Randolph H Steadman

Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, United States

Are you Randolph H Steadman?

Claim your profile

Publications (34)127.15 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Donation after cardiac death (DCD) is an important source to expand the donor pool in liver transplantation (LT). Although long-term outcomes of LT using DCD grafts have been extensively studied, perioperative complications related to DCD grafts are rarely reported. The aims of this study were to determine if DCD grafts were associated with a higher incidence of postreperfusion complications and worse outcomes in adult LT patients. After IRB approval, medical records of all adult patients who underwent LT at our medical center between 2004 and 2011 were reviewed. Postreperfusion complications and posttransplant outcomes were compared between patients receiving DCD and donation after brain death (DBD) grafts. A total of 74 patients received DCD grafts and 1261 patients received DBD grafts during the study period. Initial comparison showed that many preoperative, prereperfusion, donor variables in the DCD group differed significantly from those in the DBD group. The propensity matching was chosen to adjust the differences. Post-matching analysis showed that preoperative, prereperfusion, and donor variables were no longer different between the two groups. Postreperfusion requirements of blood products and vasopressors, posttransplant ventilation time, and the incidence of posttransplant acute renal injury, thirty-day and one-year patient and graft survivals were comparable between the two groups. However, patients receiving DCD grafts experienced a significantly higher incidence of hyperkalemia and postreperfusion syndrome (PRS) (33.8% vs. 18.8%, and 25.4% vs. 12.3%, respectively, all p<0.05). After adjusting preoperative and prereperfusion risks using the propensity matching, DCD grafts remained to be a risk factor for postreperfusion hyperkalemia and PRS. Prophylactic regiment aiming to decrease postreperfusion hyperkalemia and PRS are recommended when managing LT using DCD grafts. Liver Transpl , 2014. © 2014 AASLD.
    Liver Transplantation 04/2014; · 3.94 Impact Factor
  • Randolph H Steadman, Daniel J Cole
    Anesthesiology 05/2013; · 5.16 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Patients with end-stage liver disease (ESLD) who also have underlying coronary artery disease (CAD) may be at increased risk for undergoing hemodynamically challenging orthotopic liver transplantation. Noninvasive single-photon emission computed tomographic (SPECT) imaging is often used to determine whether a patient with ESLD has unsuspected CAD. The objective of this study was to determine the accuracy of SPECT imaging for detection of CAD in patients with ESLD. Patients with ESLD who underwent coronary angiography and SPECT imaging before orthotopic liver transplantation were analyzed retrospectively. The predictive accuracy of clinical risk factors was calculated and compared to the results of SPECT imaging. There were 473 SPECT imaging studies. Adenosine SPECT imaging had a sensitivity of 62%, specificity of 82%, positive predictive value of 30%, and negative predictive value of 95% for diagnosing severe CAD. Regadenoson SPECT imaging had a sensitivity of 35%, specificity of 88%, positive predictive value of 23%, and negative predictive value of 93% for diagnosing severe CAD. The accuracy of a standard risk factor analysis showed no statistical difference in predicting CAD compared with adenosine (sensitivity McNemar's p = 0.48, specificity McNemar's p = 1.00) or regadenoson (sensitivity McNemar's p = 0.77, specificity McNemar's p = 1.00) SPECT studies. In conclusion, the 2 pharmaceutical agents had low sensitivity but high specificity for diagnosing CAD. However, because the sensitivity of the test is low, the chances of missing patients with ESLD with CAD is high, making SPECT imaging an inaccurate screening test. A standard risk factor analysis as a predictor for CAD in patients with ESLD is less expensive, has no radiation exposure, and is as accurate as SPECT imaging.
