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Background Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients. Methods Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence. Results Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status. Conclusions These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.

The pleiotropic effects of statin therapy on inflammation and coagulation may reduce the risk of venous thromboembolism. This study evaluated whether statin therapy is associated with decreased venous thromboembolic (VTE) events following kidney transplantation.We performed a retrospective analysis of all primary kidney transplants performed between January 2014 and December 2019 at Mayo Clinic Arizona. Patients were divided into two groups depending on sustained statin therapy during the first year following transplantation. Recipient and donor clinical and demographic data were collected. The primary outcome was admission for symptomatic VTE events (deep vein thrombosis [DVT] or pulmonary embolism [PE]).Sustained statin therapy in the first year following transplant was observed in 16.1% (n = 223) of 1384 kidney transplants. The overall incidence of VTE events in the year following kidney transplant was 3.8%. VTE occurred in 4.1% of recipients treated with statins and 3.8% of the controls - (hazard ratio [HR] .92, 95% confidence interval [95% CI] .39, 2.21, p = .86). However, there were significant differences between the groups in terms of age, sex, race/ethnicity, body mass index, indication for transplant, diagnosis of diabetes and discharge antiplatelet or anticoagulant therapy. Following sensitivity analysis in which cohort matching was performed to account for these differences, there was no difference in VTE event-free survival (HR .89, 95% CI .41, 1.96, p = .78) or overall survival (HR .54, 95% CI .15, 1.94, p = .35) between patients treated with statins compared to controls.Statin therapy in the year following successful kidney transplant was not associated with a reduction in risk of VTE.

Background Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher. Materials and methods A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals. Results No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management. Conclusion When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.

We review contemporary coagulation management for patients undergoing liver transplantation. A better understanding of the complex physiologic changes that occur in patients with end-stage liver disease has resulted in significant advances in anesthetic and coagulation management. A group of internationally recognized experts have critically evaluated current approaches for coagulopathy detection and management. Strategies for blood component and factor replacement have been evaluated and recommended therapies proposed. Pharmacologic treatment and prevention of coagulopathy, management of patients receiving antiplatelet medications, and the role of transesophageal echocardiography for early detection and management of thromboses are presented.

Introduction Analyzing hospital naloxone use may assist in identification of areas for quality and safety improvement. Our primary objective is to quantitate the incidence of hospital naloxone use and to assess certain patient populations at risk. Methods During the years 2008 to 2011, each clinical scenario where naloxone was administered on an in-patient care ward was reviewed. The events were assessed to separate situations where naloxone rescue was effective in reversing opioid-induced intoxication vs. others. Further analysis was conducted to stratify patient populations at greatest risk. Results Naloxone was administered for well-defined opioid-induced respiratory depression and oversedation 61% of the time, the remainder used for patient deterioration of other etiology. Surgical populations are at risk with an incidence of 3.8/1,000 hospitalized patients, and this is the greatest within 24 hours of surgery. General surgical patients represent the highest surgical patient risk at 5.5/1,000. Medical patients represent lower risk at 2.0/1,000. Patients with patient-controlled analgesia and epidural opioid infusion are high risk at 12.1 and 13.1/1,000 patients, respectively. Many quality and safety interventions were gradually implemented in response to this data and are summarized. These include nursing and provider education, electronic medical record modification, and more stringent patient monitoring practices. Conclusion Examination of naloxone use can assist in the identification and stratification of patients at risk for opioid-induced respiratory depression and oversedation and can serve as a driver for improvements in hospital patient safety. This information can also guide other institutions interested in similar improvements.

Introduction €‚ Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-€term ONS outcomes. Methods €‚ The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records. Results €‚ Twenty-nine patients underwent a trial of ONS during the 8.5-€year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-€eight percent of patients required at least one lead revision. Discussion €‚ These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. Conclusions €‚ Randomized controlled long-€term studies in specific, intractable, primary headache disorders are indicated.

