Vijaya Komanduri

Living liver donor surgery: Report of initial anesthesia experience

Abstract The charts and anesthetic records of 12 patients who donated the left lateral segment of their liver to a related infant or child to treat liver failure were retrospectively reviewed. Blood loss, need for transfusion, fluids administered, surgical length, and perioperative complications were investigated. The records also were examined to determine the hemodynamic stability of patients undergoing donor hepatectomy to assess their need for invasive monitoring. There were no episodes of hypotension or hemodynamic instability. The average operating time was 9.6 ± 1.1 hours. The blood loss was 562 ± 244 mL (range 300 to 1100 mL). Four patients received their own cell saver blood (200 mL, 220 mL, 300 mL, 475 mL), and one patient received 1 U (350 mL) of predonated autologous blood. The average hemoglobin decreased significantly (p = 0.001) from a preoperative value of 14.1 ± 1.2 to 12.3 ± 1.8 g/dL in the recovery room. All patients were extubated in the operating room or recovery room. Patients were discharged home in 6.9 ± 1.3 days (range 5 to 9 days). Living-related liver resection can be performed with noninvasive monitoring and without the need for heterologous blood products.

The effect of insufflation pressure on CO2 pneumoperitoneum and embolism in piglets

We conducted this study to investigate the effect of insufflation pressure on the pathophysiology of CO2 pneumoperitoneum and embolism in an infant model. Twenty anesthetized piglets had stepwise intraperitoneal insufflation with CO2 for 15 min at pressures ranging from 5 to 20 mm Hg. The piglets were ventilated to baseline normocarbia (ETco2 = 30 mm Hg, Paco2 = 38 mm Hg) before beginning each insufflation. CO2 was then insufflated IV in 15 of these piglets at the same pressures. There was no reduction of blood pressure or cardiac output with intraperitoneal insufflation, but the stroke volume declined significantly (*P < 0.05) from (mean ± se) 10.6 ± 1.3 mL to 8.5 ± 1.3* mL and from 10.0 ± 1.4 mL to 7.2 ± 1.2* mL at 15 and 20 mm Hg insufflation pressure, respectively. Abdominal insufflation at 5, 10, 15, and 20 mm Hg caused an increase in ETco2 to 31.7 ± 0.8 mm Hg, 35.6 ± 1.2* mm Hg, 37.5 ± 1.5* mm Hg, and 40.1 ± 1.8* mm Hg and in Paco2 to 41.1 ± 1.3* mm Hg, 44.2 ± 1.4* mm Hg, 49.9 ± 1.8* mm Hg, and 53.0 ± 2.1* mm Hg, respectively. In contrast, the ETco2decreased to 19.4 ± 1.5* mm Hg, 20.4 ± 1.4 mm Hg, 15.2 ± 2.1* mm Hg, and 10.6 ± 2.0* mm Hg with IV insufflation using the same pressures. IV insufflation caused marked hypotension and mortality. As the insufflation pressure increased, the mortality increased (0 in 15, 1 in 15, 1 in 14, and 6 in 13* at 5, 10, 15, and 20 mm Hg; *P < 0.05 vs 0 in 15, 1 in 15, and 1 in 14). This study suggests that although intraperitoneal insufflation up to 20 mm Hg may be tolerated hemodynamically, the lowest possible pressure should be used to reduce hypercarbia. A low insufflation pressure may also prevent mortality from CO2 embolism.

Is dantrolene safe to administer in sepsis? The effect of dantrolene after endotoxin administration in dogs and rats

Hyperthermia from septic shock may be indistinguishable from malignant hyperthermia. Dantrolene may be given in septicemia if the diagnosis is unclear. To determine if dantrolene is safe to use in sepsis, two studies were performed. In study 1, 18 anesthetized dogs in which profound septic shock was induced with 5 mg/kg of intravenous Escherichia coli endotoxin were randomized to receive (30 min later) intravenous injections of 10 mg/kg of dantrolene solution, the diluent of dantrolene, or maintenance intravenous fluids alone. The use of dantrolene solution and the diluent of dantrolene resulted in similar but transient statistically significant increases in the cardiac filling pressures and cardiac outputs and decreases in the vascular resistances compared with the control dogs. In a second study, 185 rats were randomized into five equal groups. Groups 1, 2, and 3 received 15 mg/kg of intraperitoneal Escherichia coli endotoxin followed 30 min later by 10 mg/kg of dantrolene solution, the diluent of dantrolene, or normal saline. Groups 4 and 5 received normal saline followed by dantrolene or normal saline. The survival of groups 1, 2, and 3 was less at 24 h (P < 0.0001) than that of either control group, but was not significantly different from one another. The results suggest dantrolene can be administered safely under clinical conditions where the cause of hyperthermia and shock cannot clearly be ascribed to malignant hyperthermia or septicemia.

