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Centrally acting skeletal muscle relaxants (CASMR) are widely prescribed as adjuncts for acute and chronic pain. Given the recent interest in multimodal analgesia and reducing opioid consumption, there has been an increase in its use for perioperative/postoperative pain control. The mechanism of action, pharmacodynamics, and pharmacokinetics of these drugs vary. Their use has been studied in a wide range of operative and non-operative settings. The best evidence for the efficacy of CASMRs is in acute, nonoperative musculoskeletal pain and, in the operative setting, in patients undergoing total knee arthroplasty and abdominal surgery, including inguinal herniorrhaphy and hemorrhoidectomy. The risk of complications and side effects, coupled with the limited evidence of efficacy, should prompt careful consideration of individual patient circumstances when prescribing CASMRs as part of perioperative pain management strategies.

OBJECTIVES Transesophageal echocardiography (TEE) is being increasingly utilized during orthotopic liver transplantation to guide perioperative management. Obstacles of improving TEE utilization include the challenge of becoming familiar with the TEE machine, optimizing TEE images, and translating skills acquired in didactic or simulator center-based training into clinical use. METHODS In an effort to expand TEE utilization and improve workflow among the liver transplantation (LT) anesthesiologists at our institution, a LT-specific TEE guide was created to serve as a reference and educational tool during LT. A 26-question survey was distributed to all LT anesthesiologists before and 6 months after implementation of the LT-specific TEE guide. RESULTS All seven LT anesthesiologists completed the survey questions during the study period. No statistically significant difference was detected in participant-reported confidence in optimizing targeted TEE views, performing technical aspects of the exam, navigating the knobs on the TEE machine, or in ability to identify abnormal cardiac pathology during the study period. One participant became basic-TEE certified during the study period. CONCLUSIONS Implementing a liver transplant-specific TEE guide is a strategy to expand TEE utilization, encourage longitudinal TEE education and reinforce concepts learned from hands-on education sessions; however, we did not detect a difference in participant-reported confidence of performing a TEE exam, ability to identify abnormal cardiac pathology or altering workflow. Further studies with larger sample sizes will be needed to evaluate the effectiveness of a LT-specific TEE guide.

In 2016, more than 11 million people reported misuse of opioids in the previous year. In an effort to combat opioid use disorder (OUD), the use of agonist/antagonist is becoming increasingly common, with more than 2.2 million patients reporting use of a buprenorphine containing medication such as Suboxone®. Buprenorphine is a unique opioid which acts as a partial μ agonist and ĸ antagonist. These properties make it an effective tool in treating OUD and abuse. However, despite its advantages in treating OUD and abuse, buprenorphine can make it difficult to control acute perioperative pain. We present a case in which the Mayo Clinic Arizona protocol for patients undergoing minimally invasive ambulatory surgery while taking Suboxone® is successfully executed, resulting in adequate postoperative pain control and timely discharge from the postanesthesia recovery unit.

Intraoperative Transesophageal Echocardiography (TEE) during orthotopic liver transplant (OLT) is used to gather real-time information on cardiovascular function and intravascular volume status. We report a case where nonstandard TEE views were used to inspect the hepatic vasculature after allograft implantation. A 29-year-old male with secondary biliary cirrhosis with a MELD score of 20 underwent OLT using a liver from a 21-year-old brain-dead donor. Postreperfusion TEE, using the modified hepatic vein views, confirmed the presence of an inferior vena cava (IVC) suprahepatic anastomotic stenosis and hepatic vein and IVC thrombus resulting in hepatic venous outflow obstruction, allograft congestion, and hemodynamic instability. These nonstandard TEE images established the extent of suprahepatic caval outflow obstruction, in which intraoperative ultrasound was unable to definitively demonstrate. This guided real-time surgical decision-making in the postimplantation phase of the operation—ultimately leading to hepatic vein and IVC thrombectomy and revision of suprahepatic caval anastomosis.

Angioedema is a rare condition which manifests as sudden localised, non-pitting swelling of certain body parts including skin and mucous membranes. It is vital that anaesthesiologists understand this condition, as it may present suddenly in the perioperative period with airway compromise. To identify literature for this review, the authors searched the PubMed, Medline, Embase, Scopus and Web of Science databases for English language articles covering a 10-year period, 2006 through 2016. Angioedema can be either mast-cell mediated or bradykinin-induced. Older therapies for histaminergic symptoms are well known to anaesthesiologists (e.g., adrenaline, anti-histamines and steroids), whereas older therapies for bradykinin-induced symptoms include plasma and attenuated androgens. New classes of drugs for bradykinin-induced symptoms are now available, including anti-bradykinin, plasma kallikrein inhibitor and C1 esterase inhibitors. These can be used prophylactically or as rescue medications. Anaesthesiologists are in a unique position to coordinate perioperative care for this complex group of patients.