    The American journal of cardiology 01/2013; · 3.58 Impact Factor
  • R. H. Steadman
    American Journal of Transplantation 09/2012; 12(9). · 6.19 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Alterations in the central nervous system in patients with acute liver failure (ALF) present unique challenges in the perioperative period. In this retrospective study, we examined pretransplant neurological presentation and the incidence, clinical presentation, and risk factors associated with severe posttransplant brain injury (BI) in ALF patients undergoing orthotopic liver transplantation (OLT). METHODS: After institutional review board approval, ALF patients who underwent OLT between 2004 and 2010 at our center were reviewed. Pretransplant neurological presentation and severe posttransplant BI were examined. Risk factors for the latter were identified. RESULTS: During the study period, 90 (67 adults and 23 children) ALF patients underwent primary OLT. Preoperatively, all patients developed encephalopathy, 6 had seizure activity, 32 had radiological evidence of cerebral edema, and 11 had severe cerebral edema. After OLT, 7 patients developed severe posttransplant BI. Of these 7 patients, 4 had brain death, and 3 had irreversible injury that precluded them from living independently. Severe pretransplant cerebral edema and a higher posttransplant international normalized ratio (odds ratios and 95% confidence intervals: 50.2, 5.8-433.5 [P<0.001] and 3.1, 1.1-8.8 [P=0.031], respectively) were risk factors associated with severe posttransplant BI. CONCLUSIONS: Pretransplant neurological complications were prevalent, and severe posttransplant BI occurred at a rate of 7.8% and was significantly associated with severe pretransplant cerebral edema and postoperative international normalized ratio. Our findings support the use of pretransplant computed tomography. If severe pretransplant cerebral edema is confirmed, efforts should be made to aggressively control intracranial pressure and select a proper donor to minimize the risk of severe posttransplant BI and futile transplantation.
    Transplantation 08/2012; 94(7):768-774. · 3.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Recent studies suggest that the storage age of red blood cells (RBCs) may be associated with morbidity and mortality in surgical patients. We studied perioperative effects of RBC storage age in patients undergoing orthotopic liver transplant (OLT). Adult patients who received ≥5 U of RBCs during OLT between January 2004 and June 2009 were studied. The subjects were divided into two groups according to the mean storage age of RBCs they received: new or old RBCs (stored ≤14 or >14 days, respectively). Effects of storage age of transfused RBCs during OLT on intraoperative potassium (K(+)) concentrations, incidence of hyperkalemia (K(+) ≥5.5 mmol/L), postoperative morbidity, and patient and graft survival were studied. The mean serum K(+) concentrations and the incidence of hyperkalemia during OLT were significantly associated with storage age of the RBCs. Logistic analysis showed that storage age of RBCs was an independent risk factor for intraoperative hyperkalemia (odds ratios 1.067-1.085, p < 0.001) in addition to baseline K(+) concentration and units of RBCs transfused. Patient and graft survival and postoperative morbidity including postoperative ventilation, reoperation, acute renal dysfunction defined by the RIFLE criteria was not associated with old RBCs. Transfusion of RBCs stored for a longer time was associated with intraoperative hyperkalemia but not with postoperative adverse outcomes in adult OLT. Prevention and treatment of potentially harmful hyperkalemia should be considered when old RBCs are administered.
    World Journal of Surgery 06/2012; 36(10):2436-42. · 2.23 Impact Factor
  • Randolph Herbert Steadman, Yue Ming Huang
    [Show abstract] [Hide abstract]
    ABSTRACT: Simulation has become ubiquitous in medical education over the last decade. However, while many health-care professions and disciplines have embraced the use of simulation for training, its use for high-stakes testing and credentialing is less well established. This chapter explores the incorporation of simulation into training requirements and board certification, and its role for quality assurance of educational programmes and professional competence. Educational theories that underlie the use of simulation are described. The driving forces that support the simulation movement are outlined. Accreditation bodies have mandated simulation in training and maintenance of certification. It may be only a matter of time before simulation becomes one of the standards for performance assessment.
    Best practice & research. Clinical anaesthesiology. 03/2012; 26(1):3-15.
