Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery

As solid organ transplantation increases and patient survival improves, it will become more common for these patients to present for nontransplant surgery. Recipients may present with medical problems unique to the transplant, and important considerations are necessary to keep the transplanted organ functioning. A comprehensive preoperative examination with specific focus on graft functioning is required. The anesthesiologist needs to pay close attention to considerations of immunosuppressive regimens, blood product administration, drug interactions as well as the risk and benefits of invasive monitoring in these immunosuppressed patients. This article reviews the post-transplant physiology and anesthetic considerations for patients after solid organ transplantation

Upala pluća uzrokovana ventilatorom: usporedba bolesnika s kadaveričnim presatkom jetre i kirurških bolesnika bez presatka

Ventilator-associated pneumonia is a frequent complication in intensive care surgical patients, particularly those with high severity scores on admission. We studied the incidence and clinical outcome of ventilator-associated pneumonia among patients undergoing major general surgery procedures and those undergoing cadaveric liver transplantation in our hospital. Patients with the intensive care unit stay longer than four days having undergone surgery or transplantation and mechanically ventilated for more than 48 hours were included in the study. Ventilator-associated pneumonia diagnosis was based on a combination of radiological signs (progressive infiltrate on chest radiograph), clinical signs (fever >38.3 °C, leukocytes >12×109/mL) and microbiological data (positive culture from tracheal aspiration >105 or bronchoalveolar lavage >104 colonies/mL). Medical records of 1037 patients were reviewed and 157 patients were found to have been mechanically ventilated for more than 48 hours: 62 transplanted and 95 non-transplanted. Only 39 (24.84%) patients matched the criteria for ventilator-associated pneumonia. There were no differences in sex, age, duration of mechanical ventilation, length of stay or outcome between the two groups. However, the main difference was the mean severity score on admission (Simplified Acute Physiology Score II) which was higher among non-transplant patients (42±16 vs. 31±9; p=0.03). Gram-negative bacteria were the leading causative agents (82.03%) and were multidrug-resistant. In the intensive care surgical population, transplantation per se does not seem to increase patient risk for either ventilator-associated pneumonia acquisition or worse outcomes.Upala pluća uzrokovana ventilatorom česta je komplikacija u jedinicama intenzivnog liječenja kirurških bolesnika, naročito onih s visokim stupnjem disfunkcije organa kod prijma. Ispitivala se učestalost i klinički ishod upale pluća uzrokovane ventilatorom kod bolesnika podvrgnutih velikim abdominalnim operativnim zahvatima te kod bolesnika nakon kadaverične transplantacije jetre. U studiju su bili uključeni bolesnici koji su u Jedinici intenzivnog liječenja boravili duže od četiri dana, koji su prošli operaciju ili transplantaciju te koji su bili mehanički ventilirani duže od 48 sati. Dijagnoza se temeljila na kombinaciji radioloških znakova (progresija infiltrata na snimkama prsišta), kliničkih znakova (vrućica >38,3 °C, leukociti >12×109/mL) te mikrobioloških podataka (pozitivna kultura aspirata traheje >105 i/ili bronhoalveolarnog lavata >104 kolonije/mL). Pregledani su medicinski zapisi 1037 bolesnika od kojih je njih 157 bilo mehanički ventilirano duže od 48 sati: 62 transplantiranih i 95 netransplantiranih. Samo 39 (24,84%) bolesnika zadovoljilo je kriterije. Nije nađena razlika u spolu, dobi, trajanju mehaničke ventilacije, duljini boravka ili ishodu između ispitivanih skupina. Međutim, glavnu razliku činio je bodovni sustav disfunkcije organa kod prijma (Simplifi ed Acute Physiology Score II), koji je bio veći kod netransplantiranih bolesnika (42±16 prema 31±9; p=0,03). Multirezistentne gram-negativne bakterije bile su vodeći uzročnik (82,03%). U jedinicama intenzivnog liječenja kirurških bolesnika transplantacija jetre sama po sebi ne povećava rizik za nastanak upale pluća uzrokovane ventilatorom kao ni lošiji ishod tih bolesnika

Successful management of unsuspected retroperitoneal paraganglioma via the use of combined epidural and general anesthesia: a case report

