Incidence of Postreperfusion Hyperfibrinolysis in Liver Transplantation by Donor Type and Observed Treatment Strategies.

BACKGROUND: Hyperfibrinolysis is a possible complication during liver transplantation, particularly immediately after reperfusion. METHODS: We performed a retrospective study to examine the incidence, treatment, and resolution of postreperfusion hyperfibrinolysis in patients undergoing liver transplantation at Duke University Hospital from 2015 to 2020. RESULTS: Out of 535 patients undergoing liver transplantation, 21 or 3.9%, 95% CI (2.5-5.9), had hyperfibrinolysis after reperfusion. Hyperfibrinolysis occurred in 16 of 511 (3.1%) patients receiving livers from DBD donors, 5 of 18 (27.8%) patients receiving livers from donation after circulatory death (DCD) donors, and 0 of 6 (0.0%) patients receiving livers from living donors. Fibrinolysis was treated with cryoprecipitate (12/21), a combination of cryoprecipitate and tranexamic acid (3/21), or neither (6/21) and resolved within several hours in all cases. CONCLUSIONS: Anesthesiologists should be aware of the possibility of postreperfusion hyperfibrinolysis in liver transplantation, particularly with DCD donors, and may consider treatment with cryoprecipitate or tranexamic acid. Further work is needed to identify any potential differences, such as faster resolution of fibrinolysis, between different treatment modalities.

Patterns of Use in Transesophageal Echocardiography for Liver Transplantation: A Systematic Review.

Transesophageal echocardiography is frequently but not always used to guide anesthetic management during liver transplantation. We performed a systematic review of the literature to identify and summarize any studies reporting on the frequency and characteristics of TEE use for liver transplantation. Studies were identified by searching several relevant terms on PubMed and citation searching of relevant reviews. We identified 5 studies reporting the results of surveys performed between 2003 and 2018. Use of TEE for liver transplantation increased from 11.3% of centers in 2003 to greater than 90% of centers by 2014 and 2018. Only 38%-56% of centers use it routinely with the rest using it only in special circumstances. About a third of centers usually perform a comprehensive exam, with the majority performing a more limited exam based on the needs of the case. Use of TEE for liver transplantation is common but not universal. This review summarizes the current knowledge about the frequency and circumstances of use, but there is an opportunity for further systematic study and discussion.

Bleeding Complications from Transesophageal Echocardiography for Liver Transplantation: A Systematic Review.

Transesophageal echocardiography (TEE) for liver transplant has historically been avoided due to concern it may cause bleeding from esophageal varices. However, several recent studies, as well as increasing clinical experience, have indicated that it may be safe in many circumstances. We performed a systematic review of the literature to identify and summarize studies reporting complications in patients having TEE during liver transplant. Studies were identified by searching relevant key terms on PubMed as well as citation searching in relevant reviews. We identified 6 studies between 1996 and 2015 which evaluated complications of TEE during liver transplant. They reported an overall bleeding complication rate between .3% and 2.8% and a major bleeding complication rate between .0% and .8%. Most of the major bleeds had identifiable high-risk features such as recent variceal bleeding or banding. Review of the literature suggests that TEE may be safely used in patients undergoing liver transplantation, even with known varices, with a complication rate similar to that of all patients undergoing TEE. However, the risks of TEE may outweigh the potential benefits among patients undergoing liver transplant with particular high-risk features.

Impact of an enhanced recovery pathway on length of stay and complications in elective radical cystectomy: a before and after cohort study.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways aim to standardize and integrate perioperative care, incorporating the best available evidence-based practice throughout the perioperative period targeted at attenuating the surgical stress response while optimizing physiologic function, with the goal of facilitating recovery. Radical cystectomy is associated with significant postoperative morbidity, but comprehensive ERAS pathways have not been well studied in this population. METHODS: This is a before and after cohort study of an ERAS pathway for radical cystectomy at a large academic medical center. Following introduction of the ERAS pathway and a wash in period, we prospectively collected data from the next 100 consecutive subjects undergoing radical cystectomy with the ERAS pathway. This cohort was compared to a retrospective cohort of 100 consecutive patients undergoing radical cystectomy with traditional care. The primary outcome was hospital length of stay. Secondary outcomes included perioperative management, time to recovery milestones, complications, and costs. RESULTS: Implementation of an ERAS pathway for radical cystectomy was associated with reduced hospital length of stay (median LOS 10 days (IQR = 8-18) vs 7 days (IQR = 6-11); p < 0.0001), reduced time to key recovery milestones, including days to first stool (5.83 vs 3.99; p < 0.001) and days to first solid food (9.68 vs 3.2; p < 0.001), reductions in some complications, and a 26.6% reduction in overall costs (p < 0.001). CONCLUSIONS: Our data support the use of an ERAS pathway for radical cystectomy and add to the increasing body of literature supporting enhanced recovery over a wide variety of procedures. TRIAL REGISTRATION: Not applicable.

