William R. Hand

Hydroxyethyl starch and acute kidney injury in orthotopic liver transplantation: a single-center retrospective review.

BACKGROUND:Acute kidney injury (AKI) is a frequent complication of orthotopic liver transplantation (OLT). Hepatic failure pathophysiology and intraoperative events contribute to AKI after OLT. Colloids are routinely used to maintain intravascular volume during OLT. Recent evidence has implicated 6% hydroxyethyl starch (HES) (130/0.4) with AKI in critically ill patients. METHODS:We performed a retrospective cross-sectional analysis of electronic anesthesia records, surgical dictations, and perioperative laboratory results. Postoperative AKI incidence was determined by RIFLE (Risk Injury Failure Loss End-Stage) criteria. AKI was staged into Risk, Injury, and Failure based on change in serum creatinine from preoperative baseline to peak level by postoperative day 7. Uni- and multivariate analysis was used to evaluate the association between type of intraoperative colloid administered and AKI. RESULTS:One hundred seventy-four adult patients underwent OLT and had complete records for review. Of these, 50 received only 5% albumin, 25 received both 5% albumin and HES, and 99 received only HES. Albumin-only, albumin and HES, and HES-only groups were otherwise homogeneous based on patient characteristics and intraoperative variables. There was a statistically significant linear-by-linear association between type of colloid(s) administered and AKI (Rifle Criteria—Injury Stage). Patients administered HES were 3 times more likely to develop AKI within 7 days after OLT compared with albumin (adjusted odds ratio 2.94, 95% confidence interval, 1.13–7.7, P = 0.027). The linear trend between colloidal use (5% albumin only versus albumin/HES versus HES only, ranked ordering) and “injury” was statistically significant (P = 0.048). A propensity-matched analysis also showed a significant difference in the incidence of AKI between the patients receiving albumin compared with HES (P = 0.044). CONCLUSIONS:Patients receiving 6% HES (130/0.4) likely had an increased odds of AKI compared with patients receiving 5% albumin during OLT. These retrospective findings are consistent with recent clinical trials that found an association between 6% HES (130/0.4) and renal injury in critically ill patients.

Thoracolumbar interfascial plane (TLIP) block: a pilot study in volunteers.

PurposeRegional anesthesia has been shown to improve outcomes in several recent studies. The transversus abdominis plane (TAP) block provides anesthesia to the abdominal wall by introducing local anesthetic to the ventral rami of the thoracolumbar nerves. This work quantifies the area of anesthesia obtained after performing the novel thoracolumbar interfascial plane block (analogous to the TAP block but intended for the back) which targets the sensory component of the dorsal rami of the thoracolumbar nerves.MethodsTen participants underwent bilateral ultrasound-guided injections of 0.2% ropivacaine 20 mL into the fascial plane between the multifidus and longissimus muscles. After five and 20 min, respectively, the area of anesthesia was plotted on the participant’s back. Anesthesia was defined as loss of point discrimination to pinprick.ResultsParticipants reported a mean (SD) area of anesthesia surrounding the needle injection site of 137.4 (71.0) cm2 and 217.0 (84.7) cm2 at five and 20 min after injection, respectively. The mean (SD) cephalad and caudal spread of local anesthetic from the site of injection was 6.5 (1.8) cm and 3.9 (1.2) cm, respectively. There were no complications or adverse events reported.ConclusionThis report shows that a reproducible area of anesthesia can be obtained by ultrasound-guided injection of local anesthetic in the fascial plane between the multifidus and longissimus muscles of the thoracolumbar spine. The area of anesthesia consistently covered the midline and had a predictable spread. This project was registered with clinicaltrials.gov (NCT02297191).RésuméObjectifPlusieurs études récentes ont démontré que l’anesthésie régionale améliorait les résultats postopératoires. Le bloc du plan transverse abdominal (TAP) procure une anesthésie de la paroi abdominale en introduisant un anesthésique local dans les rameaux ventraux des nerfs thoraco-lombaires. Le but de cette étude est de mesurer la surface d’anesthésie obtenue après avoir réalisé un nouveau type de bloc, soit celui du plan interfascial thoraco-lombaire (analogue au bloc TAP mais pratiqué dans le dos) qui cible la composante sensorielle des rameaux dorsaux des nerfs thoraco-lombaires.MéthodeDix participants reçurent des injections bilatérales échoguidées de 20 mL de ropivacaïne 0,2 % dans le plan fascial entre les muscles multifidus et longissimus. Après cinq et 20 minutes, respectivement, la surface d’anesthésie a été tracée sur le dos du participant. L’anesthésie était définie comme la perte de discrimination à la piqûre d’épingle.RésultatsLes participants ont rapporté une surface moyenne (ÉT) d’anesthésie autour du site d’injection de 137,4 (71,0) cm2 et de 217,0 (84,7) cm2 à cinq et 20 minutes après l’injection, respectivement. La diffusion moyenne (ÉT) de l’anesthésique local depuis le site d’injection vers la tête et les membres inférieurs était de 6,5 (1,8) cm et 3,9 (1,2) cm, respectivement. Aucune complication n’a été rapportée.ConclusionCe compte-rendu démontre qu’une zone d’anesthésie reproductible peut être obtenue par injection échoguidée d’anesthésique local dans le plan fascial entre les muscles multifidus et longissimus de la colonne thoraco-lombaire. Dans tous les cas, la surface d’anesthésie recouvrait la ligne médiane et la diffusion de l’anesthésique était prévisible. Ce projet est enregistré au clinicaltrials.gov (NCT02297191).

