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Acute compartment syndrome is the physiologic consequence of increasing pressures within an enclosed anatomic space; if left untreated, it can subsequently cause irreversible necrosis, nerve injury, and tissue damage. A number of iatrogenic causes have been reported in the literature; however, to the best of our knowledge, there are no prior reports of upper extremity compartment syndrome in orthotopic liver transplant following arterial line placement. Here, we report a 52-year-old male with a history of end-stage liver disease secondary to primary sclerosing cho-langitis who presented for orthotopic liver transplant. A radial arterial line with 20-gauge catheter was placed atraumatically without complication. Intraoperatively, the patient developed severe coagulopathy. The cause was likely multifactorial, including dilution of factors from the massive blood loss during the dissection phase, a prolonged anhepatic period, and delayed graft function, resulting in decreased production of coagulation factors. This consumptive process likely subjected minor vascular injury to potential bleeding and caused a slow cumulative bleed into the right forearm, resulting in compartment syndrome. This case exemplifies the complications that can occur from arterial line placement in a liver transplant recipient who develops severe intraoperative coagulopathy. This can arguably be extrapolated to any situation caused by significant dilutional coagulopathy or a consumptive process, such as disseminated intra-vascular coagulation. As such, when large-volume blood transfusions are anticipated, we recommend that all central venous and arterial accesses be obtained under ultraso-nographic guidance and that frequent extremity physical examinations should be performed at a minimum of every hour. Correcting the underlying coagulopathy is imperative to resolve ongoing bleeding, a high index of suspicion is warranted, and immediate diagnosis and therapy are integral to improving patient outcomes.

Prior to the 1990s, prolonged postoperative intubation and admission to the intensive care unit was considered the standard of care following liver transplantation. Advocates of this practice speculated that this time allowed patients to recover from the stress of major surgery and allowed their clinicians to optimize the recipients’ hemodynamics. As evidence in the cardiac surgical literature on the feasibility of early extubation grew, clinicians began applying these principles to liver transplant recipients. Further, some centers also began challenging the dogma that patients need to be cared for in the intensive care unit following liver transplantation and instead transferred patients to the floor or stepdown units immediately following surgery, a technique known as “fast-track” liver transplantation. This article aims to provide a history of early extubation for liver transplant recipients and offer practical advice on how to select patients that may be able to bypass the intensive care unit and be recovered in a non-traditional manner.

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.

BACKGROUND Hypertrophic cardiomyopathy (HCM) presents with a hypertrophied left ventricle (LV). It is often associated with LV outflow tract obstruction (LVOTO) and a risk for sudden death. This study aimed to describe outcomes of patients with HCM who underwent liver transplant (LT). METHODS A retrospective review was conducted for patients diagnosed with HCM undergoing LT. Patient characteristics, preoperative echocardiography results, HCM risk of sudden cardiac death prediction model score, and 5-year mortality were examined. A univariable Cox proportional hazards model was used to evaluate the association between risk factors and 5-year mortality. All tests were two-sided with the alpha level set at .05. RESULTS Twenty-nine patients were included in the analysis. Six patients (21%) had a perioperative cardiopulmonary complication. The 5-year survival rate was 61% (95% CI, 45-82). The analyzed risk factors showed that 5-year post-LT survival was significantly predicted by maximal LV outflow tract gradient at rest > 60 mmHg (hazard ratio, 1.04 [95% CI, 1.01-1.06]). CONCLUSIONS Preoperative LV outflow tract resting gradient > 60 mmHg was associated with 5-year post-LT mortality. The results suggest the severity of LVOTO identified by echocardiography is a prognostic tool for patients with HCM after LT.

INTRODUCTION Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors. METHODS Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%). RESULTS Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys. CONCLUSION The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.

