Stephen Aniskevich

Ultrasound-guided transversus abdominis plane blocks for patients undergoing laparoscopic hand-assisted nephrectomy: a randomized, placebo-controlled trial.

Postoperative pain is a common complaint following living kidney donation or tumor resection using the laparoscopic hand-assisted technique. To evaluate the potential analgesic benefit of transversus abdominis plane blocks, we conducted a randomized, double-blind, placebo-controlled study in 21 patients scheduled to undergo elective living-donor nephrectomy or single-sided nephrectomy for tumor. Patients were randomized to receive either 20 mL of 0.5% ropivacaine or 20 mL of 0.9% saline bilaterally to the transversus abdominis plane under ultrasound guidance. We found that transversus abdominis plane blocks reduced overall pain scores at 24 hours, with a trend toward decreased total morphine consumption. Nausea, vomiting, sedation, and time to discharge were not significantly different between the two study groups.

Postoperative Stroke Following Administration of Intraoperative Recombinant Tissue Plasminogen Activator for the Treatment of Intracardiac Thrombus during Liver Transplantation

MASSIVE INTRACARDIAC AND PULMONARY thromboembolism have an extremely high mortality during liver transplantation. The authors describe 2 cases in which intraoperative use of tissue plasminogen activator was able to reduce the thrombus size and improve hemodynamics during liver transplantation. Although both patients survived the surgery, they suffered neurologic sequelae postoperatively. The authors discuss the current understanding of the pathophysiology, diagnosis, and management of intracardiac thromboembolism during liver transplantation.

Anesthetic pharmacology and perioperative considerations for the end stage liver disease patient

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.

Analgesic considerations for liver transplantation patients.

Orthotopic liver transplantation (OLT) recipients have been reported to have decreased perioperative opioid and intraoperative inhalational anesthetic requirements when compared to patients without liver disease undergoing other types of major abdominal surgeries. The severity of the liver disease and the process of the transplantation itself may alter the pharmacokinetic and pharmacodynamic effects of different pain medications. Chemical injury of the liver and the high degree of surgical stress may also increase the levels of neuropeptides involved in pain modulation. Per the U.S. Department of Health and Human Services Organ Procurement and Transplantation Network, more than 5,000 OLT cases are being done per year since 2000. With better understanding of the pathophysiology of liver disease and the development of perioperative anesthesia management, the recent concept of improving patient outcome following OLT includes a fast-track approach in selected patients, which may shorten or completely bypass intensive care unit stay and reduce costs. With this development, the understanding of the analgesic pharmacology in the care of the OLT patients is even more important. Proper dosage of medications can achieve adequate intraoperative anesthetic depth and postoperative pain control, while avoiding over-sedation which increases risk of prolonged postoperative mechanical ventilation. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the analgesic medications commonly administered to this patient population.

Sugammadex: a novel approach to reversal of neuromuscular blockade.

Sugammadex is the first in a new class of medications termed selective relaxant binding agents. This medication acts to encapsulate free circulating steroidal nondepolarizing neuromuscular blocking agents. The encapsulation of neuromuscular agents effectively decreases the amount of neuromuscular blocker interacting at the neuromuscular receptor. This binding has a very high association rate, rendering the incidence of residual block extremely low, while avoiding the side effects associated with traditional reversal agents. Currently approved for clinical use in over 50 countries, sugammadex was not approved by the US FDA in 2008 due to concerns over potential hypersensitivity reactions. It is hoped that further study and clinical experience will help to better define the risk associated with sugammadex and eventually lead to the approval of this novel medication in the USA.

Intra-operative predictors of postoperative Takotsubo syndrome in liver transplant recipients—An exploratory case-control study

Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy or stress‐induced cardiomyopathy, has been described following a variety of surgeries and disease states. The relationship between intra‐operative anesthesia management and the development of this syndrome has never been fully elucidated.

Pharmacologic and Perioperative Considerations for Antihypertensive Medications

BACKGROUND As the prevalence of hypertension continues to increase, physicians routinely encounter patients preoperatively receiving one or more cardiovascular medications to manage hypertension. Thus, the physicians knowledge of perioperative antihypertensive medication management is crucial to ensure patient safety. OBJECTIVE We discuss the decisions to continue or stop antihypertensive medications to reduce the risk of perioperative complications. METHOD We conducted a review of the original research studies, review articles, and editorials present on PubMed within the past 60 years. The authors included peer-reviewed articles that they deemed relevant to current practice. Search terms of perioperative surgical home, preoperative medication instruction, surgery, and perioperative management were used in combination with the key words α-agonist, antihypertensive, β-blocker, calcium-channel blocker, diuretic, hypertension, renin-angiotensin-aldosterone system inhibitor, and vasodilator. The reference lists of each selected article were also reviewed for additional sources of information. RESULTS The number of articles about perioperative management of antihypertension medications increased in more recent years. Evidence showed clear support of the continuation or withholding of most medications. However, no clear recommendation was found on the continuation of reninangiotensin- aldosterone system inhibitors in the perioperative period. CONCLUSION Current evidence supports the perioperative continuation of β-blockers, calciumchannel blockers, and α-2 agonists. However, diuretics should be discontinued on the day of the surgery and resumed in the postoperative period. Debates persist about the continuation of reninangiotensin- aldosterone system inhibitors.

Atrioventricular Sequential Pacing for Hypertrophic Cardiomyopathy During Liver Transplantation

Hypertrophic cardiomyopathy is a myocardial disorder that carries an increased risk of morbidity and mortality during liver transplantation. We describe the use of atrioventricular sequential pacing, placed preoperatively, to assist with intraoperative management of a patient with severe refractory hypertrophic cardiomyopathy undergoing orthotopic piggyback liver transplantation. We discuss the pathogenesis and treatment of this infrequent but serious comorbidity.

Anesthesia for Pancreas Transplantation

As the frequency of pancreas transplants increase worldwide, clinicians are faced with providing care to recipients who may present with multiple comorbidities related to their underlying diabetes. This review summarizes the perioperative management of pancreas transplant recipients from the viewpoint of the anesthesiologist. Preoperative evaluation, intraoperative care and postoperative pain control are all discussed.

A Review of the Safety and Efficacy of Sugammadex in Anesthetic Practice

Sugammadex, the first in a novel class of medications termed selective relaxant binding agents, was developed to rapidly and completely encapsulate aminosteroid neuromuscular blocking agents, thus removing them from the neuromuscular junction. When used properly, sugammadex has the potential to decrease the incidence of residual neuromuscular block and its associated complications, as well as, avoid the side effects associated with cholinesterase inhibitors. Sugammadex may also have a role in the management of patients with difficult airways and rocuronium- induced anaphylaxis. Currently available in over 70 countries worldwide, fears of hypersensitivity reactions have delayed its release in the United States. The article looks to examine the role of sugammadex in anesthesia and detail its pharmacologic profile.