Living related liver transplantation in infants and children: Report of anesthetic care and early postoperative morbidity and mortality

STUDY OBJECTIVE To determine those infants at high risk for perioperative complications and mortality following living, related liver transplantation. DESIGN Retrospective chart review. SETTING Large metropolitan teaching hospital. MEASUREMENTS AND MAIN RESULTS The charts and anesthetic records of the 12 infants and children who received the left lateral hepatic segment from a living relative the past 2 years at our institution were reviewed. The records were examined to determine the causes of perioperative morbidity and to identify patients at high risk for serious complications and mortality. All infants and children (mean +/- SD age, 29+/-30 months; weight, 13.6 +/-6.8 kg) survived the operation (8.3+/-1.7 hours) without intraoperative complications. The average blood loss, including 500 mL of recipient blood used to flush the liver before reperfusion, was 1483 +/-873 mL (119+/-70 mL/kg). Three infants developed portal vein thrombosis, and one of these infants also had hepatic artery thrombosis. The risk of vessel thrombosis was significantly higher (3/3 vs. 0/9; p<0.0045) in infants less than 9 kg body weight, as was the risk of death (2/3 vs. 0/9; p<0.045). Both children who died had vascular thrombosis. Other serious complications were bleeding, 6; infection, 7; acute rejection, 3; and bile leak, 2. CONCLUSIONS Infants and children can successfully undergo living, related liver transplantation. However, the risks of vascular complications and death are greater in infants less than 9 kg body weight.

Differential diagnosis of thyroid crisis and malignant hyperthermia in an anesthetized porcine model.

The intra-operative differential diagnosis between thyroid crisis and malignant hyperthermia can be difficult. Also stress alone can trigger MH. The purposes of this study were: 1) to investigate the metabolic and hemodynamic differences between thyroid crisis and MH, 2) determine how thyroid crisis affects the development of MH, and 3) determine if the stress of thyroid crisis can trigger MH in susceptible individuals. We studied MH susceptible and normal swine. Two groups of animals (MH susceptible and normal) were induced into thyroid crisis (critical core hyperthermia, sustained tachycardia and increase in oxygen consumption) by pretreatment with intraperitoneal triiodothyronine (T3) followed by large hourly intravenous injections of T3. Two similar groups were given intravenous T3 but no pretreatment. These animals did not develop thyroid crisis and served as controls. Thyroid crisis did not result in metabolic changes or rigidity characteristic of an acute episode of MH. When the animals were subsequently challenged with MH triggering agents (halothane plus succinylcholine) dramatic manifestations of fulminant MH episodes (acute serious elevation in exhaled carbon dioxide, arterial CO2, rigidity and acidemia) were noted only in the MH susceptible animals. Although thyroid crisis did not trigger MH in the susceptible animals it did decrease the time to trigger MH (14.1 +/- 7.2 minutes versus 47.2 +/- 17.7 minutes, p < 0.01) in susceptible animals. Hormone induced elevations in temperature and possibly other unidentified factors during thyroid crisis may facilitate the triggering of MH following halothane and succinylcholine challenge.

Hemodynamic and Metabolic Manifestations of Acute Endotoxin Infusion in Pigs with and without the Malignant Hyperthermia Mutation

BACKGROUND The hypermetabolic state induced by acute endotoxemia and malignant hyperthermia (MH) may be indistinguishable. The aims of this study were (1) to investigate the differences between MH and sepsis, (2) to determine whether acute endotoxemia can trigger MH, and (3) to establish the effects of dantrolene in these two disorders. METHODS Three groups of swine were studied. All pigs were invasively monitored and initially anesthetized with nontriggering agents. A placebo MH-susceptible group (n = 5) received normal saline whereas the endotoxin groups (MH-susceptible, n = 6; MH-negative, n = 4) received intravenous endotoxin (250 microg/kg total) during 2.5 h. Halothane (1.5%) and succinylcholine (2-4 mg/kg) were then administered, followed by two doses of dantrolene (4 mg/kg total). RESULTS Endotoxin infusion resulted in pulmonary hypertension and systemic hypotension in pigs with and without the MH mutation, but did not trigger MH. Halothane and succinylcholine triggered MH, evidenced by a markedly higher oxygen consumption in the MH-susceptible pigs that received endotoxin (325+/-196 ml/min) and those that did not (374+/-110 ml/min) compared to the MH-negative pigs (69+/-15 ml/min, P<0.0009), as well as muscular rigidity in the susceptible animals. Dantrolene reversed these changes. Three of the six MH-susceptible pigs that received endotoxin died; two died soon after triggering and one after dantrolene administration. In contrast, none of the MH-negative pigs or the MH-susceptible pigs that did not receive endotoxin died (0 of 9 vs. 3 of 6, P = 0.044). CONCLUSION Endotoxemia does not trigger MH, but may worsen outcome if it occurs.

LIVING LIVER DONOR SURGERY: REPORT OF INITIAL ANESTHESIA EXPERIENCE

The charts and anesthetic records of 12 patients who donated the left lateral segment of their liver to a related infant or child to treat liver failure were retrospectively reviewed. Blood loss, need for transfusion, fluids administered, surgical length, and perioperative complications were investigated. The records also were examined to determine the hemodynamic stability of patients undergoing donor hepatectomy to assess their need for invasive monitoring. There were no episodes of hypotension or hemodynamic instability. The average operating time was 9.6 +/- 1.1 hours. The blood loss was 562 +/- 244 mL (range 300 to 1100 mL). Four patients received their own cell saver blood (200 mL, 220 mL, 300 mL, 475 mL), and one patient received 1 U (350 mL) of predonated autologous blood. The average hemoglobin decreased significantly (p = 0.001) from a preoperative value of 14.1 +/- 1.2 to 12.3 +/- 1.8 g/dL in the recovery room. All patients were extubated in the operating room or recovery room. Patients were discharged home in 6.9 +/- 1.3 days (range 5 to 9 days). Living-related liver resection can be performed with noninvasive monitoring and without the need for heterologous blood products.