Liver grafts from donation after circulatory death (DCD) are a source of organs to decrease wait-list mortality. While there have been lower rates of graft loss, there are concerns of an increased incidence of intraoperative events in recipients of DCD grafts. We aim to look at the incidence of intraoperative events between recipients of livers from DCD and donation after brain death (DBD) donors. We collected data for 235 DCD liver recipients between 2006 and 2017. We performed a 1:1 propensity match between these patients and patients with DBD donors. Variables included recipient age, liver disease etiology, biological Model for End-Stage Liver Disease (MELD) score, allocation MELD score, diagnosis of hepatocellular carcinoma, and year of transplantation. DCD and DBD groups had no significant differences in incidence of postreperfusion syndrome (P = 0.75), arrhythmia requiring cardiopulmonary resuscitation (P = 0.66), and treatments for hyperkalemia (P = 0.84). In the DCD group, there was a significant increase in amount of total intraoperative and postreperfusion blood products (with exception of postreperfusion packed red blood cells) utilized (P < 0.05 for all products), significant differences in postreperfusion thromboelastography parameters, as well as inotropes and vasopressors used (P < 0.05 for all infusions). There was no difference in patient (P = 0.49) and graft survival (P = 0.10) at 1, 3, and 5 years. In conclusion, DCD grafts compared with a cohort of DBD grafts have a similar low incidence of major intraoperative events, but increased incidence of transient vasopressor/inotropic usage and increased blood transfusion requirements. This does not result in differences in longterm outcomes. While centers should continue to look at DCD liver donors, they should be cognizant regarding intraoperative care to prevent adverse outcomes.

Once thought impossible, liver transplant anesthesiologists are now performing early extubation followed by a brief stay in the postoperative care unit and transfer to the surgical ward. This process has been coined “fast tracking” and has been shown to decrease ventilator associated complications with no effect on long term graft function. We will review the history of early extubation and its evolution toward fast track anesthesia, describe its application in the care of liver transplant recipients, discuss the anesthetic management, and finally provide a blueprint for the implementation of a fast track process.

During the coronavirus disease 2019 (COVID-19) pandemic, the study institution recognized the importance of providing preoperative COVID-19 testing and symptom screening to ensure patient safety. A multidisciplinary quality improvement team used Define, Measure, Analyze, Improve, and Control methodology to understand the issues, identify solutions, and streamline patient flow. The existing preoperative evaluation (POE) clinic was utilized as a centralized entity to provide COVID-19 testing, symptom screening, and infection prevention education in addition to routine preoperative medical optimization. With the new process, the percentage of patients with COVID-19 testing results returned before surgery increased from 10% to 100%. Of the 593 asymptomatic patients screened by the POE clinic, 2 were found to have positive results. These patients had their surgeries postponed until proper recovery. The study institution has extended this new process to all surgical patients, warranting facility readiness for the resumption of elective surgery.

Resumo Descrevemos um caso incomum de insuficiencia hepatica hiperaguda apos a anestesia geral em uma paciente que recebeu um transplante simultâneo de rim‐pâncreas. Apesar de uma avaliacao agressiva das causas estruturais, imunologicas, virais e toxicologicas, uma causa definitiva nao pode ser identificada. A paciente precisou de um transplante de figado que resultou em prolongamento da internacao hospitalar. Discutimos as potenciais causas da insuficiencia hepatica fulminante e o manejo da anestesia no periodo perioperatorio de seu subsequente transplante de figado.

Background Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disorder that presents with a hypertrophied nondilated left ventricle. In the absence of other known causes of cardiomyopathy, it is often associated with left ventricular outflow tract obstruction during systole, systolic anterior motion of the mitral valve, mitral regurgitation, and increased risk of sudden cardiac death. When HCM coexists with end-stage liver disease, it can be further complicated by cirrhosis-associated cardiovascular abnormalities, including hyperdynamic circulation, systolic and diastolic dysfunction, and electrophysiologic abnormalities. Methods We retrospectively examined patient characteristics, comorbidities, preoperative echocardiogram results, sudden cardiac death risk prediction model score, and 1-year postoperative mortality of patients with HCM who underwent liver transplantation at our institution from January 1, 2000, through January 1, 2015. Results Of the 2,812 liver transplantations performed during the study period, we identified 15 patients with a preoperative diagnosis of HCM. When comparing the patients who did vs did not survive the first year after orthotopic liver transplantation, we identified significant differences in maximal left ventricular wall thickness (P = .004) and resting left ventricular outflow tract gradient (P = .004). Preoperative left atrium size (measured by echocardiography; P = .66) and the sudden cardiac death risk prediction model score (P = .32) were not significantly associated with 1-year survival. Conclusions Preoperative left ventricular outflow tract gradient exceeding 60 mm Hg was strongly associated with death during the first year after transplant. These results suggest that the severity of HCM influences patient outcomes.