This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

Objective: Occipital nerve stimulation can be effective therapy for recalcitrant headache disorders. Lead migration remains the primary technical adverse event associated with this therapy. Revision surgery for occipital nerve stimulator leads sometimes requires exposure of all components including internal pulse generator, extension cables, connectors, and leads with multiple incisions. However, minimizing the invasiveness of revision surgery reduces the time, infection risk, and discomfort associated with the procedure. We describe two techniques that attempt to minimize the extent of revision surgery necessary for lead migration. Materials and Methods: We describe two minimally invasive revision techniques. One uses a 14-gauge Tuohy needle converted to a slotted needle. The other uses a standard Tuohy needle inserted subcutaneously into the anchor site along the desired course of the lead. Results: Both techniques allow replacement of a migrated occipital nerve stimulator lead while eliminating the need to access connector or battery sites with multiple incisions. Conclusions: When migration occurs, the techniques described can simplify lead revision while minimizing the invasiveness of the procedure.

Objective: To document the per patient rate of vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections. Background: Anecdotal observations at our institution suggested that vasovagal reactions are much more common during cervical epidural steroid injections than lumbar injections, and more frequent than previously reported. Methods: Records of 249 patients undergoing their first cervical epidural steroid injection were reviewed for vasovagal reactions and other adverse events. For comparison, a first lumbar epidural steroid injection performed by the same staff physician was matched to each cervical procedure and reviewed for complications. Results: The incidence of vasovagal reaction was 7 points more common (P

Objective Perioperative hydroxy-3-methyl glutaryl coenzyme A reductase inhibitors (statins) have been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to assess patient understanding of the potential benefits of perioperative statins in a select population already on chronic therapy. A secondary aim was to determine the frequency with which patients recalled having a discussion with their provider regarding perioperative statins. Design Survey. Setting Teaching hospital. Participants Patients taking daily statins presenting to a preoperative medical evaluation clinic were offered a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period. Interventions None. Measurements and Main Results One hundred thirty-two patients completed the questionnaire. The mean age was 68.3 years (standard deviation, 9.0); 42% were female. The most frequent surgical referral to the clinic was orthopedics, at 36%. The most common statin prescribed was atorvastatin, in 35% of patients. Twenty-seven percent of patients (n = 36) recognized that perioperative statins are beneficial; 44% of these patients (n = 14) cited decreased cholesterol during the procedure as the reason, representing 12% of the total sampled population. Twenty-two percent (n = 8) of those recognizing the benefit of perioperative statins identified a decrease in the risk of heart attack or death as the reason. This represented only 6% of the total sample. One percent of surgeons mentioned statins in relation to the planned surgery; 2% of primary or prescribing physicians mentioned the medication in relation to surgery. Conclusions This study suggested low patient understanding of the potential importance and reasons for perioperative statins. In addition, this study also suggested that the information regarding the importance of perioperative statins is not being relayed to the patient at the level of the surgeon or primary care physician. All physicians involved in perioperative care can offer improved patient education to promote compliance with statin therapy in hopes of a favorable impact on perioperative outcomes.

Objectives Patient satisfaction is tied to outcome, but there is scant literature on the relationship of patient perceived outcome and attributes of the pain clinic visit, including the patient interaction with the pain management specialist. The primary purpose of this study is to identify attributes of the patient–provider interaction most strongly associated with patient perceived outcome of their clinic visit. The secondary aim is to correlate patient perceived outcome with patient self-rated overall health. Methods A patient satisfaction survey conducted via phone approximately 3 weeks after the patient's pain clinic visit. Results The response rate was 60.2%; 987 patient surveys collected between 2006 and 2010 were used in the analysis. Four factors were significantly associated with the outcome: (1) Explanations by the physician of the patient's condition and treatment, (2) clear instructions regarding post-appointment activities, (3) knowing the patient as a person, and (4) the patient's self-rated health. In terms of the secondary objective, those who answered very good/excellent regarding their self-rated health had an 87% increased odds of better (very good/excellent) outcome of their pain clinic visit (or 1.87 times the odds of better outcome) compared with those who answered poor/fair/good. Conclusions Our results suggest that pain physicians may positively impact patient perceived outcomes of clinic visits by explaining the patient's condition and treatment, providing instructions, and taking the time to understand the patient and their values.

