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Statin therapy may reduce the risk of venous thromboembolism (VTE), which may impact solid organ transplant outcomes. We evaluated the incidence of VTE and other complications after liver transplantation stratified by hyperlipidemia status and statin use using a retrospective cohort study approach from a high-volume liver transplant center. We reviewed all primary orthotopic liver transplant (OLT) records from January 2014-December 2019 from our center. Intraoperative deaths were excluded. Recipient and donor clinical and demographic data were collected. We developed risk-adjusted models to assess the effect of statin use on the occurrence of VTE, hepatic artery complications, graft failure, and death, accounting for clinical covariates and competing risks. 672 OLT recipients were included in the analysis. 11.9% (n=80) of this cohort received statin therapy. 47 patients (7.0%) had VTE events. Hepatic artery complications occurred in 40 patients (6.0%). 42 (6.1%) patients experienced graft loss while 9.1% (n=61) of the cohort died during the study interval. 268 (39.9%) OLT recipients had hyperlipidemia, of which 80 (29.8%) were treated with statins. Of those treated with statins, 0% of patients had VTE vs. 7.9% of those not on statins (p=0.01). Hepatic artery complications were identified in 1.2% of the statin group and 6.8% of the non-statin group. Untreated hyperlipidemia was associated with a 2.1-fold higher risk of hepatic artery complications vs no hyperlipidemia status patients (p=0.05). Statins were associated with significantly better risk-adjusted thromboembolic event-free survival (absence of DVT, PE, CVA, MI, HAC, and death) (90% statins vs. 73.9% untreated; HR =0.37, p = 0.01). These data indicate that statin therapy is correlated with a lower rate of VTE and hepatic artery complications after liver transplantation. Prospective studies are warranted.

Introduction Sub-anesthetic ketamine is frequently used as an analgesic to reduce perioperative opioid consumption and has also been shown to have antidepressant effects. Side effects of ketamine include dizziness, diplopia, nystagmus, and psychomimetic effects. It is unclear what clinical factors may be associated with ketamine-related adverse drug events (ADEs). Methods We performed a retrospective review of 95 patients who received sub-anesthetic ketamine infusions at our institution. Data examined associations between ketamine-related ADEs and various clinical characteristics including chronic pain, depression, or psychiatric disorder, patient physical characteristics, chronic opioid use, perioperative opioid use, dose and duration of ketamine infusions, pain scores, and perioperative medications such as serotonergic agents, central nervous system (CNS) depressants, and analgesics. Results Overall incidence of ketamine-related ADEs was 29.5% and the incidence of psychomimetic effects was 14.8%. We observed that patients with a history of depression have a lower incidence of ketamine-related ADEs compared to patients without a history of depression (10.3% vs 37.3%; p value = 0.007). Conclusion Patients with depression were found to have a statistically significant reduction in the incidence of ketamine-related ADEs. We found no statistically significant positive associations between ketamine-related ADEs and other clinical factors such as a history of chronic pain, psychiatric disease, patient physical characteristics, perioperative opioid use, dose of ketamine infusion, or co-administration of other CNS depressants.

Magnetic gastroesophageal reflux devices are becoming a common treatment option for reflux refractory to medical therapy. These devices are inserted laparoscopically with successful outcomes; however, patients may still complain of dysphagia after implantation. Echocardiographers may be hesitant to perform transesophageal echocardiography (TEE) in these patients as esophageal surgery and dysphagia represent relative contraindications to performing TEE. However, we present 2 cases where intraoperative TEE was performed in patients with reflux devices without complication or image degradation. The described cases, in addition to a review of the perioperative management of these devices, support the use of TEE in this patient population.

Background. Utilization of intraoperative transesophageal echocardiography (TEE) during orthotopic liver transplantation (OLT) is expanding annually in high-volume transplant centers. During OLT intraoperative TEE is used to gather real-time information on cardiovascular function and intravascular volume status. Although standardized TEE views exist, there are nontraditional views described in the literature which have the potential to diagnose evolving pathology and define normal variants of hepatic vasculature. Methods. A literature review was completed utilizing the PubMed database for English-only, peer-reviewed publications discussing nontraditional use of intraoperative TEE during OLT and hepatic vascular-related surgeries from 2009 to 2019. Both case reports and review articles were considered. Results. The PubMed literature search offered 8 publications for analysis, including 7 case reports and 1 article review, revealing several nontraditional TEE views not included in a comprehensive transesophageal echocardiographic examination. These nontraditional views were generally obtained using modifications to the transgastric and bicaval views to visualize liver vasculature. We present the various techniques for obtaining these views from the 8 articles identified. Conclusions. At high-volume transplant centers, TEE use during OLT is increasing. Intraoperative TEE is a valuable tool to assess hepatic vascular structures critical to allograft/organ function without interruption of the surgical procedure. Nontraditional use of TEE to diagnose intraoperative noncardiac pathology in OLT appears underutilized and underreported. The modified hepatic and modified transgastric views we describe can be used to evaluate hepatic vasculature, influence surgical decision-making and ultimately improve patient care.

Surgical stress can result in major adverse cardiac events, and this accounts for significant morbidity and mortality. More effective analgesia provided by regional block can allow for improved postoperative function which can improve recovery times and reduce potential complications. Furthermore, there are cardiovascular benefits with the use of different regional techniques for both cardiac and non-cardiac patients. In this chapter we review some of the different regional techniques for cardiac and non-cardiac patients including neuraxial block, epidural block, paravertebral and intercostal nerve blocks, as well as peripheral nerve block in patients with cardiac disease who are undergoing non-cardiac surgery.