08-4.42); whereas PKR, LVEF, and cardiac index demonstrated no associations. When SMII and PKR were incorporated into a EuroSCORE II risk model, predictive performance improved (net reclassification index improvement 0.457; p = 0.001); whereas a model incorporating LVEF and cardiac index demonstrated no improvement (0.130; p = 0.318). CONCLUSION: The present study demonstrated that SMII, but not PKR, as a measure of cardiac function was associated with major complications. The study's data may guide investigations of more suitable perioperative goal-directed therapies to reduce complications after cardiac surgery.

Anesthetic considerations for combined heart--liver transplantation in patients with Fontan-associated liver disease.

PURPOSE OF REVIEW: The success of the Fontan procedure has led to increased survival of patients born with certain congenital heart disease to the point that new sequlae, as a result of Fontan circulation, are being discovered. Included among these is Fontan-associated liver disease (FALD). The purpose of this review is to present available literature on the perioperative management of the combined heart--liver transplantation (CHLT) in patients with FALD. RECENT FINDINGS: The perioperative management of a combined heart-liver transplant in a patient with Fontan circulation is complex. The patient is at risk for hemodynamic disturbances, significant blood loss, coagulopathies, and metabolic derangements. The maintenance of an appropriate transpulmonary pressure gradient is paramount to success. Postoperative management should be accomplished by a multidisciplinary care team. Limited series have demonstrated good outcomes in patients who have undergone CHLT. SUMMARY: The perioperative management of CHLT in patients with FALD is complex and available literature is limited. Future studies are needed to further assess proper perioperative management of patients with FALD who undergo CHLT.

Emergency Manual Implementation in a Large Academic Anesthesia Practice: Strategy and Improvement in Performance on Critical Steps.

BACKGROUND: The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps. METHODS: We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds. RESULTS: We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19-25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16-20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation. CONCLUSIONS: Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized.

Ocular injury during spine surgery.

PURPOSE: Ocular injury and vision loss are rare complications of surgery. Spine surgery has been identified as particularly high risk for postoperative vision loss; nevertheless, ocular injuries have not been comprehensively assessed in this patient population. METHODS: This historical cohort study assessed incidence, cause, and risk factors of perioperative ocular injury after spine surgery at a tertiary care medical centre from January 1, 2006 through January 31, 2018. Patients were included who had ocular injury identified during an ophthalmology consultation in the first seven postoperative days. Differences in demographic, laboratory, intraoperative, and postoperative characteristics between those experiencing or not experiencing ocular injury were assessed with Fisher exact and Wilcoxon signed-rank tests for categorical and continuous variables, respectively. RESULTS: Of 20,128 qualifying spine surgeries, 39 cases of perioperative ocular injuries were identified (39/20,128; 0.19% [95% confidence interval (CI), 0.14 to 0.26]). The most common ocular injury was blurry vision of unknown cause (13/39; 33%; 95% CI, 18.6 to 46.4), followed by ischemic optic neuropathy (9/39; 23%; 95% CI, 12.6 to 38.3) and corneal abrasion (7/39; 18%; 95% CI, 9.0 to 32.7). All cases of blurry vision of unknown cause were diagnosed via ophthalmology consultation and resolved within several days. Patients with perioperative ocular injury were more likely to have baseline anemia, have undergone fusion and instrumentation procedures, and had longer operative times with greater crystalloid, colloid, and transfusion requirements and more blood loss. CONCLUSIONS: Although not representing a causal relationship, these data suggest that surgical factors may have a greater role than demographic characteristics or other clinical factors in the development of perioperative ocular injury. Surgeons, anesthesiologists, and patients should be aware of the increased risk of ocular injury that accompanies longer, more extensive spine operations.