INTRODUCTION: Similar to pheochromocytomas, paragangliomas can secrete catecholamines, although they are usually non-functional and clinical presentation is non-specific. We present a case of accidental, intra-operatively diagnosed neuroendocrine-active sympathetic paraganglioma, which was suspected and confirmed during elective retroperitoneal tumor removal. CASE PRESENTATION: A 25-year-old Caucasian Croatian man, American Society of Anesthesiologists status 1, underwent elective surgery for retroperitoneal tumor removal. The tumor had been discovered by chance during a routine examination and was suspected to be a sarcoma. Our patient had no history of previous medical conditions nor did he have symptoms characteristic of a neuroendocrine secreting tumor. The results of ultrasound and magnetic resonance imaging studies showed a large, well demarcated retroperitoneal tumor mass in his upper abdomen localized between the aorta and vena cava, measuring approximately 9×6×4.5cm. In the operating room an epidural catheter was inserted at the T7 to T8 level prior to induction of general anesthesia. Epidural analgesia was maintained by an infusion pump with local anesthetic and opiate mixture. During the surgical excision of the tumor, hemodynamic changes occurred, with hypertension (205/110mmHg) and tachycardia (up to 120 beats/minute). In spite of the fact that the surgical field of work did not include adrenal glands whose direct manipulation could explain this occurrence, there was a high degree of suspicion for the presence of a neurosecreting tumor. His clinical symptoms were relieved after administration of urapidil, esmolol and magnesium sulfate. After tumor excision, our patient developed severe hypotension. Hemodynamic stability was reinstated with aggressive volume replacement, with crystalloids and colloids, vasopressors and hydrocortisone. His post-operative course was unremarkable and on the eighth post-operative day our patient was discharged from hospital, with no consequences or symptoms on follow-up two years after surgery. CONCLUSIONS: Our patient’s case emphasizes the need to consider the presence of extra-adrenal paragangliomas in the differential diagnosis of retroperitoneal tumors, despite their rare occurrence. In our patient’s case, invasive hemodynamic monitoring during combined general anesthesia and epidural analgesia and early recognition of catechol-induced symptoms raised suspicion of the existence of a paraganglioma, and this led to an adequate therapeutic approach and favorable outcome of the surgery. Pre-operative recognition of paragangliomas could lead to better pre-operative preparation, but even high clinical suspicion in undiagnosed forms during surgery and the availability of rapid and short-acting vasodilatators, α-blockers and β-blockers might favor good outcome

Ventilator-associated pneumonia: comparing cadaveric liver transplant and non-transplant surgical patients

Ventilator-associated pneumonia is a frequent complication in intensive care surgical patients, particularly those with high severity scores on admission. We studied the incidence and clinical outcome of ventilator-associated pneumonia among patients undergoing major general surgery procedures and those undergoing cadaveric liver transplantation in our hospital. Patients with the intensive care unit stay longer than four days having undergone surgery or transplantation and mechanically ventilated for more than 48 hours were included in the study. Ventilator-associated pneumonia diagnosis was based on a combination of radiological signs (progressive infiltrate on chest radiograph), clinical signs (fever >38.3 °C, leukocytes >12×109/mL) and microbiological data (positive culture from tracheal aspiration >105 or bronchoalveolar lavage >104 colonies/mL). Medical records of 1037 patients were reviewed and 157 patients were found to have been mechanically ventilated for more than 48 hours: 62 transplanted and 95 non-transplanted. Only 39 (24.84%) patients matched the criteria for ventilator-associated pneumonia. There were no differences in sex, age, duration of mechanical ventilation, length of stay or outcome between the two groups. However, the main difference was the mean severity score on admission (Simplified Acute Physiology Score II) which was higher among non-transplant patients (42±16 vs. 31±9; p=0.03). Gram-negative bacteria were the leading causative agents (82.03%) and were multidrug-resistant. In the intensive care surgical population, transplantation per se does not seem to increase patient risk for either ventilator-associated pneumonia acquisition or worse outcomes

Nonelective surgery at night and in-hospital mortality - Prospective observational data from the European Surgical Outcomes Study

BACKGROUND Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION None. MAIN OUTCOME MEASURES Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed