A survey of anesthesiologists' role, trust in anesthesiologists, and knowledge and fears about anesthesia among predominantly Hispanic patients from an inner-city county preoperative anesthesia clinic.

STUDY OBJECTIVE: To determine the difference between the Hispanic and non-Hispanic public's knowledge about anesthesia, anesthesiologist's expertise, and role of the anesthesiologist in and out of the operating room (OR). DESIGN: Cross-sectional survey. SETTING: Los Angeles inner-city county hospital preoperative anesthesia clinic. PATIENTS: Predominantly Hispanic population. INTERVENTIONS: A 54-question survey in English and Spanish was distributed to adult patients. MEASUREMENTS: Demographic data, knowledge of the anesthesiologist's roles/responsibilities, knowledge of anesthesia, trust in anesthesiologists, and fears related to anesthesia were collected. Descriptive analysis and multiple regression analysis of the data were used to report knowledge, trust, and fear, and the predictive role of patient characteristics. MAIN RESULTS: 300 (88% of eligible pts) completed the survey. Patient demographics were as follows: Hispanics (73%), female (63%), mean age 47 ± 14 years, high school-educated or below (71%), previous surgery (67%), possessing a chronic medical condition (49%), self-reported health of fair to poor (58%). Seventy percent of patients recognized anesthesiologists as specially trained doctors. Mean ± SD trust scores in doctors were 2.6 ± 1.2 out of a maximum 4. Patients with a better perception of their self-health (P < 0.01) and with higher knowledge scores (P < 0.01) had significantly higher trust in the doctors. Women (P = 0.01) patients, those patients with chronic medical condition (P < 0.02), and patients with greater knowledge scores had greater fear or concerns about anesthesia. Mean ± SD knowledge score about anesthesia was 6.3 ± 2.8 (range 0-13). Patients who had surgery previously (P < 0.01) had higher knowledge scores. CONCLUSION: Most Hispanic patients believe that anesthesiologists are specialist doctors and that they put patients to sleep, but these patients are uncertain of their exact role or function during surgery or outside of the OR. High concerns or fears about devastating but rare complications of anesthesia remain. Educational efforts should be directed at this group especially, with the goal of alleviating preoperative anxiety.

Long-term outcomes of primary trabeculectomy in diabetic patients with primary open angle glaucoma.

AIMS: To evaluate primary trabeculectomy with adjunctive mitomycin-C (MMC) in diabetic patients with primary open angle glaucoma (POAG). METHODS: Patients with diabetes mellitus (DM) without retinopathy who had ≥6 months of postoperative follow-up were retrospectively compared with a control group selected from the pool of patients without DM matched case-by-case to the diabetic group by age, gender, race, preoperative intraocular pressure (IOP) and lens status. Surgical success was defined as IOP ≤15 and >5 mm Hg (± glaucoma medications) without complications or additional glaucoma surgery. RESULTS: 41 eyes (29 patients) with DM and 81 eyes (64 patients) without DM were compared. Kaplan-Meier cumulative survival rates at 60 months were 57.8±9.3% (DM group) and 68.6±5.3% (control group), and the mean trabeculectomy survival times were 63 months (DM group, 95% CI 50.3 to 75.7) and 74.6 months (control group, 95% CI 67.1 to 82.1; p=0.095). Mean postoperative IOP of control group was statistically significant lower at 2-, 3-, 6- and 7-year follow-up visits (p<0.05). Rates of postoperative complications and additional glaucoma surgeries required were not different between the two groups. CONCLUSIONS: POAG patients with DM without retinopathy undergoing primary trabeculectomy with MMC do not achieve the same long-term IOP control and may have a lower long-term surgical survival rate compared with patients without DM.

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.

Severe intraoperative hyperglycemia is independently associated with surgical site infection after liver transplantation.

BACKGROUND: Surgical site infection (SSI) is a common postoperative complication associated with increased morbidity and mortality in patients undergoing liver transplantation (LT). Although intraoperative hyperglycemia has been shown to be associated with adverse postoperative outcomes including overall infection rate in LT patients, a relationship between intraoperative hyperglycemia and SSI in LT has not been established. We sought to determine if intraoperative hyperglycemia was associated with SSI after LT. METHODS: Patients undergoing LT at our medical center between January 2004 and November 2007 were included in the study. Recipient, donor, and intraoperative variables including a variety of glucose indices were retrospectively analyzed. Independent risk factors of SSI were identified using a multivariate logistic regression model. RESULTS: Of 680 patients, 76 (11.2%) experienced postoperative SSIs. Among all intraoperative glucose indices analyzed, severe hyperglycemia (>or= 200 mg/dL) was independently associated with postoperative SSI (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.26-4.03, P=0.006). Other independent risk factors include repeat surgery (OR 6.58, 95% CI 3.41-12.69, P<0.001), intraoperative administration of vasopressor (OR 3.14, 95% CI 1.65-5.95, P<0.001), preoperative mechanical ventilation (OR 3.01, 95% CI 1.70-5.33, P<0.001), and combined liver and kidney transplantation (OR 2.95, 95% CI 3.41-12.69, P<0.001). CONCLUSIONS: Severe, but not mild or moderate, intraoperative hyperglycemia is independently associated with postoperative SSI and should be avoided during LT surgery.

