Stable perfluorocarbon emulsions for the delivery of halogenated ether anesthetics.

Background: Research into injectable volatile anesthetics has been ongoing for approximately 40 years, with limited success, in an attempt to address the deficiencies of inhalational anesthesia. The purpose of this work was to formulate and optimize volatile anesthetic carrier emulsions based on our prior work in perfluorocarbon emulsions.

Methods: Perfluorocarbons were screened for their volatilty and emulsion stability.

Organ Donor Management: Part 1. Toward a Consensus to Guide Anesthesia Services During Donation After Brain Death.

Worldwide 715 482 patients have received a lifesaving organ transplant since 1988. During this time, there have been advances in donor management and in the perioperative care of the organ transplant recipient, resulting in marked improvements in long-term survival. Although the number of organs recovered has increased year after year, a greater demand has produced a critical organ shortage.

Factors associated with mortality within 24h of liver transplantation: An updated analysis of 65,308 adult liver transplant recipients between 2002 and 2013.

Study Objectives: Intracardiac and pulmonary thromboembolism (ICPTE), its risk factors and contribution to 24-hour mortality after adult liver transplantation for end-stage liver disease.

Design: Retrospective analysis of Standard Transplant Analysis and Research electronic database files.

Setting: Perioperative.

Society for the Advancement of Transplant Anesthesia: Liver Transplant Anesthesia Fellowship-White Paper Advocating Measurable Proficiency in Transplant Specialties Training.

The anesthesia community has openly debated if the care of transplant patients was generalist or specialist care ever since the publication of an opinion paper in 1999 recommended subspecialty training in the field of liver transplantation anesthesia. In the past decade, liver transplant anesthesia has become more complex with a sicker patient population and evolving evidence-based practices. Transplant training is currently not required for accreditation or certification in anesthesiology, and not all anesthesia residency programs are associated with transplant centers.

Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy.

Lingual tonsils are lymphatic tissues located at the base of the tongue that may hypertrophy causing difficulty and sometimes inability to ventilate or intubate during anesthesia. Routine airway assessment fails to diagnose lingual tonsil hypertrophy. There is limited experience with use of videolaryngoscopy in cases of lingual tonsil hypertrophy.

Detrimental graft survival of size-mismatched graft for high model for end-stage liver disease recipients in liver transplantation.

Background: In orthotopic liver transplantation (OLT) size-mismatch may cause adverse outcomes. We previously reported on a method to predict donor-recipient size-mismatch using the body surface area index (BSAi). In this study, we hypothesized that graft survival of size-mismatch transplantation deteriorates with higher model for end-stage liver disease (MELD) score at transplantation.

Serum acidosis prior to reperfusion facilitates hemodynamic recovery following liver transplantation.

Introduction: Reperfusion is the most critical event during liver transplantation, and sustained leakage of acidic preservation solution from the liver graft contributes to marked hemodynamic instability. Recent laboratory studies with hepatocyte cultures have revealed that low pH may protect hepatocyte mitochondria against ischemia-reperfusion injury by inhibiting the mitochondrial permeability transition (MPT), the so-called "pH paradox." However, the clinical significance of this pH paradox theory remains largely unknown.

Hemodynamic recovery following postreperfusion syndrome in liver transplantation.

Objectives: The authors' current understanding of the phenomenon of significant and sustained decrease in arterial pressure following liver graft reperfusion (postreperfusion syndrome [PRS]), is derived from relatively small observational reports, and no large scale analysis of PRS exists up to date. This study investigated its incidence, risk factors, temporal course of hemodynamic recovery, and its impact on functional graft outcome.

Design: Retrospective observational study of 1,024 electronic records of orthotopic liver transplant recipients.

Peak Serum AST Is a Better Predictor of Acute Liver Graft Injury after Liver Transplantation When Adjusted for Donor/Recipient BSA Size Mismatch (ASTi).

Background. Despite the marked advances in the perioperative management of the liver transplant recipient, an assessment of clinically significant graft injury following preservation and reperfusion remains difficult. In this study, we hypothesized that size-adjusted AST could better approximate real AST values and consequently provide a better reflection of the extent of graft damage, with better sensitivity and specificity than current criteria.

Invasive renal cell carcinoma with inferior vena cava tumor thrombus: cardiac anesthesia in liver transplant settings.

Objectives: Resection of renal cell carcinomas (RCC) with tumor thrombus invasion into the inferior vena cava (IVC) is associated with significant perioperative morbidity and mortality. This study examined the intra- and inter-departmental collaboration among cardiac, liver transplantation, and urologic surgeons and anesthesiologists in caring for these patients.

Design: After IRB approval, medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010 in this institution, were reviewed.

Coronary artery disease and its risk factors in patients presenting for liver transplantation.