Objectives Patient perception of healthcare quality is of growing interest. It has been shown that patient satisfaction is associated with compliance with medical advice and clinical outcome. The 3-fold purpose of this study was to identify which attributes of the patient–physician interaction most strongly correlated with patients' perceptions of provider quality of care, to identify key drivers that move patients' perception of overall provider quality from “very good” to “excellent,” and to identify features of the pain clinic experience that were most important to patients but were simultaneously perceived as lacking. Methods Randomized patient satisfaction survey conducted via telephone approximately 3 weeks after the patient's pain clinic visit. Results A total of 999 patients participated in the survey over 5 years (estimated response rate 60.2%). Thoroughness, listening, and time spent with the provider were the 3 attributes most strongly associated with the patients' perceptions of provider quality of care, while thoroughness, listening, punctuality, and clear instructions were the drivers of “very good” vs. “excellent” patient perceived overall provider quality. Areas identified for clinic improvement include thoroughness, providing adequate explanations and instructions, and including patient preferences in decision making. Conclusions These results may guide pain clinic physicians as they seek to improve patient perceptions of their care and ultimately patient outcomes.

Background: This report describes a pontine hemorrhage in a patient following implantation of an intrathecal drug delivery system. Case report: A 70-year-old old female patient with metastatic breast carcinoma underwent placement of an implantable intrathecal drug delivery system. Before implant she was neurologically intact with only mild memory deficiencies attributed to narcotics and malignancy. No recent brain magnetic resonance imaging (MRI) was on record. On post-implant day 2 after the initiation of intrathecal hydromorphone 0.45 mg/day and bupivacaine 2.7 mg/day, she developed dizziness, lethargy, and mild gait instability. Despite decreasing drug dosages, these symptoms progressed over the ensuing days, and subsequently the patient developed upper extremity numbness and tinnitus. The device was turned off on post-implant day 9 with the patient showing no signs of improvement. She underwent computerized tomography scan of the head, which identified an acute pontine hemorrhage. A follow-up MRI scan confirmed the hemorrhage and revealed a previously undiagnosed underlying metastatic lesion with surrounding vasogenic edema. She was treated with supportive measures in hospice and expired 20 days after implantation. Conclusions: This case emphasizes several important points. First, changes in neurologic and mental status after initiating intrathecal drug therapy may be related to new or pre-existing pathology and not due to intrathecal medications. Second, consideration should be given to central nervous system imaging before intrathecal pump insertion in patients with widely metastatic malignancies. Finally, cerebral spinal fluid hypotension from dural puncture may have contributed to the timing of the hemorrhage in this patient.

Millions of patients suffer from medically refractory and disabling primary headache disorders. This problem has led to a search for new and innovative treatment modalities, including neuromodulation of the occipital nerves.The primary aim of this study is to describe an implantation technique for the Bion microstimulator and document stimulation parameters and stimulation maps after Bion placement adjacent to the greater occipital nerve. The secondary aim is to document outcome measures one year post-implant.Prospective, observational feasibility study.Nine patients with medically refractory primary headache disorders participated in this study. Approximately 6 months after Bion insertion, stimulation parameters and maps were documented for all patients. At one year, outcome measures were collected including the Migraine Disability Assessment Score.At 6 months, the mean perception threshold was 0.47 mA, while the mean discomfort threshold was 6.8 mA (stimulation range 0.47-6.8 mA). The mean paresthesia threshold was 1.64 mA and the mean usage range was 16.0. There were no major complications reported such as device migration, infection, or erosion. One patient stopped using her Bion before the 12-month follow-up visit. At one year, 7 of the 8 patients were judged as having obtained fair or better results in terms of reduction of disability; 5 patients had greater than a 90% reduction in disability.Small, heterogeneous patient population without control group. Not blinded or randomized.The Bion can be successfully inserted adjacent to the greater occipital nerve in an effort to treat refractory primary headache disorders. This microstimulator may provide effective occipital stimulation and headache control while minimizing the risks associated with percutaneous or paddle leads implanted subcutaneously in the occipital region.