  • Journal of cardiothoracic and vascular anesthesia 09/2011; · 1.06 Impact Factor
  • Journal of cardiothoracic and vascular anesthesia 02/2011; 25(6):1092-4. · 1.06 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Acute renal injury (ARI) and acute renal failure (ARF) are serious complications after liver transplantation (LT). Few studies apply the risk, injury, function, loss, and end-stage criteria on the patients who have normal preoperative renal function. The aims of this study were to identify the incidence, risk factors, and impact of ARI and ARF in this patient population. After institutional review board approval, adult LT patients who had preoperative serum creatinine less than or equal to 1.5mmol/L were reviewed. Postoperative ARI and ARF were determined by the risk, injury, function, loss, and end-stage criteria. Risk factors were determined by multivariable regression. Postoperative outcomes were compared among patients with or without ARI or ARF. Among 334 patients included the study, 20.4% and 18.0% had ARI or ARF in the first week after LT, respectively. Then 118 ARI or ARF patients were matched with patients without post-LT renal injury by gender, creatinine, and body mass index. Multivariable analysis showed that increased requirement of red blood cell transfusion (odds ratio [OR] 2.7-8.8, P<0.05), vasopressors (OR 2.2, P=0.018), and pre-LT albumin less than or equal to 3.5 mg/dL (OR: 2.8, P=0.003) as risk factors for post-LT ARI or ARF. Both ARI and ARF were associated with longer hospital stay and higher reoperation rate. ARF, but not ARI, was associated with higher 30-day graft failure and mortality rates. Post-LT ARI or ARF occurred frequently in patients with normal preoperative renal function and was associated with both preoperative and intraoperative risk factors. Although both post-LT ARI and ARF are associated with significant post-LT morbidity, the impact of ARF is greater.
    Transplantation 02/2011; 91(3):348-53. · 3.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Even though numerous cases of massive thromboemboli have been reported in the literature, intracardiac thromboemboli (ICTs) incidentally found during orthotopic liver transplantation (OLT) have not been examined. In this study, we retrospectively examined the incidence, risk factors, and management of incidental ICTs during OLT. After institutional review board approval, adult patients who underwent OLT between January 2004 and December 2008 at our center were reviewed. ICTs were identified and confirmed by the examination of OLT datasheets, anesthesia records, and recorded transesophageal echocardiography (TEE) clips. The clinical presentation, management, and outcomes of the patients with ICTs were reviewed. Risk factors were analyzed by multivariate logistic regression. During the study period, 426 of the 936 adult OLT patients (45.5%) underwent intraoperative TEE monitoring. Incidental ICTs were identified in 8 of these 426 patients (1.9%). Two ICTs occurred before reperfusion, and 6 ICTs occurred after reperfusion. The treatment was at the discretion of the treating physicians; however, none of the patients received an anticoagulant or thrombolytics. Multivariate analysis identified 2 independent risk factors for intraoperative incidental ICTs: the presence of symptomatic or surgically treated portal hypertension (a history of gastrointestinal bleeding, a transjugular intrahepatic portosystemic shunt procedure, or portocaval shunt surgery) before OLT and intraoperative hemodialysis (odds ratios of 4.05 and 7.29, respectively; P < 0.05 for both). In conclusion, incidental ICTs during OLT occurred at a rate of 1.9% and were associated with several preoperative and intraoperative risk factors. The use of TEE allows early identification, which may be important. Our management for incidental ICTs is described; however, no conclusions can be made about the optimal therapy.
    Liver Transplantation 12/2010; 16(12):1421-7. · 3.94 Impact Factor
  • Source
    Randolph H Steadman, Adriaan Van Rensburg, David J Kramer
    [Show abstract] [Hide abstract]
    ABSTRACT: A number of conditions can lead to acute liver failure. Determining the cause has important prognostic implications that guide decisions regarding the likelihood of spontaneous recovery, or conversely, the need for transplantation. Neurological deterioration is associated with intracranial hypertension, which requires meticulous management. The decision to employ invasive intracranial pressure monitoring is controversial because of associated risks and the lack of controlled studies. Recent literature addressing the use of intracranial pressure monitoring is reviewed. Even tertiary care units that specialize in liver disease treat acute liver failure patients infrequently. Knowledge of the latest guidelines and treatment protocols can lead to improved patient care.