Detection of elevated intracranial pressure in robot-assisted laparoscopic radical prostatectomy using ultrasonography of optic nerve sheath diameter.

Background: Robot-assisted laparoscopic radical prostatectomy (RALRP) is becoming an increasingly frequent procedure. Pneumoperitoneum and steep trendelenburg positioning associated with this surgery may increase patient’s risk for elevated intracranial pressure (ICP). We conducted a prospective observational trial using ultrasonographic analysis of optic nerve sheath diameter (ONSD) to determine if ICP increased to levels >20 mm Hg during RALRP surgery. Materials and Methods: The study includes 25 patients, without any history of increased ICP, undergoing RALRP. Ultrasonographic analysis of ONSD was performed immediately after induction of general anesthesia and again at the end of the procedure. A threshold value of ≥5.2 mm for ONSD was used for determination of raised ICP (>20 mm Hg). Age, race, body mass index, American Society of Anesthesiologists Physical Status Classification System class, total intraoperative IV fluids, and surgery duration were recorded, as well as, mean arterial pressure (MAP), end-tidal CO2, and end-tidal isoflurane concentration. Results: Mean preinduction ONSD, in the 25 patients studied, was 4.5+0.5 mm and mean postoperative ONSD was 5.5+0.5 mm. Controlling for preinduction ONSD, postoperative ONSD was significantly associated with MAP (P=0.048) and the association of postoperative ONSD with end-tidal CO2 trended toward significance (P=0.072). Conclusions: This study demonstrates an increase in ONSD in patients undergoing RALRP. These findings confirm ICP rises to ≥20 mm Hg during RALRP surgery. This increase in ICP is significantly associated with increasing MAP. Patients with intracranial pathology should be counseled to the risks RALRP may pose with regard to intracranial hypertension.

Effect of a Cognitive Aid on Adherence to Perioperative Assessment and Management Guidelines for the Cardiac Evaluation of Noncardiac Surgical Patients

Background:The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. Methods:Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. Results:All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). Conclusions:Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.

Characteristics and intraoperative treatments associated with head and neck free tissue transfer complications and failures.

Objective To investigate the association between perioperative patient characteristics and treatment modalities (eg, vasopressor use and volume of fluid administration) with complications and failure rates in patients undergoing head and neck free tissue transfer (FTT). Study Design A retrospective review of medical records. Setting Perioperative hospitalization for head and neck FTT at 1 tertiary care medical center between January 1, 2009, and October 31, 2011. Subjects and Methods Consecutive patients (N = 235) who underwent head and neck FTT. Demographic, patient characteristic, and intraoperative data were extracted from medical records. Complication and failure rates within the first 30 days were collected Results In a multivariate analysis controlling for age, sex, ethnicity, reason for receiving flap, and type and volume of fluid given, perioperative complication was significantly associated with surgical blood loss (P = .019; 95% confidence interval [CI], 1.01-1.16), while the rate of intraoperative fluid administration did not reach statistical significance (P = .06; 95% CI, 0.99-1.28). In a univariate analysis, FTT failure was significantly associated with reason for surgery (odds ratio, 5.40; P = .03; 95% CI, 1.69-17.3) and preoperative diagnosis of coronary artery disease (odds ratio, 3.60; P = .03; 95% CI, 1.16-11.2). Intraoperative vasopressor administration was not associated with either FTT complication or failure rate. Conclusions FTT complications were associated with surgical blood loss but not the use of vasoactive drugs. For patients undergoing FTT, judicious monitoring of blood loss may help stratify the risk of complication and failure.

Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer

The purpose of this study was to determine the effect of algorithmic physiologic management on patients undergoing head and neck free tissue transfer and reconstruction.

A Smartphone-based Decision Support Tool Improves Test Performance Concerning Application of the Guidelines for Managing Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy.

Background:The American Society of Regional Anesthesia and Pain Medicine (ASRA) consensus statement on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy is the standard for evaluation and management of these patients. The authors hypothesized that an electronic decision support tool (eDST) would improve test performance compared with native physician behavior concerning the application of this guideline. Methods:Anesthesiology trainees and faculty at 8 institutions participated in a prospective, randomized trial in which they completed a 20-question test involving clinical scenarios related to the ASRA guidelines. The eDST group completed the test using an iOS app programmed to contain decision logic and content of the ASRA guidelines. The control group completed the test by using any resource in addition to the app. A generalized linear mixed-effects model was used to examine the effect of the intervention. Results:After obtaining institutional review board’s approval and informed consent, 259 participants were enrolled and randomized (eDST = 122; control = 137). The mean score was 92.4 ± 6.6% in the eDST group and 68.0 ± 15.8% in the control group (P < 0.001). eDST use increased the odds of selecting correct answers (7.8; 95% CI, 5.7 to 10.7). Most control group participants (63%) used some cognitive aid during the test, and they scored higher than those who tested from memory alone (76 ± 15% vs. 57 ± 18%, P < 0.001). There was no difference in time to completion of the test (P = 0.15) and no effect of training level (P = 0.56). Conclusions:eDST use improved application of the ASRA guidelines compared with the native clinician behavior in a testing environment.

Epsilon-Aminocaproic Acid in Liver Transplantation: A Three-Year, Retrospective Review

The primary aim was to determine whether EACA affected transfusion requirements. Secondary outcomes were effect of EACA use on fibrinogen level, operative time, and hepatic artery or portal vein thrombus formation. We examined the association between EACA and RBC and FFP transfusion volume; factor 7 administrations, presence of thrombosis, mortality, change in fibrinogen levels, and MELD score. Chi-square tests and Fisher’s exact test were used for comparing categorical variables. Student’s t-test or Mann-Whitney U test was used to examine associations between EACA usage and all continuous outcomes. All analyses were conducted in SAS v. 9.3 (SAS Institute, Cary, NC).

Intraoperative diagnosis of stanford type a dissection by transesophageal echocardiogram in a patient presenting for renal transplantation.

A 48-year-old patient with hypertensive end-stage renal disease presented for cadaveric renal transplantation. On physical exam, a previously undocumented diastolic murmur was heard loudest at the left lower sternal border. The patient had a history of pericardial effusions and reported “a feeling of chest fullness” when lying flat. As such, a transesophageal echocardiogram (TEE) was performed after induction of anesthesia to evaluate the pericardial space and possibly determine the etiology and severity of the new murmur. The TEE revealed a Stanford Type A aortic dissection. The renal transplant was cancelled (organ reassigned within region), and the patient underwent an urgent ascending and proximal hemiarch aortic replacement. This case demonstrates the importance of a thorough physical exam and highlights the utility of TEE for noncardiac surgical cases.

Partial anomalous pulmonary venous return: Scimitar vein

Scimitar syndrome is a rare association of congenital cardiopulmonary anomalies characterized by partial anomalous pulmonary venous return, in which an abnormal right pulmonary vein drains into the inferior vena cava. This case exemplifies the role of transesophageal echocardiography in perioperative management and surgical decision-making.