RéSUMé: OBJECTIF: Les lésions oculaires et la perte de vision sont des complications chirurgicales rares. La chirurgie du rachis a été identifiée comme une intervention entraînant un risque particulièrement élevé de perte de vision postopératoire; cependant, les lésions oculaires n'ont pas été évaluées de manière exhaustive chez cette population de patients. MéTHODE: Cette étude de cohorte historique a évalué l'incidence, la cause et les facteurs de risque de lésion oculaire périopératoire après une chirurgie du rachis dans un centre médical de soins tertiaires entre le 1er janvier 2005 et le 31 janvier 2018. Les patients ayant subi une lésion oculaire diagnostiquée lors d'une consultation en ophtalmologie au cours des sept premiers jours postopératoires ont été inclus. Les différences de caractéristiques démographiques, de laboratoire, peropératoires et postopératoires entre les patients ayant subi ou non une lésion oculaire ont été évaluées à l'aide du test exact de Fisher et du test des rangs signés de Wilcoxon pour les variables catégoriques et continues, respectivement. RéSULTATS: Parmi les 20 128 chirurgies du rachis éligibles, 39 cas de lésions oculaires périopératoires ont été identifiés (39/20,128; 0,19 % [intervalle de confiance (IC) 95 %, 0,14 à 0,26]). La lésion oculaire la plus fréquente était une vision floue de cause inconnue (13/39; 33 %; IC 95 %, 18,6 à 46,4), suivie d'une neuropathie optique ischémique (9/39; 23 %; IC 95 %, 12,6 à 38,3) et d'une abrasion cornéenne (7/39; 18 %; IC 95 %, 9,0 à 32,7). Tous les cas de vision floue de cause inconnue ont été diagnostiqués lors d'une consultation en ophtalmologie et se sont résolus après plusieurs jours. Les patients ayant subi une lésion oculaire périopératoire étaient plus susceptibles de présenter une anémie de départ, d'avoir subi des interventions de fusion et instrumentation rachidiennes, et d'avoir subi une chirurgie plus longue nécessitant davantage de cristalloïdes, de colloïdes et de transfusions, ainsi que d'avoir subi des pertes sanguines plus importantes. CONCLUSION: Bien que n'établissant pas de relation causale, ces données suggèrent que les facteurs chirurgicaux pourraient jouer un rôle plus important que les caractéristiques démographiques ou les autres facteurs cliniques dans l'apparition d'une lésion oculaire périopératoire. Chirurgiens, anesthésiologistes et patients devraient être conscients du risque accru de lésion oculaire qui accompagne les opérations du rachis plus longues et plus importantes.

Perioperative blood product administration and thromboembolic events in patients with treated polycythemia vera: a case-control study.

BACKGROUND: Patients with polycythemia vera (PV) have historically been considered to be at high risk for perioperative hemorrhagic and thromboembolic complications. However, no recent studies have compared these outcomes between treated PV patients and patients without PV undergoing similar procedures. STUDY DESIGN AND METHODS: Patients with PV who underwent surgery with anesthesia from June 1, 2006, to May 31, 2011, were randomly matched (sex, age, type of surgical procedure, surgical year) at a ratio of 1:4 with control patients without PV. Conditional logistic regression analysis adjusting for surgical duration, preoperative hemoglobin, platelet count, and cardiovascular disease was used to assess the association between PV and blood product transfusions, thromboembolism, and other major cardiovascular and pulmonary complications. RESULTS: Fifty-six PV patients who underwent 79 surgeries were matched with 312 controls. During hospitalization, 35 (44.3%) and 82 (25.9%) PV and control patients, respectively, were transfused with blood products. PV patients were at increased risk for transfusion intraoperatively (odds ratio [OR], 4.35; 95% confidence interval [CI], 1.79-10.57; p = 0.001) and during hospitalization (OR, 4.35; 95% CI, 1.84-10.31; p < 0.001). The likelihood of thromboembolic complications and/or other major complications did not differ between the two study groups (thromboembolic-OR 1.53, 95% CI 0.39-6.02, p = 0.540; other major complications-OR 2.15, 95% CI 0.93-4.96, p = 0.073). CONCLUSIONS: Medically managed PV patients had an increased likelihood of receiving blood products perioperatively. Given the low number of observed thromboembolic events, we cannot make definitive conclusions regarding the association between PV and thromboembolism.

A case report and anesthetic implications of situs inversus totalis in video-assisted thoracoscopic pulmonary resection.

Introduction and importance: Reports are limited on video-assisted thoracoscopic surgery for lung malignancy of patients with situs inversus totalis (SIT). Patients with SIT have significant anatomic differences with implications that are important for surgery, anesthesia, and nursing to understand in order to provide care for this patient population. Case presentation: A 64-year-old man with SIT and lung adenocarcinoma needed flexible bronchoscopy and wedge resection of a 9×8 mm adenocarcinoma in the right upper lobe and underwent video-assisted thoracoscopic surgery. Clinical discussion: Preoperative planning, including collaboration with the surgical team, allowed safe monitoring, induction of anesthesia, and airway isolation in this patient allowing them to have successful resection of their pulmonary malignancy. Postoperative care was enhanced by detailed communication and understanding of the patient's anatomy and implications of this condition for post anesthesia care unit nursing care. Conclusion: Patients with rare clinical conditions and backgrounds may require surgical and anesthetic intervention. The authors describe important anesthetic considerations of preoperative evaluation, airway management, cardiac monitoring, and vascular access that should be noted and taken into account for patients with SIT. Proper preparation, planning, and communication allow for patients with SIT to safely undergo surgical procedures.

Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes.

BACKGROUND: Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution. METHODS: The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis. RESULTS: The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01). CONCLUSIONS: This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.

Intraoperative Dysrhythmias Cease After Venting During Intramedullary Nailing of an Impending Femur Fracture: A Case Report.

CASE: A 76-year-old woman with multiple myeloma and osteoporosis presented with right hip pain and an impending atypical femoral fracture in the setting of chronic bisphosphonate use. After preoperative medical optimization, she was scheduled for prophylactic intramedullary nail fixation. Intraoperatively, the patient experienced episodes of severe bradycardia and asystole associated with intramedullary reaming, which ceased after distal venting of the femur. No additional intraoperative or postoperative complications were encountered, and the patient recovered uneventfully. CONCLUSION: Femoral canal venting may be an appropriate intervention for similar transient dysrhythmias caused by intramedullary reaming.

Neuraxial labor analgesia for vaginal delivery and its effects on childhood learning disabilities.

BACKGROUND: In prior work, children born to mothers who received neuraxial anesthesia for cesarean delivery had a lower incidence of subsequent learning disabilities compared with vaginal delivery. The authors speculated that neuraxial anesthesia may reduce stress responses to delivery, which could affect subsequent neurodevelopmental outcomes. To further explore this possibility, we examined the association between the use of neuraxial labor analgesia and development of childhood learning disabilities in a population-based birth cohort of children delivered vaginally. METHODS: The educational and medical records of all children born to mothers residing in the area of 5 townships of Olmsted County, Minnesota from 1976 to 1982 and remaining in the community at age 5 years were reviewed to identify those with learning disabilities. Cox proportional hazards regression was used to compare the incidence of learning disabilities between children delivered vaginally with and without neuraxial labor analgesia, including analyses adjusted for factors of either potential clinical relevance or that differed between the 2 groups in univariate analysis. RESULTS: Of the study cohort, 4684 mothers delivered children vaginally, with 1495 receiving neuraxial labor analgesia. The presence of childhood learning disabilities in the cohort was not associated with use of labor neuraxial analgesia (adjusted hazard ratio, 1.05; 95%confidence interval, 0.85-1.31; P = 0.63). CONCLUSION: The use of neuraxial analgesia during labor and vaginal delivery was not independently associated with learning disabilities diagnosed before age 19 years. Future studies are needed to evaluate potential mechanisms of the previous finding indicating that the incidence of learning disabilities is lower in children born to mothers via cesarean delivery under neuraxial anesthesia compared with vaginal delivery.

The Success of a Simulation-Based Transesophageal Echocardiography Course for Liver Transplant Anesthesiologists.

INTRODUCTION: Transesophageal echocardiography (TEE) is increasingly used for intraoperative management during orthotopic liver transplantation. Proficient TEE use requires skill and knowledge to accurately assess the hemodynamic status and guide clinical management. Currently there are no TEE educational tracks specifically focused on perioperative liver transplant management and barriers to obtaining basic certification exist. METHODS: A 4-hour simulation-based learning (SBL) course was provided to improve liver transplant anesthesiologist TEE knowledge and skill. Learners received training and education using a TEE simulator in small groups focusing on basic image acquisition, relevant anatomy, hemodynamic calculations, and pathology germane to the liver transplant period. Knowledge assessment and survey responses were assessed at the beginning and completion of the course. Learners completed TEE examinations with simulated pathology during high-fidelity simulations following the course. RESULTS: Seventeen anesthesiologists completed the course. The median baseline knowledge assessment score was 55.0% (37-70). The median postcourse knowledge assessment score improved to 95.0% (94-100) (P < .001). All anesthesiologists were able to identify TEE pathology during high-fidelity simulation. Survey responses yielded significant median score improvement in all areas assessed using a 5-point Likert scale. CONCLUSIONS: A small group, simulation TEE course delivered over 4 hours can increase knowledge and skill in TEE use for liver transplant anesthesiologists.

Anesthesia and myotonic dystrophy type 2: a case series.