Background Pulmonary conditions such as asthma and chronic obstructive pulmonary disease (COPD) are common conditions that warrant special consideration in the perioperative period. When these patients undergo surgical interventions, they have risk of complications such as bronchospasm, hypoxia, and even postoperative respiratory failure that warrant unplanned intensive care unit admission. Thus, clinicians must be familiar with pulmonary medication regimens that are critical for maintaining stable homeostasis of these chronic conditions. Objective To discuss the medications most commonly used to treat pulmonary conditions and to describe strategies for handling these treatment regimens in the perioperative period. Method We conducted an online search of studies and review articles through PubMed and Medline that addressed pharmacology and perioperative management of pulmonary medications, with an emphasis on those treating patients with asthma or COPD. Results Long-term medications for pulmonary disease are used to slow the progression of these conditions and reduce the occurrence of acute exacerbations. As such, these medications should be continued in the perioperative period. If the medications include oral corticosteroids or high-dose inhaled corticosteroids, stress-dose corticosteroid supplementation may be warranted to avoid adrenal insufficiency. Inhaled medications can be delivered through the anesthetic circuit, and some agents may be used to treat exacerbations during surgery. Conclusion Patients with chronic pulmonary conditions have risk of perioperative complications. Their pulmonary treatment regimens should be maintained in the perioperative period to reduce the risk of such complications.

Background Pain continues to be the most common medical concern, and perioperative health care providers are encountering increasing numbers of patients with chronic pain conditions. It is important to have a clear understanding of how long-term use of pain medications impacts anesthesia during the intraoperative and postoperative periods. Objective To review common medications used to treat chronic pain and summarize current recommendations regarding perioperative care. Method We reviewed the literature by searching PubMed and Google Scholar for articles from 2000-2016. The search strategy included searching for the various classes of pain medications and including the terms perioperative, anesthesiology, and recommendations. We also reviewed the reference lists of each article to identify other relevant sources regarding the perioperative management of pain medications. Results After the literature review, we were able to establish the pharmacology, anesthetic interactions, and recommendations for management of each of the common classes of pain medication. Conclusion Management of postoperative pain is an important concern for all perioperative health care providers. Although most pain medications should be continued in the perioperative period, it is important to preoperatively discontinue those that antagonize pain receptors to avoid significant postoperative morbidities associated with poorly managed pain.

Background As the prevalence of hypertension continues to increase, physicians routinely encounter patients preoperatively receiving one or more cardiovascular medications to manage hypertension. Thus, the physician's knowledge of perioperative antihypertensive medication management is crucial to ensure patient safety. Objective We discuss the decisions to continue or stop antihypertensive medications to reduce the risk of perioperative complications. Method We conducted a review of the original research studies, review articles, and editorials present on PubMed within the past 60 years. The authors included peer-reviewed articles that they deemed relevant to current practice. Search terms of perioperative surgical home, preoperative medication instruction, surgery, and perioperative management were used in combination with the key words α-agonist, antihypertensive, β-blocker, calcium-channel blocker, diuretic, hypertension, renin-angiotensin-aldosterone system inhibitor, and vasodilator. The reference lists of each selected article were also reviewed for additional sources of information. Results The number of articles about perioperative management of antihypertension medications increased in more recent years. Evidence showed clear support of the continuation or withholding of most medications. However, no clear recommendation was found on the continuation of reninangiotensin- aldosterone system inhibitors in the perioperative period. Conclusion Current evidence supports the perioperative continuation of β-blockers, calciumchannel blockers, and α-2 agonists. However, diuretics should be discontinued on the day of the surgery and resumed in the postoperative period. Debates persist about the continuation of reninangiotensin- aldosterone system inhibitors.