What Does a Red Meat Allergy Have to Do With Anesthesia? Perioperative Management of Alpha-Gal Syndrome.

Over the past decade, there has been a growing awareness of a new allergic syndrome known as alpha-gal allergy or alpha-gal syndrome, commonly recognized as a red meat allergy. We performed a review of the literature to identify articles that provide both background on this syndrome in general and any reports of reactions to medications or medical devices related to alpha-gal syndrome. Alpha-gal syndrome results from IgE to the oligosaccharide galactose-α-1,3-galactose, expressed in the meat and tissues of noncatarrhine mammals. It is triggered by the bite of the lone star tick and has been implicated in immediate-onset hypersensitivity to the monoclonal antibody cetuximab and delayed-onset hypersensitivity reactions after the consumption of red meat. There is growing recognition of allergic reactions in these patients to other drugs and medical devices that contain alpha-gal. Many of these reactions result from inactive substances that are part of the manufacturing or preparation process such as gelatin or stearic acid. This allergy may be documented in a variety of ways or informally reported by the patient, requiring vigilance on the part of the anesthesiologist to detect this syndrome, given its serious implications. This allergy presents a number of unique challenges to the anesthesiologist, including proper identification of a patient with alpha-gal syndrome and selection of anesthetic and adjunctive medications that will not trigger this allergy.

Enhanced Recovery After Surgery and Multimodal Strategies for Analgesia.

Enhanced recovery after surgery is an evidence-based, multimodal approach to the perioperative care of a patient undergoing surgery. These pathways seek to attenuate the stress response to surgery facilitating postoperative recovery. Analgesia is a critical component of these pathways, because optimal pain relief is critical for patients to mobilize quickly after surgery, preventing such complications as infection and thromboembolism. Traditional analgesic regimens for major surgery rely heavily on opioids to provide analgesia but can cause a wide range of serious side effects, delaying recovery. Enhanced recovery protocols should incorporate multimodal analgesic strategies that minimize opioid use and optimize analgesia.

Elective Venovenous Extracorporeal Membrane Oxygenation for Resection of Endotracheal Tumor: A Case Report.

We present a case in which we electively used venovenous extracorporeal membrane oxygenation (VV-ECMO) to facilitate safe resection of a nearly obstructing airway tumor near the carina in a 37-year-old male. The patient was brought to the operating room and underwent bifemoral cannulation for VV-ECMO under light sedation while maintaining spontaneous ventilation. After VV-ECMO was initiated, general anesthesia was induced, and the tumor was resected via rigid bronchoscopy. After resection, the patient was intubated, weaned from ECMO, decannulated, awoken, extubated, and taken to the postanesthesia care unit for recovery.

Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection.

OBJECTIVE: To determine whether there is an association between transfusion of fresh frozen plasma and infection in critically ill surgical patients. DESIGN: Retrospective study. SETTING: A 24-bed surgical intensive care unit in a university hospital. PATIENTS: A total of 380 non-trauma patients who received fresh frozen plasma from 2004 to 2005 were compared with 2,058 nontrauma patients who did not receive fresh frozen plasma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated the relative risk of infectious complication for patients receiving and not receiving fresh frozen plasma. T-test allowed comparison of average units of fresh frozen plasma transfused to patients with and without infectious complications to describe a dose-response relationship. We used multivariate logistic regression analysis to evaluate the association between fresh frozen plasma and infectious complication, controlling for the effect of red blood cell transfusion, Acute Physiology and Chronic Health Evaluation II, and patient age. A significant association was found between transfusion of fresh frozen plasma and ventilator-associated pneumonia with shock (relative risk 5.42, 2.73-10.74), ventilator-associated pneumonia without shock (relative risk 1.97, 1.03-3.78), bloodstream infection with shock (relative risk 3.35, 1.69-6.64), and undifferentiated septic shock (relative risk 3.22, 1.84-5.61). The relative risk for transfusion of fresh frozen plasma and all infections was 2.99 (2.28-3.93). The t-test revealed a significant dose-response relationship between fresh frozen plasma and infectious complications (p = .02). Chi-square analysis showed a significant association between infection and transfusion of fresh frozen plasma in patients who did not receive concomitant red blood cell transfusion (p < .01), but this association was not significant in those who did receive red blood cells in addition to fresh frozen plasma. The association between fresh frozen plasma and infectious complications remained significant in the multivariate model, with an odds ratio of infection per unit of fresh frozen plasma transfused equal to 1.039 (1.013-1.067). This odds ratio resembled that noted for each unit of packed red blood cells, 1.074 (1.043-1.106). CONCLUSIONS: Transfusion of fresh frozen plasma is associated with an increased risk of infection in critically ill patients.