Study Objective: To determine the distribution of coronary artery disease (CAD) and its risk factors across the various etiologies of end-stage liver disease, and to elucidate the relationship between severe alcohol consumption and CAD.

Design: Retrospective multicenter study analysis.

Setting: National Standard Transplant Analysis and Research file data.

A matter of life or limb? A review of traumatic injury patterns and anesthesia techniques for disaster relief after major earthquakes.

Background: All modalities of anesthetic care, including conscious sedation, general, and regional anesthesia, have been used to manage earthquake survivors who require urgent surgical intervention during the acute phase of medical relief. Consequently, we felt that a review of epidemiologic data from major earthquakes in the context of urgent intraoperative management was warranted to optimize anesthesia disaster preparedness for future medical relief operations. The primary outcome measure of this study was to identify the predominant preoperative injury pattern (anatomic location and pathology) of survivors presenting for surgical care immediately after major earthquakes during the acute phase of medical relief (0-15 days after disaster).

Crystalloid flush with backward unclamping may decrease post-reperfusion cardiac arrest and improve short-term graft function when compared to portal blood flush with forward unclamping during liver transplantation.

During liver transplant (LT), the release of vasoactive substances into the systemic circulation is associated with severe hemodynamic instability that is injurious to the recipient and/or the post-ischemic graft. Crystalloid flush with backward unclamping (CB) and portal blood flush with forward unclamping (PF) are two reperfusion methods to reduce reperfusion-related cardiovascular perturbations in our center. The primary aim of this study was to compare these two methods.

Determination of the safe range of graft size mismatch using body surface area index in deceased liver transplantation.

In live donor liver transplantation, rigorous standardized criteria for matching of liver volume between donor and recipient have prevented graft loss because of size mismatch. In deceased whole liver transplantation, the safe donor-recipient size mismatch range remains unknown. We developed a multivariate survival model (generalized additive model) to estimate hazard risk of body surface area index (BSAi) for 3-year graft survival using data derived from the national registry database between 2005 and 2010.

Resuscitation in a multiple casualty event.

A major weakness in the emergency medical response to multiple casualty events continues to be the resuscitation component, which should consist of the systematic application of basic, advanced, and prolonged life support and definitive care within 24 hours. There have been major advances in emergency medical care over the last decade, including the feasibility of point-of-care ultrasound to aid in rapid assessment of injuries in the field, damage control resuscitation, and resuscitative surgery protocols, delivered by small trauma/resuscitation teams equipped with regional anesthesia capability for rapid deployment. Widespread adoption of these best practices may improve the delivery of resuscitative care in future multiple casualty events.

Devastating intracardiac and aortic thrombosis: a case report of apparent catastrophic antiphospholipid syndrome during liver transplantation.

Fewer than 80 cases of intracardiac thrombosis and intraoperative pulmonary thromboembolism during liver transplantation have been described. We present a patient who suffered an intraoperative fulminant intracardiac and aortic thrombosis and posthumously was found to have had high anticardiolipin immunoglobulin M concentration and markers of hyperfibrinolysis in preoperatively collected plasma. Hemostatic therapy in the presence of circulating antiphospholipid antibodies and the pathogenesis of a catastrophic antiphospholipid syndrome are discussed.

Reversal of hypercoagulability with hydroxyethyl starch during transplantation: a case series.

During transplant surgery, clot formation resulting in life-threatening thromboembolic phenomena or graft loss may be a consequence unless close monitoring of coagulation and anticoagulation treatment is instituted in a timely manner. Three cases with a hypercoagulable state, as determined by thrombelastography at the time of surgery, but whose hypercoagulation was gradually attenuated with hydroxyethyl starch infusion during transplantation, are presented.

Surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake: the importance of regional anesthesia.

The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care.

The effect of methylene blue during orthotopic liver transplantation on post reperfusion syndrome and postoperative graft function.

Background/purpose: In orthotopic liver transplantation (OLT), a major component of the post-reperfusion syndrome is hypotension, which may lead to additional graft liver ischemia-reperfusion injury. A proposed mechanism of reperfusion hypotension is the massive induction of oxidative stress triggering the release of pro-inflammatory mediators, including nitric oxide (NO). Methylene blue (MB) is an inhibitor of inducible NO synthase and an NO scavenger that has been shown to attenuate reperfusion hypotension.

Body surface area index predicts outcome in orthotopic liver transplantation.

Background/purpose: In living donor liver transplantation (LDLT), matching of liver volume between donor and recipient is critical to the success of the procedure; mismatch can result in 'small- or large-for-size syndrome'. In orthotopic liver transplantation (OLT), matching criteria are less stringent and non-uniform. We sought to determine whether a new parameter, the ratio of donor to recipient body surface area (BSAi), is predictive of size mismatch and/or post-transplant morbidity or mortality.