BACKGROUND: Myotonic dystrophy type 2 (DM2) is a genetically distinct disorder that shares some phenotypical features of myotonic dystrophy type 1 (DM1). However, anesthetic management of patients with DM2 has not been described. The purpose of this study is to report the anesthetic management of a series of patients with DM2 and to describe their response to anesthesia. METHODS: We performed a computerized search of the Mayo Clinic medical records database looking for patients with DM2 who underwent general anesthesia. The medical records were reviewed for anesthetic technique, medications used, and postoperative complications. RESULTS: We identified 19 patients with DM2 who underwent 39 general anesthetics, 17 monitored anesthetic care cases, and two regional anesthetics. The patients exhibited normal responses to succinylcholine, nondepolarizing neuromuscular blockers, neostigmine, induction agents, and volatile anesthetics. Serious postoperative complications related to DM2 did not occur. CONCLUSION: In our series, patients with DM2 tolerated commonly used anesthetics without obvious complications, and they exhibited normal responses to muscle relaxants. These observations suggest that these medications may be used safely in patients with DM2.

Influence of Intraoperative Transesophageal Echocardiography and Pulmonary Artery Catheter Monitoring on Outcomes in Liver Transplantation.

Anesthetic management of orthotopic liver transplantation (OLT) can be challenging. Management involves responding to sudden hemodynamic shifts, addressing instability, and performing ongoing volume assessment. To best prepare for these perturbations, various monitors are used intraoperatively. We sought to explore the impact of transesophageal echocardiography (TEE) and pulmonary artery catheter (PAC) use on outcomes of patients undergoing OLT. METHODS: We retrospectively reviewed records of patients who underwent OLT at a single institution and included all who were monitored intraoperatively with TEE alone, PAC alone, or both methods concurrently (TEE + PAC). We determined whether these groups had differences in length of hospitalization (primary outcome), 30-day mortality rate, and other outcomes. RESULTS: Three hundred eighteen liver transplant operations were included in the study. Patients in the TEE + PAC group had the shortest median length of hospitalization (TEE + PAC, 8.6 days; TEE, 10.3; PAC, 9.1; P = 0.04). The TEE + PAC group also had the lowest 30-day mortality rate (TEE + PAC, n = 1 [1.3%]; TEE, n = 5 [12.8%]; PAC, n = 7 [3.5%]; P = 0.009). However, the TEE + PAC group also had the highest rate of a new postoperative need for dialysis (TEE + PAC, n = 8 [10.3%]; TEE, n = 2 [5.1%]; PAC, n = 1 [0.5%]; P < 0.001). CONCLUSIONS: Compared with either TEE alone or PAC alone, intraoperative monitoring with TEE + PAC during OLT was associated with the shortest length of hospitalization and lowest 30-day mortality rate. Transplant anesthesiologists should be aware of the potential benefit on patient mortality and hospital length of stay with concurrent intraoperative TEE + PAC monitoring and the increased need for new postoperative dialysis.

Perioperative risks of narcolepsy in patients undergoing general anesthesia: A case-control study.

STUDY OBJECTIVE: To compare the perioperative outcomes between patients with narcolepsy and matched controls undergoing anesthetic management. DESIGN: Retrospective 2:1 matched study design. SETTING: Large tertiary medical center. PATIENTS: Narcoleptic patients who underwent general anesthesia from January 1, 2011, through September 30, 2015, were matched with controls by age, sex, and type and year of surgery. MEASUREMENTS: Medical records were reviewed for episodes of respiratory depression during phase I recovery and for other meaningful perioperative outcomes. MAIN RESULTS: The perioperative courses of 76 narcoleptic patients and their controls were examined. Compared to controls, narcoleptic patients were more often prescribed central nervous system stimulants (73.7% vs 4.0%, P<0.001) and antidepressants (46.1% vs 27.6%, P=0.007) and more often had obstructive sleep apnea (40.8% vs 19.1%, P<0.001). The intraoperative course was similar. The number of episodes of respiratory depression was not different between patients and controls (5 [6.6%] vs 12 [7.9%], respectively; P=0.80). Narcoleptic patients had a higher frequency of emergency response team activations (5 of 76 [6.6%]; 95% CI, 2.2%-14.7%) compared to controls (2 of 152 [1.3%]; 95% CI, 0.2%-4.7%) (P=0.04). Hemodynamic instability was the indication for all emergency response team activations except 1, which was for a narcoleptic patient who had excessive postoperative sedation and respiratory depression. CONCLUSIONS: Narcoleptic patients had similar intraoperative courses as the matched controls, including phase I anesthetic recovery. However, they had a higher rate of emergency response team activations than the controls, which suggests that patients with narcolepsy may be at increased perioperative risk.