    Current opinion in organ transplantation 06/2010; 15(3):368-73. · 3.27 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Reoperations for hemorrhage following liver transplantation (OLT) are commonly associated with increased morbidity and mortality. We sought to determine the incidence and risk factors for reoperation for hemorrhage among adult liver transplantations. We retrospectively analyzed 668 patients transplanted between January 2004 and November 2007. Within 30 days following transplantation one hundred eleven patients (16.6%) underwent 156 reoperations for hemorrhage, averaging 1.4 reoperations per patient. More than half of the reoperations occurred during the first 2 postoperative days. One-third of patients required 2 or more reoperations. Multivariate logistic regression analysis showed 4 independent risk factors: grafts from donors with multiple extended criteria, severe intraoperative glucose variability, intraoperative use of vasopressors, and red blood cell transfusion requirement. In conclusion, we identified several independent risk factors for reoperation due to hemorrhage following OLT. Avoidance of severe intraoperative glucose variability and careful evaluation of the benefits and risks of utilizing extended criteria donors must be considered before transplantation.
    Transplantation Proceedings 06/2010; 42(5):1738-43. · 0.95 Impact Factor
  • Randolph H Steadman
    Anesthesiology 03/2010; 112(4):775-6. · 5.16 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Anesthesiologists are responsible for the management of perioperative cardiopulmonary arrest in children. This study used simulation to assess the pediatric resuscitation skills of experienced anesthesia residents. Nineteen anesthesia residents were evaluated using a pediatric pulseless electrical activity scenario. The authors used a standardized checklist to evaluate the residents' diagnostic and therapeutic interventions. After the onset of pulseless electrical activity, 79% of residents initiated cardiopulmonary resuscitation within 1 min. Approximately one third (31%) performed chest compressions at the recommended rate. Epinephrine was administered by 95% of residents, but only one third used the correct pediatric dose. All residents administered fluid boluses, but only 16% administered the recommended volume. Only one fourth of the residents considered hyperkalemia as a cause of pulseless electrical activity. None of the residents asked for dosing aids. During this simulated pediatric emergency, anesthesia residents demonstrated an acceptable knowledge of general resuscitation maneuvers. However, a subset of resuscitation skills was incorrectly performed, mostly related to age or weight. Importantly, many residents did not consider the full differential diagnosis of pulseless electrical activity. Anesthesia residents may benefit from additional pediatric resuscitation training and practice using cognitive aids to access dosages and complicated diagnostic algorithms.
    Anesthesiology 03/2010; 112(4):993-7. · 5.16 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To assess the effectiveness of an insulin regimen in divided doses designed to target risk factors of hyperkalemia in patients undergoing liver transplantation. Retrospective comparison of the divided insulin dose regimen with a conventional large-bolus insulin method during liver transplantation. University-based, academic, tertiary center. Adult patients whose baseline potassium levels were >/=4.0 mmol/L and received insulin therapy during liver transplantation at the authors' medical center between January 2004 and April 2007. Insulin was administered either in divided doses (1-2 units) for each unit of red blood cells transfused or in a large-bolus in patients at high risk for hyperkalemia during liver transplantation. Among 717 patients who underwent liver transplantation, 50 patients received insulin in divided doses, and 101 patients received a large-bolus of insulin. Perioperative characteristics were comparable except for higher insulin doses in the large-bolus group. The divided insulin regimen was associated with significantly lower mean potassium levels within 2 hours before reperfusion of the graft compared with the conventional group (p < 0.005). The mean glucose levels in the divided group were significantly lower in both the pre- and postreperfusion periods than in the conventional group (p < 0.05 to <0.001). The divided insulin dose regimen that specifically targets the risk factors for prereperfusion hyperkalemia is associated with significantly lower prereperfusion potassium and pre- and postreperfusion glucose levels and provides a useful alternative to the conventional large-bolus method in management of intraoperative hyperkalemia during liver transplantation.