Preoperative characteristics and intraoperative transfusion and vasopressor requirements in patients with low vs. high MELD scores.

Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation.

A review of patients with pulmonary aspiration of gastric contents during anesthesia reported to the Departmental Quality Assurance Committee.

STUDY OBJECTIVE: Preoperative risk factors for pulmonary aspiration of gastric contents during anesthesia are well studied. There is lack of information as to factors or circumstances leading to aspiration. DESIGN: A retrospective review of cases of pulmonary aspiration reported to the Departmental Quality Assurance (QA) Committee was undertaken. SETTING: This study took place at a large tertiary care university hospital based in a metropolitan city. PATIENTS: The study identified all patients reported to the QA Committee as having pulmonary aspiration during January 1991 to December 1994 and July 1996 to December 2000. INTERVENTIONS: No interventions were done. MEASUREMENTS: The medical records of all patients thus identified were reviewed to see if they had pulmonary aspiration according to strict criteria. Presence of preoperative known risk factors, prophylactic measures used against pulmonary aspiration, and perioperative events were noted. MAIN RESULTS: A total of 47 patients were reported to the QA Committee as having pulmonary aspiration during this period. Upon review, 23 patients had pulmonary aspiration (definite aspiration, n = 12; probable aspiration, n = 11) and 24 patients did not meet the criteria for pulmonary aspiration of gastric contents. The incidence of pulmonary aspiration overall was 1 per 8671 anesthetics and 1 per 4385 anesthetics in patients younger than 16 years. If all 47 cases reported to QA Committee are presumed to have had pulmonary aspiration, then the overall incidence of aspiration is 1 in 4243 anesthetics. Eighteen of 23 patients had a preoperative risk factor, but preventive measures against aspiration had been used in only 4 patients. Five patients did not have any apparent preoperative risk factor. CONCLUSIONS: This study confirms that pulmonary aspiration of gastric contents is a rare complication during modern anesthesia. Preoperative risk factor was present in most patients who had pulmonary aspiration. A clear understanding of risk factor/s is needed to prevent further cases of pulmonary aspiration.

Systemic vasodilation is a predominant cause of hypotension in a patient with familial amyloid polyneuropathy during liver transplantation.

A patient with familial amyloid polyneuropathy underwent a living, nonrelated orthotopic liver transplant and developed hypotension after induction of anesthesia. Causes of hypotension in patients with familial amyloid polyneuropathy are discussed. Transesophageal echocardiographic monitoring was invaluable in differentiating various causes of hypotension and in diagnosing peripheral vasodilation as the predominant cause of hypotension.

Comparison of RBCs and FFP with whole blood during liver transplant surgery.

BACKGROUND: Component therapy has become the accepted standard of care in transfusion medicine. In instances of large blood loss, the transfusion of whole blood rather than the combination of RBCs and FFP is rational and may be preferred. STUDY DESIGN AND METHODS: In a controlled, prospective, randomized study of 33 patients undergoing orthotopic liver transplantation, the effectiveness of component therapy (RBCs and FFP) was compared with the use of whole blood. Coagulation tests (prothrombin time and activated partial thromboplastin time), clotting factor levels (FV, FVIII, fibrinogen), platelet counts, the number of donor exposures, and the total volume of blood transfused for the whole-blood group and the component-therapy group were compared at designated times before surgery, during surgery, and 24 hours after surgery. RESULTS: There was a significant difference (p=0.015) in the median number of donor exposures for RBCs and FFP, with fewer occurring in the whole-blood group (n=14.5) compared with the component group (n=25). There was no significant difference between groups in coagulation profiles during any of the phases of surgery except for a mild decrease in fibrinogen levels in the whole-blood group at the conclusion of surgery. There were no differences between the groups in the median volume of blood component replacement, the median age of blood components, the patients' Hct or the number of RBC-containing components transfused. CONCLUSION: Whole blood, when compared with component therapy, is associated with fewer donor exposures yet provided equally effective replacement therapy for blood loss in liver transplantation patients.