Since the advent of liver transplantation, optimal anesthesia care is necessary for positive perioperative outcomes. In the context of liver transplantation using grafts from donation after circulatory death (DCD) donors, the anesthesiologist must understand the pathophysiology of these grafts and their predisposition to an increased incidence of intraoperative events such as post-reperfusion syndrome, which can affect both short- and long-term outcomes. Although there is minimal research in this area, it generally supports that DCD grafts result in a higher incidence of intraoperative instability. Anesthesiologists should be aware of these implications and prepare accordingly for these cases, with considerations for advanced monitoring and alternative therapies for vasoplegia and cardiopulmonary collapse.

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.

Liver transplantation is a complex procedure performed on critically ill patients with multiple comorbidities, which requires the anesthesiologist to be facile with complex hemodynamics and physiology, vascular access procedures, and advanced monitoring. Over the past decade, there has been a continuing debate whether or not liver transplant anesthesia is a general or specialist practice. Yet, as significant data have come out in support of dedicated liver transplant anesthesia teams, there is not a guarantee of liver transplant exposure in domestic residencies. In addition, there are no standards for what competencies are required for an individual seeking fellowship training in liver transplant anesthesia. Using the Accreditation Council for Graduate Medical Education guidelines for residency training as a model, the Society for the Advancement of Transplant Anesthesia Fellowship Committee in conjunction with the Liver Transplant Anesthesia Fellowship Task Force has developed the first proposed standardized core competencies and milestones for fellowship training in liver transplant anesthesiology.

Improvements in early survival after liver transplant (LT) have allowed for the selection of LT candidates with multiple comorbidities. Cardiovascular disease is a major contributor to post-LT complications. We performed a literature search to identify the causes of cardiac disease in the LT population and to describe techniques for diagnosis and perioperative management. As no definite guidelines for preoperative assessment (except for pulmonary heart disease) are currently available, we recommend an algorithm for preoperative cardiac work-up.

MASSIVE INTRACARDIAC AND PULMONARY thromboembolism have an extremely high mortality during liver transplantation. The authors describe 2 cases in which intraoperative use of tissue plasminogen activator was able to reduce the thrombus size and improve hemodynamics during liver transplantation. Although both patients survived the surgery, they suffered neurologic sequelae postoperatively. The authors discuss the current understanding of the pathophysiology, diagnosis, and management of intracardiac thromboembolism during liver transplantation.

Kidney transplants are routinely performed at medical centers around the world. Concurrent with improved surgical techniques, a better understanding of the pharmacology involved in the perioperative anesthetic management has led to improved outcomes in these patients. This chapter reviews the perioperative pharmacologic considerations surrounding kidney transplant patients from the viewpoint of the transplant anesthesiologist.

Stroke is a devastating complication that is difficult to diagnose in the perioperative setting because of the effects of anesthetic and analgesic agents. Lingering anesthesia effects hinder clinicians in identifying stroke symptoms, frequently resulting in a delay in diagnosis and treatment and in unfavorable outcomes. The authors performed a systematic search in PubMed and the Cochrane Central Register. The search aimed to identify studies published between January 1990 and December 2015 related to the common etiologic factors, incidence, risk factors, risk modifiers, and early management of perioperative stroke. Additional articles were identified after review of the references of selected articles. Although perioperative stroke is uncommon, the mortality rate is high. Patients have higher risk of perioperative stroke when undergoing cardiac and vascular operations than uncomplicated orthopedic and general procedures. Preoperative optimization for preexisting risk factors may reduce the rate of perioperative stroke. Prompt, early management can improve patient outcomes. Recognition of the incidence, risk factors, and causes of perioperative stroke may lead to prevention and proper management.

We describe an unusual case of hyperacute hepatic failure following general anesthesia in a patient receiving a simultaneous kidney-pancreas transplant. Despite an aggressive evaluation of structural, immunological, viral, and toxicological causes, a definitive cause could not be elucidated. The patient required a liver transplant and suffered a protracted hospital course. We discuss the potential causes of fulminant hepatic failure and the perioperative anesthesia management of her subsequent liver transplantation.

Manometry, blood gas analysis and colour of blood are often used as adjuncts to verify central venous access and rule out inadvertent arterial puncture. Several clinical scenarios may make these te...