    Journal of cardiothoracic and vascular anesthesia 04/2009; 24(1):80-3. · 1.06 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Surgical site infection (SSI) is a common postoperative complication associated with increased morbidity and mortality in patients undergoing liver transplantation (LT). Although intraoperative hyperglycemia has been shown to be associated with adverse postoperative outcomes including overall infection rate in LT patients, a relationship between intraoperative hyperglycemia and SSI in LT has not been established. We sought to determine if intraoperative hyperglycemia was associated with SSI after LT. Patients undergoing LT at our medical center between January 2004 and November 2007 were included in the study. Recipient, donor, and intraoperative variables including a variety of glucose indices were retrospectively analyzed. Independent risk factors of SSI were identified using a multivariate logistic regression model. Of 680 patients, 76 (11.2%) experienced postoperative SSIs. Among all intraoperative glucose indices analyzed, severe hyperglycemia (>or= 200 mg/dL) was independently associated with postoperative SSI (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.26-4.03, P=0.006). Other independent risk factors include repeat surgery (OR 6.58, 95% CI 3.41-12.69, P<0.001), intraoperative administration of vasopressor (OR 3.14, 95% CI 1.65-5.95, P<0.001), preoperative mechanical ventilation (OR 3.01, 95% CI 1.70-5.33, P<0.001), and combined liver and kidney transplantation (OR 2.95, 95% CI 3.41-12.69, P<0.001). Severe, but not mild or moderate, intraoperative hyperglycemia is independently associated with postoperative SSI and should be avoided during LT surgery.
    Transplantation 04/2009; 87(7):1031-6. · 3.78 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Tracheal intubation via laryngoscopy is a fundamental skill, particularly for anaesthesiologists. However, teaching this skill is difficult since direct laryngoscopy allows only one individual to view the larynx during the procedure. The purpose of this study was to determine if video-assisted laryngoscopy improves the effectiveness of tracheal intubation training. In this prospective, randomized, crossover study, 37 novices with less than six prior intubation attempts were randomized into two groups, video-assisted followed by traditional instruction (Group V/T) and traditional instruction followed by video-assisted instruction (Group T/V). Novices performed intubations on three patients, switched groups, and performed three more intubations. All trainees received feedback during the procedure from an attending anaesthesiologist based on standard cues. Additionally, during the video-assisted part of the study, the supervising anaesthesiologist incorporated feedback based on the video images obtained from the fibreoptic camera located in the laryngoscope. During video-assisted instruction, novices were successful at 69% of their intubation attempts whereas those trained during the non-video-assisted portion were successful in 55% of their attempts (P=0.04). Oesophageal intubations occurred in 3% of video-assisted intubation attempts and in 17% of traditional attempts (P<0.01). The improved rate of successful intubation and the decreased rate of oesophageal intubation support the use of video laryngoscopy for tracheal intubation training.
    BJA British Journal of Anaesthesia 10/2008; 101(4):568-72. · 4.24 Impact Factor
  • Randolph H Steadman
    [Show abstract] [Hide abstract]
    ABSTRACT: Anesthesiologists pioneered the use of simulation for health care years ago, and expanded the use of the technology in the 1980s and 1990s. Now, the American Society of Anesthesiologists is supporting an accreditation process for simulation programs to ensure that practicing anesthesiologists and their patients benefit from innovative, experiential training that has the potential to improve care and foster a higher level of patient safety. The development of this accreditation process is discussed along with its anticipated benefits.
    Journal of Critical Care 07/2008; 23(2):203-6. · 2.50 Impact Factor
  • Victor W Xia, Masahiko Taniguchi, Randolph H Steadman
    [Show abstract] [Hide abstract]
    ABSTRACT: Significant changes have been witnessed recently in patients presenting for liver transplantation. The growing number of liver transplantations performed, the increasingly successful outcomes, the expansion of indications, and the implementation of the Model for End-Stage Liver Disease (MELD) system are driving forces for those changes. The purpose of this review is to examine those changes and their effect in perioperative management. Patients who present for liver transplantation today have higher MELD scores and more advanced liver disease. Studies show that high MELD score patients are associated with high perioperative risks and undergo a more difficult perioperative course than patients with low MELD score. More specifically, they have more preoperative comorbidities, more baseline laboratory abnormalities, and higher requirements for intraoperative transfusion and vasopressors. Progress has been also made in management in patients with hepatocellular carcinoma, fulminant hepatic failure, and coronary artery disease prior to liver transplantation. Patients who present for liver transplantation today are more acutely ill compared with a few years ago and have more comorbidities, higher perioperative risks, and a more difficult perioperative course. Further characterization of the changes and associated perioperative risks and strategies to manage those risks are needed.
    Current opinion in organ transplantation 07/2008; 13(3):280-4. · 3.27 Impact Factor