Perioperative Care of Patients Using Wearable Diabetes Devices.

The increasing prevalence of diabetes mellitus has been accompanied by a rapid expansion in wearable continuous glucose monitoring (CGM) devices and insulin pumps. Systems combining these components in a "closed loop," where interstitial glucose measurement guides automated insulin delivery (AID, or closed loop) based on sophisticated algorithms, are increasingly common. While these devices' efficacy in achieving near-normoglycemia is contributing to increasing usage among patients with diabetes, the management of these patients in operative and procedural environments remains understudied with limited published guidance available, particularly regarding AID systems. With their growing prevalence, practical management advice is needed for their utilization, or for the rational temporary substitution of alternative diabetes monitoring and treatments, during surgical care. CGM devices monitor interstitial glucose in real time; however, there are potential limitations to use and accuracy in the perioperative period, and, at the present time, their use should not replace regular point-of-care glucose monitoring. Avoiding perioperative removal of CGMs when possible is important, as removal of these prescribed devices can result in prolonged interruptions in CGM-informed treatments during and after procedures, particularly AID system use. Standalone insulin pumps provide continuous subcutaneous insulin delivery without automated adjustments for glucose concentrations and can be continued during some procedures. The safe intraoperative use of AID devices in their hybrid closed-loop mode (AID mode) requires the CGM component of the system to continue to communicate valid blood glucose data, and thus introduces the additional need to ensure this portion of the system is functioning appropriately to enable intraprocedural use. AID devices revert to non-AID insulin therapy modes when paired CGMs are disconnected or when the closed-loop mode is intentionally disabled. For patients using insulin pumps, we describe procedural factors that may compromise CGM, insulin pump, and AID use, necessitating a proactive transition to an alternative insulin regimen. Procedure duration and invasiveness is an important factor as longer procedures increase the risk of stress hyperglycemia, tissue malperfusion, and device malfunction. Whether insulin pumps should be continued through procedures, or substituted by alternative insulin delivery methods, is a complex decision that requires all parties to understand potential risks and contingency plans relating to patient and procedural factors. Currently available CGMs and insulin pumps are reviewed, and practical recommendations for safe glycemic management during the phases of perioperative care are provided.

Thoracic Epidural Anesthesia After a Transversus Abdominis Plane Block With Liposomal Bupivacaine in a Patient With Chronic Opioid Use: A Case Report.

Liposomal bupivacaine is a long-acting local anesthetic drug that provides extended analgesia. A 45-year-old man with metastatic colon cancer and an intrathecal morphine pump for chronic pain underwent a transverse colectomy for a malignant transverse colon obstruction in this case report. The patient reported severe pain despite preoperative fascial plane blocks with liposomal bupivacaine and postoperative pain management strategies. As a result, an exploratory laparotomy was performed to rule out any underlying causes, but no new injuries were discovered. On postoperative day 1, a thoracic epidural catheter was inserted to provide better pain relief for the patient. The patient's pain was well-controlled by postoperative day 4, allowing the epidural catheter to be removed. On postoperative day 5, the patient was discharged home without complications. This case highlights the difficulties in managing post-laparotomy pain as well as the potential benefits of combining multiple analgesic modalities. It also emphasizes the pharmacokinetic properties of liposomal bupivacaine, emphasizing the need for caution due to its prolonged systemic presence and potential for systemic anesthetic toxicity.

2018 Clinical Update in Liver Transplantation.

Liver transplantation (LT) continues to be the gold standard for treating end-stage liver disease, and challenges that are posed to the anesthesiologist during transplantation are well known. Successful liver transplantation requires knowledge, recognition, and treatment of hemodynamic and metabolic disturbances by the anesthesiologist. End-stage liver disease causes unique derangements to the clotting cascade, increasing risk both for hemorrhagic and thrombotic events. Cirrhotic cardiomyopathy may be masked for years because of low systemic vascular resistance in cirrhosis, and overt heart failure can be precipitated by LT. Surveys of high-volume transplant centers show an overall transesophageal echocardiography (TEE) use rate of 95%. Guidelines on the use of TEE in LT have mirrored safety findings in several studies and suggest TEE may be used for patients with esophageal varices if the benefit outweighs the risk. This review will cover organ system dysfunction in liver cirrhosis and the implications for liver cirrhosis patients and review recent advances in pathophysiology and treatments. In addition, the authors will highlight the concept of enhanced recovery after surgery and how it pertains to the LT patient population. Lastly, the authors review recent advances in organ preservation and optimization.

Trainee experience and success of urgent airway management.

BACKGROUND: There are limited data regarding emergent, non-operating room, intubations performed by all levels of anesthesia residents. This study was a large retrospective review of all non-operating room emergent intubations performed at a single tertiary medical center. The study evaluated the rate of difficult intubations by level of resident training, compared success rates for direct versus video laryngoscopy and evaluated the rate and success of rescue video laryngoscopy following failed direct laryngoscopy. METHODS: All emergent non-operating room intubations at a tertiary university medical center from July 1, 2009, to August 1, 2012, were reviewed and all study data were collected from the medical records. Intubations were classified as being initiated with either direct or video methods. The total number of attempts required and the rate of success were compared by resident year and intubation type. RESULTS: Out of a total of 788 emergent intubations, 741 were performed by anesthesia residents. The higher level anesthesia residents (CA-2 and CA-3) had a statistically significant decrease in the number of attempts needed when compared to CA-1 residents. Rate of success did not vary by resident training year, but success rates were higher for cases initiated with video laryngoscopy. Among direct initiated cases, 8% failed initial direct laryngoscopy and were then successfully intubated with rescue video laryngoscopy. CONCLUSIONS: During emergent, non-operating room intubations, senior level residents used fewer attempts at intubations with direct laryngoscopy. Successful intubation was improved by beginning residents when video laryngoscopy was utilized. Complications were not affected by the presence of the attending anesthesiologist.

Liver Transplantation: Intraoperative Transesophageal Echocardiography Findings and Relationship to Major Postoperative Adverse Cardiac Events.

OBJECTIVE: The primary aim of the study was to describe the most common intraoperative transesophageal echocardiography (TEE) findings during the 3 separate phases of orthotopic liver transplantation (OLT). The secondary aim of the study was to determine if the abnormal TEE findings were associated with major postoperative adverse cardiac events (MACE) and thus may be amenable to future management strategies. DESIGN: Data were collected retrospectively from the electronic medical record and institutional echocardiography database. SETTING: Single university hospital. PARTICIPANTS: A total of 100 patients undergoing OLT via total cavaplasty technique. INTERVENTIONS: Intraoperative TEE was performed in all 3 phases of OLT. MEASUREMENT AND MAIN RESULTS: TEE findings of 100 patients who had TEE during OLT during the dissection, anhepatic, and reperfusion phases of transplantation were recorded after blind review. Findings then were analyzed to see if those findings were predictive of postoperative MACE. Intraoperative TEE findings varied among the different phases of OLT. Common TEE findings at reperfusion were microemboli (n = 40, 40%), isolated right ventricular dysfunction (n = 22, 22%), and intracardiac thromboemboli (n = 20, 20%). CONCLUSIONS: Intraoperative echocardiography findings during liver transplantation varied during each phase of transplantation. The presence of intracardiac thromboemboli or biventricular dysfunction on intraoperative echocardiography was predictive of short- and long-term major postoperative adverse cardiac events.