The primary aim of this study was to determine whether specific preoperative clinical characteristics were associated with low-volume transfusion in liver transplant recipients. Low-volume transfusion was defined as transfusion of2100 mL of packed red blood cells intraoperatively during liver transplant. The ability to accurately predict low-volume transfusion could increase patient safety, decrease complications associated with transfusion, improve blood management, and decrease transplant case cost.Data were retrieved by retrospective chart review of 266 patients who received a liver transplant at the Mayo Clinic (Jacksonville, FL, USA). The primary outcome was low-volume transfusion. Associations of preoperative information with low-volume transfusion were explored using single-variable and multivariable logistic regression models; missing data were imputed with the sample median for continuous data and the most frequent category for categorical variables.Low-volume transfusion occurred in 23% of first-time liver transplant recipients (62/266 patients; 95% confidence interval, 18%-29%). History of hepatitis C virus infection (P = .048), history of hepatocellular carcinoma (P = .050), short cold ischemia time (P = .006), and low international normalized ratio (P = .002) were independently associated with low-volume transfusion during liver transplant in a multivariable logistic regression model.Multiple studies have shown increased morbidity and mortality after orthotopic liver transplant when more than 6 U of packed red blood cells are administered within 24 hours of surgical incision. A method to identify low-volume transfusion candidates could help predict patient outcomes, decrease blood handling, and reduce costs. If patients with low-volume transfusion could be identified, fewer blood products would need to be prepared in advance. Although elevated preoperative coagulation parameters decrease the probability of low-volume transfusion, a definitive profile of a low-volume transfusion liver transplant recipient was not established.

Sugammadex, the first in a novel class of medications termed selective relaxant binding agents, was developed to rapidly and completely encapsulate aminosteroid neuromuscular blocking agents, thus removing them from the neuromuscular junction. When used properly, sugammadex has the potential to decrease the incidence of residual neuromuscular block and it's associated complications, as well as, avoid the side effects associated with cholinesterase inhibitors. Sugammadex may also have a role in the management of patients with difficult airways and rocuronium- induced anaphylaxis. Currently available in over 70 countries worldwide, fears of hypersensitivity reactions have delayed it's release in the United States. The article looks to examine the role of sugammadex in anesthesia and detail its pharmacologic profile.

Hypertrophic cardiomyopathy is a myocardial disorder that carries an increased risk of morbidity and mortality during liver transplantation. We describe the use of atrioventricular sequential pacing, placed preoperatively, to assist with intraoperative management of a patient with severe refractory hypertrophic cardiomyopathy undergoing orthotopic piggyback liver transplantation. We discuss the pathogenesis and treatment of this infrequent but serious comorbidity.

Introduction Takotsubo syndrome (TTS), also known as Takotsubo's cardiomyopathy or stress induced cardiomyopathy, has been described following a variety of surgeries and disease states. The relationship between intraoperative anesthesia management and the development of this syndrome has never been fully elucidated. Objectives The primary objective of this study was to determine the relationship of multiple intraoperative factors on the pathogenesis of TTS. Methods A single center retrospective review of all liver transplants performed at Mayo Clinic Florida from January 2005- December 2014. Patients developing left ventricular dilation and a concomitant decrease in ejection fraction, a negative cardiac catheterization or stress test within 30 days of transplantation were identified. Cases were matched 2:1 to controls with respect to MELD, age, sex, and indication for transplantation. Our evaluation included liver graft characteristics, intraoperative medications, and intraoperative hemodynamic measurements. Results We identified 24 cases of TTS from a pool of 1752 transplants, for an incidence of 1.4%. No statistically significant differences in intraoperative measures between the two groups were identified (all P≥0.08). Conclusion Our exploratory, single center retrospective review evaluating 46 intraoperative characteristics found no association with the development of TTS. This article is protected by copyright. All rights reserved.

