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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. · 4.00 Impact Factor
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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. · 2.36 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 09/2011; · 1.06 Impact Factor
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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. · 4.00 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 02/2011; 25(6):1092-4. · 1.06 Impact Factor
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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. · 3.39 Impact Factor
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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. · 1.22 Impact Factor
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Randolph H Steadman
Anesthesiology 03/2010; 112(4):775-6. · 5.36 Impact Factor
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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. · 5.36 Impact Factor
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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
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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. · 4.00 Impact Factor
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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. · 1.22 Impact Factor
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Randolph H Steadman
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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. · 2.13 Impact Factor
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Randolph H Steadman
Journal of Cardiothoracic and Vascular Anesthesia 11/2007; 21(5):756-7. · 1.64 Impact Factor
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ABSTRACT: Hyperkalemia poses serious hazards to patients undergoing orthotopic liver transplantation (OLT), and its predictors have not been thoroughly examined.
We retrospectively studied 1124 consecutive adult patients who underwent OLT. Hyperkalemia was defined as serum K+ > or =5.5 mmol/L. A total of 47 recipient, donor, intraoperative, and laboratory variables were initially analyzed in univariate analyses. Independent predictors of hyperkalemia in three periods of OLT (prereperfusion, early postreperfusion, and late postreperfusion) were determined in multivariate logistic regression analyses.
Of 1124 patients, 10.2%, 19.1%, and 7.9% had hyperkalemia in the prereperfusion, early postreperfusion, and late postreperfusion periods, respectively. Higher baseline K+ and red blood cell transfusion were independent predictors of prereperfusion hyperkalemia. Higher baseline K+ (or prereperfusion K+) and donation after cardiac death donor were independent predictors of early postreperfusion hyperkalemia. Higher baseline K+, longer warm ischemia time, longer donor hospital stay, lower intraoperative urine output, and the use of venovenous bypass were independent predictors of late postreperfusion hyperkalemia.
Several laboratory, intraoperative, and donor variables were identified as independent predictors of hyperkalemia in the different periods. Such information may be used for more targeted preemptive interventions in patients who are at risk of developing hyperkalemia during adult OLT.
Anesthesia and analgesia 09/2007; 105(3):780-5. · 3.08 Impact Factor
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ABSTRACT: In this retrospective study of 268 children undergoing liver transplantation, we investigated the incidence of intraoperative potassium (K+) disturbances and the risk factors for hypokalemia in the preperfusion and postreperfusion periods. Overall, hypokalemia was the predominant disturbance, occurring in 72.0% of pediatric patients during liver transplantation. Hypokalemia was more common during the postreperfusion period than the prereperfusion period. Hyperkalemia, though a commonly cited complication, was infrequent during pediatric liver transplantation. Using multivariate logistic regression analysis, baseline serum K+ < or =3.5 mmol/L, base excess >5 mmol/L, and creatinine < or =0.5 mg/dL were found to be predictors for hypokalemia in the prereperfusion period; and body weight < or =15 kg, K+ < or =3.5 mmol/L, fresh-frozen plasma transfusion >90 mL/kg, and absence of ascites at surgery were independent predictors for hypokalemia in the postreperfusion period. These findings support the use of K+ replacement to maintain normokalemia and avoid the potential complications related to hypokalemia in pediatric liver transplantation, especially in children with the risk factors for hypokalemia.
Anesthesia and analgesia 10/2006; 103(3):587-93. · 3.08 Impact Factor
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ABSTRACT: We describe a program for community anesthesiologists designed to evaluate clinical skills and provide additional training in the latest technologies in anesthesiology. This educational program was established for previously trained anesthesiologists who require additional training for either remedial purposes or because of a prolonged absence from practice. All enrollees had an active, unrestricted California medical license and malpractice insurance. Approximately half of the participants had been in active practice at the time of enrollment; the remainder had been away from practice from 1 to 9 yr. The first 24 graduates of the fellowship spent an average of 9 wk (range, 3-24 wk) in the program to meet their individualized goals. Graduates were surveyed an average of 15 mo after completion of the fellowship. All respondents indicated that they would enroll in the program again; 80% indicated they learned new technical skills, 73% stated that the fellowship introduced them to a greater variety of drugs, and 50% indicated that the fellowship changed their approach to patient care. This program may serve as a model for any discipline of medicine and is particularly relevant for those with a substantial component of technical skills expected of its practitioners.
Anesthesia and analgesia 08/2006; 103(1):126-30, table of contents. · 3.08 Impact Factor
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Victor W Xia,
Bin Du,
Michelle Braunfeld,
Gundappa Neelakanta,
Ke-Qin Hu,
Hamid Nourmand,
Philip Levin,
Ronald Enriquez,
Jonathan R Hiatt,
R Mark Ghobrial,
Douglas G Farmer,
Ronald W Busuttil, Randolph H Steadman
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ABSTRACT: Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation.
Liver Transplantation 04/2006; 12(4):614-20. · 3.39 Impact Factor
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ABSTRACT: To determine whether full-scale simulation (SIM) is superior to interactive problem-based learning (PBL) for teaching medical students acute care assessment and management skills.
Randomized controlled trial.
Simulation center at a U.S. medical school.
Thirty-one fourth-year medical students in a week-long acute care course.
After institutional review board approval and informed consent, eligible students were randomized to either the SIM or PBL group. On day 1, all subjects underwent a simulator-based initial assessment designed to evaluate their critical care skills. Two blinded investigators assessed each student using a standardized checklist. Subsequently, the PBL group learned about dyspnea in a standard PBL format. The SIM group learned about dyspnea using the simulator. To equalize simulator education time, the PBL group learned about acute abdominal pain on the simulator, whereas the SIM group used the PBL format. On day 5, each student was tested on a unique dyspnea scenario.
Mean initial assessment and final assessment checklist scores and their change for the SIM and PBL groups were compared using the Student's t-test. A p < .05 was considered significant. The SIM and PBL groups had similar mean (PBL 0.44, SIM 0.47, p = .64) initial assessment scores (earned score divided by maximum score) and were deemed equivalent. The SIM group performed better than the PBL group on the final assessment (mean, PBL 0.53, SIM 0.72, p < .0001). When each student's change in score (percent correct on final assessment minus percent correct on the initial assessment) was compared, SIM group students performed better (mean improvement, SIM 25 percentage points vs. PBL 8 percentage points, p < .04)
For fourth-year medical students, simulation-based learning was superior to problem-based learning for the acquisition of critical assessment and management skills.
Critical Care Medicine 02/2006; 34(1):151-7. · 6.33 Impact Factor
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ABSTRACT: This article reviews the current status and controversies of the 3 commonly used antifibrinolytics-epsilon-aminocaproic acid, tranexamic acid and aprotinin-during liver transplantation. There is no general consensus on how, when or which antifibrinolytics should be used in liver transplantation. Although these drugs appear to reduce blood loss and decrease transfusion requirements during liver transplantation, their use is not supported uniformly in clinical trials. Aprotinin has been studied more extensively in clinical trials and appear to offer more advantages compared to two other antifibrinolytics. Because of the diverse population of liver transplant recipients and the potential adverse effects of antifibrinolytics, especially life-threatening thromboembolism, careful patient selection and close monitoring is prudent. Further studies addressing the risks and benefits of antifibrinolytics in the setting of liver transplantation are warranted.
Liver Transplantation 02/2005; 11(1):10-8. · 3.39 Impact Factor
