Publications by authors named "Stephen Aniskevich"

28 Publications

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Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia.

Clin Transplant 2021 Oct 12:e14504. Epub 2021 Oct 12.

Department of Anesthesiology, University of Colorado, Aurora, CO.

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. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/ctr.14504DOI Listing
October 2021

Responding to the COVID-19 Pandemic: A New Surgical Patient Flow Utilizing the Preoperative Evaluation Clinic.

Am J Med Qual 2020 12 1;35(6):444-449. Epub 2020 Aug 1.

Mayo Clinic, Jacksonville, FL.

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.
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http://dx.doi.org/10.1177/1062860620946741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672706PMC
December 2020

Nonopioid Modalities for Acute Postoperative Pain in Abdominal Transplant Recipients.

Transplantation 2020 04;104(4):694-699

Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.

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.
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http://dx.doi.org/10.1097/TP.0000000000003053DOI Listing
April 2020

Intraoperative Events in Liver Transplantation Using Donation After Circulatory Death Donors.

Liver Transpl 2019 12 18;25(12):1833-1840. Epub 2019 Oct 18.

Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL.

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.
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http://dx.doi.org/10.1002/lt.25643DOI Listing
December 2019

Recommendations From the Society for the Advancement of Transplant Anesthesiology: Liver Transplant Anesthesiology Fellowship Core Competencies and Milestones.

Semin Cardiothorac Vasc Anesth 2019 Dec 12;23(4):399-408. Epub 2019 Aug 12.

Mayo Clinic, Jacksonville, FL, USA.

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.
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http://dx.doi.org/10.1177/1089253219868918DOI Listing
December 2019

Upper Extremity Compartment Syndrome Following Radial Artery Puncture in a Patient Undergoing Orthotopic Liver Transplant.

Exp Clin Transplant 2021 Sep 5;19(9):986-989. Epub 2018 Oct 5.

From the Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA.

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.
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http://dx.doi.org/10.6002/ect.2017.0339DOI Listing
September 2021

[Fulminant hepatic failure after simultaneous kidney-pancreas transplantation: a case report].

Braz J Anesthesiol 2018 Sep - Oct;68(5):535-538. Epub 2018 Jun 19.

Mayo Clinic Florida, Division of Hepatobiliary and Transplant Anesthesia, Department of Anesthesiology, Jacksonville, Estados Unidos. Electronic address:

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.
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http://dx.doi.org/10.1016/j.bjan.2018.01.013DOI Listing
June 2018

Cardiac diseases among liver transplant candidates.

Clin Transplant 2018 07 19;32(7):e13296. Epub 2018 Jun 19.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA.

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.
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http://dx.doi.org/10.1111/ctr.13296DOI Listing
July 2018

Pharmacology and Perioperative Considerations of Pain Medications.

Curr Clin Pharmacol 2017 ;12(3):164-168

Department of Anesthesiology, Columbia University Medical Center, New York, United States.

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.
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http://dx.doi.org/10.2174/1574884712666171027122211DOI Listing
April 2019

Perioperative Pulmonary Medication Management.

Curr Clin Pharmacol 2017 ;12(3):182-187

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States.

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.
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http://dx.doi.org/10.2174/1574884712666170918150757DOI Listing
April 2019

Pharmacologic and Perioperative Considerations for Antihypertensive Medications.

Curr Clin Pharmacol 2017 ;12(3):135-140

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, United States.

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.
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http://dx.doi.org/10.2174/1574884712666170918152004DOI Listing
April 2019

Perioperative stroke: incidence, etiologic factors, and prevention.

Minerva Anestesiol 2017 Nov 13;83(11):1178-1189. Epub 2017 Sep 13.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA.

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.
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http://dx.doi.org/10.23736/S0375-9393.17.11976-0DOI Listing
November 2017

Intra-operative predictors of postoperative Takotsubo syndrome in liver transplant recipients-An exploratory case-control study.

Clin Transplant 2017 Nov 14;31(11). Epub 2017 Sep 14.

Department of Anesthesiology, Mayo Clinic Florida, Jacksonville, FL, USA.

Introduction: Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy or stress-induced cardiomyopathy, has been described following a variety of surgeries and disease states. The relationship between intra-operative 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 intra-operative factors on the pathogenesis of TTS.

Methods: A single-center retrospective review of all liver transplants performed at Mayo Clinic Florida from January 2005 to 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, intra-operative medications, and intra-operative 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 intra-operative measures between the two groups were identified (all P ≥ .08).

Conclusion: Our exploratory, single-center retrospective review evaluating 46 intra-operative characteristics found no association with the development of TTS.
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http://dx.doi.org/10.1111/ctr.13092DOI Listing
November 2017

Pharmacology and Perioperative Considerations for Diabetes Mellitus Medications.

Curr Clin Pharmacol 2017 ;12(3):157-163

Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, United States.

Background: Given the prevalence of diabetes mellitus in modern society, health care providers are frequently tasked with managing glucose control in the perioperative period. When determining perioperative diabetes management, the clinician must balance the need to maintain relative euglycemia at the time of surgery with preventing hypoglycemia or hyperglycemia in a fasting surgical patient. This balance requires an understanding of the pharmacology of these medications, the type of surgery, and the patient's degree of diabetic control.

Objective: We discuss the various medications used in the treatment of diabetes mellitus and the current recommendations regarding perioperative care.

Method: A review of the current literature present on Pubmed and Medline was conducted between the years 2000-2016. The reference lists of each selected article were also reviewed for additional sources of information.