Stephen Aniskevich,1 C Burcin Taner,2 Dana K Perry,2 Christopher B Robards,3 Steven B Porter,3 Colleen S Thomas,4 Ilana I Logvinov,5 Steven R Clendenen41Department of Anesthesia, Division of Transplant Anesthesia, 2Department of Transplantation, 3Department of Anesthesia, Division of Regional Anesthesia, 4Division of Health Sciences Research, Section of Biostatistics, 5Department of Anesthesia, Mayo Clinic Florida, Jacksonville, FL, USAAbstract: Postoperative pain is a common complaint following living kidney donation or tumor resection using the laparoscopic hand-assisted technique. To evaluate the potential analgesic benefit of transversus abdominis plane blocks, we conducted a randomized, double-blind, placebo-controlled study in 21 patients scheduled to undergo elective living-donor nephrectomy or single-sided nephrectomy for tumor. Patients were randomized to receive either 20 mL of 0.5% ropivacaine or 20 mL of 0.9% saline bilaterally to the transversus abdominis plane under ultrasound guidance. We found that transversus abdominis plane blocks reduced overall pain scores at 24 hours, with a trend toward decreased total morphine consumption. Nausea, vomiting, sedation, and time to discharge were not significantly different between the two study groups.Keywords: transversus abdominis plane block, nephrectomy, kidney donor, ultrasound guidance

Select liver transplantation (LT) recipients in our program are transferred from operating room to postanesthesia care unit for recovery and extubation with transfer to the ward, completely eliminating an intensive care unit (ICU) stay. Developing a reliable method to determine patients suitable for fast-tracking would be of practical benefit to centers considering this practice. The aim of this study was to create a fast-tracking probability score that could be used to predict successful assignment of care location after LT. Recipient, donor and operative characteristics were assessed for independent association with successful fast-tracking to create a probability score. Of the 1296 LT recipients who met inclusion criteria, 704 (54.3%) were successfully fast-tracked and 592 (45.7%) were directly admitted to the ICU after LT. Based on nine readily available variables at the time of LT, we created a scoring system that classified patients according to the likelihood of being successfully fast-tracked to the surgical ward, with an area under the curve (AUC) of 0.790 (95% CI: 0.765-0.816). This score was validated in an independent group of 372 LT with similar AUC. We describe a score that can be used to predict successful fast-tracking immediately after LT using readily available clinical variables.

Orthotopic liver transplantation (OLT) recipients have been reported to have decreased perioperative opioid and intraoperative inhalational anesthetic requirements when compared to patients without liver disease undergoing other types of major abdominal surgeries. The severity of the liver disease and the process of the transplantation itself may alter the pharmacokinetic and pharmacodynamic effects of different pain medications. Chemical injury of the liver and the high degree of surgical stress may also increase the levels of neuropeptides involved in pain modulation. Per the U.S. Department of Health and Human Services Organ Procurement and Transplantation Network, more than 5,000 OLT cases are being done per year since 2000. With better understanding of the pathophysiology of liver disease and the development of perioperative anesthesia management, the recent concept of improving patient outcome following OLT includes a fast-track approach in selected patients, which may shorten or completely bypass intensive care unit stay and reduce costs. With this development, the understanding of the analgesic pharmacology in the care of the OLT patients is even more important. Proper dosage of medications can achieve adequate intraoperative anesthetic depth and postoperative pain control, while avoiding over-sedation which increases risk of prolonged postoperative mechanical ventilation. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the analgesic medications commonly administered to this patient population.

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.

As the frequency of pancreas transplants increase worldwide, clinicians are faced with providing care to recipients who may present with multiple comorbidities related to their underlying diabetes. This review summarizes the perioperative management of pancreas transplant recipients from the viewpoint of the anesthesiologist. Preoperative evaluation, intraoperative care and postoperative pain control are all discussed.

The authors report the first clinical application of a bilateral transversus abdominis plane block for treating pain after a pancreas transplant. In this case, a 36-year-old chronic opioid user presented postoperatively with severe incisional pain following a pancreas transplant. The pain was not ameliorated with opioids and was successfully treated with the administration of bilateral transversus abdominis plane blocks with 0.5% ropivicaine. Pain relief lasted for 6 hours.

Laparoscopic surgery presents unique hemodynamic challenges for the anesthetic management of patients. Hemodynamic changes induced by pneumoperitoneum were measured using a new noninvasive device, the Endotracheal Cardiac Output Monitor (ECOM) (ConMed Corp, Utica, NY). This monitor provides measurements—including cardiac output (CO), systemic vascular resistance (SVR), and stroke volume variation (SVV)—that were previously unavailable noninvasively. A better understanding of the applicability and reliability of this new technology in the clinical setting is important for patient safety. CONCLUSIONS

We present a case of intraoperative gastric variceal bleeding during liver transplant. After an uneventful induction and surgical dissection, our patient developed hemodynamic instability during the anhepatic phase. We believe that an increase in portal pressures, owing to clamping of the portal system, led to spontaneous variceal rupture; however, placement of an oral gastric tube or transesophageal echocardiography probe may have contributed to this also. After intraoperative banding, the patient was stabilized and surgery proceeded uneventfully. The patient had no long-term sequelae. Anesthesiologists involved in the care of patients with end-stage liver disease should be aware of this infrequent intraoperative complication and be prepared to treat it appropriately.

p ATIENTS WITH advanced liver disease are prone to multiple hemodynamic abnormalities.1,2 This susceptibility can e attributed to several factors, including a hyperdynamic left entricle and chronically lowered systemic vascular resistance SVR). Surgical manipulation and blood loss during liver translantation can further worsen this precarious hemodynamic alance. A case of refractory hypotension secondary to dynamic left entricular outflow tract obstruction (DLVOTO) in a patient ith a normal preoperative cardiac evaluation is presented. ntraoperative transesophageal echocardiography (TEE) played vital role in the diagnosis and management of this disorder fter standard pharmacologic therapies failed to improve the lood pressure. The authors believe that intraoperative TEE hould be used whenever hemodynamic instability is refractory o standard therapy during liver transplantation.

Historically, patients undergoing liver transplantation were left intubated and extubated in the intensive care unit (ICU) after a period of recovery. Proponents of this practice argued that these patients were critically ill and need time to be properly optimized from a physiological and pain standpoint prior to extubation. Recently, there has been a growing movement toward early extubation in transplant centers worldwide. Initially fueled by research into early extubation following cardiac surgery, extubation in the operating room or soon after arrival to the ICU, has been shown to be safe with proper patient selection. Additionally, as experience at determining appropriate candidates has improved, some institutions have developed systems to allow select patients to bypass the ICU entirely and be admitted to the surgical ward after transplant. We discuss the history of early extubation and the arguments in favor and against fast track anesthesia. We also described our practice of fast track anesthesia at Mayo Clinic Florida, in which, we extubate approximately 60% of our patients in the operating room and send them to the surgical ward after a period of time in the post anesthesia recovery unit.

Purpose Intraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation (OLT) out of concern about rupture of esophageal varices. Complications associated with TEE in OLT were evaluated. Methods We retrospectively reviewed charts and TEE videos of all OLT cases from January 2003 through December 2013 at Mayo Clinic (Jacksonville, Florida). Results Of the 1811 OLTs performed, we identified 232 patients who underwent intraoperative TEE. Esophageal variceal status was documented during presurgical esophagogastroduodenoscopy in 230 of the 232 patients. Of these, 69 (30.0 %), had no varices; 113 (49.1 %), 41 (17.8 %), and 7 (3.0 %) had grades I, II, and III varices, respectively. Two patients (0.9 %) had no EGD performed because of acute liver failure. During OLT, 1 variceal rupture (0.4 %) occurred after placement of an oral gastric tube and TEE probe; the patient required intraoperative variceal banding. Most patients had preexisting coagulopathy at the time of probe placement. The mean (SD) laboratory test results were as follows: prothrombin time, 21.7 (6.6) seconds; international normalized ratio, 1.9 (1.3); partial thromboplastin time, 43.8 (13.3) seconds; platelet, 93.7 (60.8) × 1000/μL; and fibrinogen, 237.8 (127.6) mg/dL. Conclusion TEE was a relatively safe procedure with a low incidence of major hemorrhagic complications in patients with documented esophagogastric varices and coagulopathy undergoing OLT. It appeared to effectively disclose cardiac information and allowed rapid reaction for proper patient management.