Use of an intraoperative veno-venous bypass during liver transplantation: an observational, single center, cohort study.

BACKGROUND: As previous studies demonstrated conflicting results, we investigated the hemodynamic and renal outcomes of the intra-operative use of a veno-venous bypass during liver transplantation. METHODS: The intraoperative levels of mean artery pressure, cardiac index, inferior vena cava and renal perfusion pressures were compared in liver transplant patients receiving or not the bypass. RESULTS: We enrolled 38 patients: 20 with the bypass and 18 without. No differences characterized the two groups regarding gender (P=0.95), age (P=0.32), BMI (P=0.09), liver disease indicating LT and preoperative serum creatinine levels. Patients with the bypass received more intraoperative fluids (crystalloids and colloids) but with no difference in terms of intraoperative blood products and vasopressors requirements (P=0.33). After clamping of the inferior vena cava, patients with the bypass showed higher mean artery pressure. Simultaneously, pressure in the inferior vena cava below the clamp level sharply increased vs. baseline (P<0.0001) independently of the use of the bypass and remained high until clamp release. Consequently, renal perfusion pressure dropped abruptly (P<0.0001) after vena cava clamping and returned to baseline only upon clamp removal. Overall, 18 subjects developed postoperative acute kidney injury which was equally distributed between patients with (n=9) or without (N.=8) the bypass. CONCLUSIONS: Our data suggest that the use of a veno-venous bypass fails to release the increased renal venous backflow from inferior vena cava clamping resulting in renal congestion with reduced renal perfusion pressure.

Continuous Femoral Catheter for Postoperative Analgesia After Total Knee Arthroplasty.

INTRODUCTION: Postoperative pain management in the total knee replacement (TKR) represent a fundamental step for a positive outcome, allowing rapid mobilization, already on the first day. Further, continuous peripheral nerve block techniques have been reported to allow effective and safe control of acute postoperative pain, ensuring the implementation and completion of an accurate and intensive joint rehabilitation program. AIM: The aim of this study was to assess early mobility and compliance of patients that underwent TKR surgery using the femoral block. METHODS: For the study, all patients that underwent TKR from 2015 to 2018 with ASA score between II-III was evaluated. Patients underwent vital parameters monitoring and were treated initially with midazolam (0.05mg / kg) e.v. combined sciatic block + femoral perineural catheter positioning using a peripheral nerve stimulation-assisted technique. RESULTS: Intraoperatively, satisfactory analgesia was guaranteed in all patients, associated with a complete muscle relaxation of the affected limb. High patient compliance, associated with good control of acute postoperative pain was obtained in the first 24 hours after surgery (VAS 0- 1). The ROM outcomes were good in all rehabilitation stages, managing to reach 90 degrees bending on the seventh day with an average KSS score of 88-90. Patient satisfaction and impact on quality of life were assessed with the SF-36 showing average scores of 78. CONCLUSION: Continuous femoral nerve blocking ensures good postoperative analgesia in TKR allowing an early joint mobilization, a rapid functional recovery of the knee and increasing patient compliance during the post-operative rehabilitation program.

Postoperative Pain Evaluation After Robotic Transaxillary Thyroidectomy Versus Conventional Thyroidectomy: A Prospective Study.

BACKGROUND: Robot-assisted transaxillary thyroidectomy (RATT) is an emerging technique with excellent cosmetic results but is supposedly more invasive and painful than conventional thyroidectomy (CT). This prospective study compared pain after RATT and CT. METHODS: Inclusion criteria were a nodule <5 cm and volume <30 mL. Patients received the same analgesia. Pain was evaluated by visual analog scale (VAS) in the recovery room (VASrr), on the first postoperative day at 8:00 a.m. (VAS 8 a.m.) and 8:00 p.m. (VAS 8 p.m.), at 8:00 a.m. on the second postoperative day (VAS 8*a.m.), and after 7 days (VAS 7). Operative time and complications were evaluated. RESULTS: From May 2015 to September 2015, 124 patients (all women) underwent thyroidectomy: 62 underwent RATT and 62 underwent CT. Mean age was 39.7 ± 10.2 years in the RATT group and 41.4 ± 12.5 years in the CT group. Groups were comparable for thyroid volume and nodule diameter. Operative time was longer in the RATT group than in the CT group (119.4 ± 25.5 versus 70.3 ± 11.0 minutes). Complications were three transient hypocalcemia in RATT and four in the CT group. No definitive complications occurred. VASrr was lower in the RATT group (1.79 ± 2.06 versus 2.5 ± 1.18; P < .0001). There was no difference between groups for VAS 8 a.m., VAS 8 p.m., and VAS 8*a.m., but VAS 7 was higher in the RATT group (0.85 ± 1.77 versus 0.17 ± 0.52; P < .010). DISCUSSION: RATT is as safe and effective as CT. Patients undergoing RATT, surprisingly, experienced less pain in the immediate postoperative period. However, the VAS 7 score was higher in the RATT group, probably because the intact neck is favorable in the early phase of recovery, but the large dissection takes longer for healing.