Conclusion: Perioperative control of blood glucose levels is associated with less morbidity and improved surgical outcomes in patients with and without DM. Preoperatively, clinicians need to thoughtfully adjust diabetic medications on the basis of patient comorbidities, the duration of the fasting period, and the duration of surgery. Intraoperative and postoperative strategies typically use insulin to maintain blood glucose levels in the range of 80 to 180 mg/dL.
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http://dx.doi.org/10.2174/1574884712666170810115847DOI Listing
April 2019

Preoperative Clinical Characteristics That Identify Potential Low-Volume Transfusion Candidates Among Orthotopic Liver Transplant Patients.

Exp Clin Transplant 2016 Aug;14(4):405-11

From the Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA.

Objectives: 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 of < 2100 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.

Materials And Methods: 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.

Results: 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.

Conclusions: 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.
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August 2016

Atrioventricular Sequential Pacing for Hypertrophic Cardiomyopathy During Liver Transplantation.

A A Case Rep 2015 Oct;5(8):134-8

From the Departments of *Anesthesiology and †Transplant, and ‡Division of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, Florida.

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.
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http://dx.doi.org/10.1213/XAA.0000000000000219DOI Listing
October 2015

Fast track anesthesia for liver transplantation: Review of the current practice.

World J Hepatol 2015 Sep;7(20):2303-8

Stephen Aniskevich, Sher-Lu Pai, Department of Anesthesiology, Division of Hepatobiliary and Abdominal Organ Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, United States.

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.
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http://dx.doi.org/10.4254/wjh.v7.i20.2303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568490PMC
September 2015

Complications related to intraoperative transesophageal echocardiography in liver transplantation.

Springerplus 2015 4;4:480. Epub 2015 Sep 4.

Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224 USA.

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.
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http://dx.doi.org/10.1186/s40064-015-1281-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4559558PMC
September 2015

Intracardiac thrombosis during liver transplant: A 17-year single-institution study.

Liver Transpl 2015 Oct;21(10):1280-5

Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL.

Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right- and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.
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http://dx.doi.org/10.1002/lt.24161DOI Listing
October 2015

Postoperative Stroke Following Administration of Intraoperative Recombinant Tissue Plasminogen Activator for the Treatment of Intracardiac Thrombus During Liver Transplantation.

J Cardiothorac Vasc Anesth 2015 Oct 23;29(5):1314-8. Epub 2014 Oct 23.

Department of Transplantation, Division of Transplant Surgery, Mayo Clinic, Jacksonville Florida.

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http://dx.doi.org/10.1053/j.jvca.2014.07.010DOI Listing
October 2015

Ultrasound-guided transversus abdominis plane blocks for patients undergoing laparoscopic hand-assisted nephrectomy: a randomized, placebo-controlled trial.

Local Reg Anesth 2014 25;7:11-6. Epub 2014 May 25.

Division of Health Sciences Research, Section of Biostatistics, Jacksonville, FL, USA.

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.
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http://dx.doi.org/10.2147/LRA.S61589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012349PMC
May 2014

Anesthetic pharmacology for kidney transplantation.

Curr Clin Pharmacol 2015 ;10(1):47-53

Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.

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.
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http://dx.doi.org/10.2174/1574884709666140212100059DOI Listing
February 2016

Analgesic considerations for liver transplantation patients.

Curr Clin Pharmacol 2015 ;10(1):54-65

Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.

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.
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http://dx.doi.org/10.2174/1574884709666140212101228DOI Listing
February 2016

Anesthetic pharmacology and perioperative considerations for the end stage liver disease patient.

Curr Clin Pharmacol 2015 ;10(1):35-46

Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, 4500 San Pablo Road, Jacksonville, FL 32224, USA.

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.
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http://dx.doi.org/10.2174/1574884709666140212110036DOI Listing
February 2016

Bilateral transversus abdominis plane block for managing pain after a pancreas transplant.

Exp Clin Transplant 2011 Aug;9(4):277-8

Mayo Clinic Florida, Dept of Anesthesiology, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.

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.
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August 2011

Sugammadex: a novel approach to reversal of neuromuscular blockade.

Expert Rev Neurother 2011 Feb;11(2):185-98

Mayo Clinic, Department of Anesthesiology, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.

Sugammadex is the first in a new class of medications termed selective relaxant binding agents. This medication acts to encapsulate free circulating steroidal nondepolarizing neuromuscular blocking agents. The encapsulation of neuromuscular agents effectively decreases the amount of neuromuscular blocker interacting at the neuromuscular receptor. This binding has a very high association rate, rendering the incidence of residual block extremely low, while avoiding the side effects associated with traditional reversal agents. Currently approved for clinical use in over 50 countries, sugammadex was not approved by the US FDA in 2008 due to concerns over potential hypersensitivity reactions. It is hoped that further study and clinical experience will help to better define the risk associated with sugammadex and eventually lead to the approval of this novel medication in the USA.
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http://dx.doi.org/10.1586/ern.11.2DOI Listing
February 2011

Acute gastric variceal bleeding during orthotopic liver transplant.

Exp Clin Transplant 2010 Sep;8(3):266-8

Mayo Clinic Florida, Jacksonville, FL 32224, USA.

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.
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September 2010

Dynamic left ventricular outflow tract obstruction during liver transplantation: the role of transesophageal echocardiography.

J Cardiothorac Vasc Anesth 2007 Aug 5;21(4):577-80. Epub 2007 Apr 5.

Department of Anesthesiology, Mayo Clinic, Jacksonville, FL 32224, USA.

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http://dx.doi.org/10.1053/j.jvca.2006.07.024DOI Listing
August 2007
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