In most cases of post-dural puncture headache, the positional symptoms will resolve spontaneously within 2 weeks. Conservative therapies include oral analgesics and hydration, bed rest, and abdominal binders. For refractory cases, an autologous epidural blood patch remains the treatment of choice. However, in certain cases the use of autologous blood for the blood patch may place the patient at risk for infectious or malignant contamination of the central nervous system. Coccidioidomycosis results from inhalation of the arthroconidia (spore) stage of the fungal lifecycle. The most common manifestation of coccidioidomycosis is acute pulmonary symptoms, while the most feared complication is meningitis. Immunocompromised patients are at increased risk of fungemia; therefore, introduction of fungal elements into the central nervous system can occur if autologous blood is used for an epidural blood patch. We report a case of persistent dural-puncture headache in the setting of disseminated coccidioidomycosis. An autologous blood epidural blood patch was considered but deferred due to risk of coccidioidomycosis meningitis. Other epidural space interventions such as fibrin glue injection or saline infusions were judged to be too imprecise or ineffective. The patient was successfully treated with allogeneic blood donated by his wife, but only after testing of her blood as is required for any directed blood donation. Allogeneic epidural blood patches are an option for refractory dural puncture headaches when autologous blood may cause meningitis or malignant seeding of the central nervous system.

Objective: Drug-eluting coronary stent use is common. Antiplatelet drug use after stent placement is necessary to prevent stent thrombosis. It has been recommended that at the time of stent placement, patients be given instructions regarding stopping antiplatelet drugs before elective surgery. Unfortunately, patients may be given inappropriate preoperative instructions by health care providers or may stop the drugs on their own. This can lead to perioperative myocardial infarctions and death. Design: Survey. Setting: Preoperative evaluation clinic of 2 teaching hospitals. Participants: One hundred sixteen patients with coronary stents completed a 13-question survey. The questionnaire assessed patient understanding of stent type and the risks of stopping antiplatelet drugs, in addition to communication among the patient, their surgeon, and their treating cardiologist before elective surgery. Intervention: None. Measurements and Main Results: The majority of patients stated either they had received no instructions from their implanting cardiologist regarding future surgery and antiplatelet drugs or they were unsure if any instructions had been given. Most patients (57%) received antiplatelet instructions regarding their planned surgery from their surgeon, whereas only 14% received instructions with (known) cardiology input. The majority of patients were unaware or unsure of any risk in prematurely stopping their antiplatelet drugs. Conclusion: Many patients are unaware of their stent type and the risks of inappropriately stopping antiplatelet drugs. Furthermore, they may have received either inappropriate preoperative instructions or no instructions at all. The opportunity exists to improve preoperative communication with patients in order to minimize perioperative thrombotic risks of coronary stents.

Perioperative beta-adrenergic blockade has been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to determine patient knowledge of the importance of perioperative beta-blockade in a population already taking chronic therapy and to assess the effectiveness of medical and surgical providers in patient education regarding these benefits.Survey.Teaching hospital.One hundred twenty-six patients taking daily beta-blockers presenting to a preoperative medical evaluation clinic completed a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period.None.Mean coronary artery disease risk factors per individual were 3.2 (standard deviation, 1.5). Forty-nine percent indicated that beta-blockers are beneficial in the perioperative period. Of those identifying benefit, 8% recognized decrease in myocardial infarction or decrease in mortality as the reason. Sixty-nine percent of patients who identified perioperative benefit cited blood pressure control as the reason. This correlated to the 67% of the total sample who identified their indication for the medication as antihypertensive. Only 7% recalled their prescribing physician ever mentioning the beta-blocker in relation to surgery. The same percentage recalled their surgeon mentioning it in relation to the planned procedure.This study suggests low patient understanding of the potential importance and reasons for perioperative beta-blockade. Patients who recognized perioperative benefit identified antihypertensive versus cardioprotective effects. Clinicians can improve education of patients already taking daily beta-blockers regarding these potential benefits.

A mathematical instrument was developed to supplement the diagnostic information available to physicians in the emergency room to improve physicians' diagnostic accuracy in managing patients with acute ischemic heart disease and thereby reduce inappropriate coronary care unit admissions. The instrument was empirically derived and is based on nine clinical, historical, and electrocardiographic predictive variables. Probabilities of acute ischemic heart disease generated by the instrument were given to the house staff in an emergency room during alternate months. Comparison of the control months (455 patients) with the experimental months (401 patients) showed the following: The overall diagnostic accuracy increased from 83% to 91% (P less than 0.005), the overdiagnostic accuracy increased from 51% to 33% (P less than 0.01), and the admission rate to the coronary care unit fell from 26% to 14% (P less than 0.001), while the inappropriate discharge rate from the emergency room did not change, 3% versus 3% (not significant).