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Scaravilli V, Guzzardella A, Madotto F, Morlacchi LC, Bosone M, Bonetti C, Musso V, Rossetti V, Russo FM, Sorbo LD, Blasi F, Nosotti M, Zanella A, Grasselli G. Hemodynamic failure and graft dysfunction after lung transplant: A possible clinical continuum with immediate and long-term consequences. Clin Transplant 2023; 37:e15122. [PMID: 37694497 DOI: 10.1111/ctr.15122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The postoperative hemodynamic management after lung transplant (LUTX) is guided by limited evidence. We aimed to describe and evaluate risk factors and outcomes of postoperative vasoactive support of LUTX recipients. METHODS In a single-center retrospective analysis of consecutive adult LUTX, two cohorts were identified: (1) patients needing prolonged vasoactive support (>12 h from ICU admission) (VASO+); (2) or not (VASO-). Postoperative hemodynamic characteristics were thoroughly analyzed. Risk factors and outcomes of VASO+ versus VASO- cohorts were assessed by multivariate logistic regression and propensity score matching. RESULTS One hundred and thirty-eight patients were included (86 (62%) VASO+ versus 52 (38%) VASO-). Vasopressors (epinephrine, norepinephrine, dopamine) were used in the first postoperative days (vasoactive inotropic score at 12 h: 6 [4-12]), while inodilators (dobutamine, levosimendan) later. Length of vasoactive support was 3 [2-4] days. Independent predictors of vasoactive use were: LUTX indication different from cystic fibrosis (p = .003), higher Oto score (p = .020), longer cold ischemia time (p = .031), but not preoperative cardiac catheterization. VASO+ patients showed concomitant hemodynamic and graft impairment, with longer mechanical ventilation (p = .010), higher primary graft dysfunction (PGD) grade at 72 h (PGD grade > 0 65% vs. 31%, p = .004, OR 4.2 [1.54-11.2]), longer ICU (p < .001) and hospital stay (p = .013). Levosimendan as a second-line inodilator appeared safe. CONCLUSIONS Vasoactive support is frequently necessary after LUTX, especially in recipients of grafts of lesser quality. Postoperative hemodynamic dysfunction requiring vasopressor support and graft dysfunction may represent a clinical continuum with immediate and long-term consequences. Further studies may elucidate if this represents a possible treatable condition.
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Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan(MI), Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Fabiana Madotto
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Letizia Corinna Morlacchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Marco Bosone
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Claudia Bonetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Valeria Musso
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Valeria Rossetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Filippo Maria Russo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Mario Nosotti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Cardio-thoraco-vascular diseases, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
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Kim HJ, Shin SW, Park S, Kim HY. A Review of Anesthesia for Lung Transplantation. J Chest Surg 2022; 55:293-300. [PMID: 35924536 PMCID: PMC9358164 DOI: 10.5090/jcs.22.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Lung transplantation is the only treatment option for patients with end-stage lung disease. Although more than 4,000 lung transplants are performed every year worldwide, the standardized protocols contain no guidelines for monitoring during lung transplantation. Specific anesthetic concerns are associated with lung transplantation, especially during critical periods, including anesthesia induction, the initiation of positive pressure ventilation, the establishment and maintenance of one-lung ventilation, pulmonary artery clamping, pulmonary artery unclamping, and reperfusion of the transplanted lung. Anesthetic management according to the special risks associated with a patient’s existing lung disease and surgical stage is the most important factor. Successful anesthesia in lung transplantation can improve hemodynamic stability, oxygenation, ventilation, and outcomes. Therefore, anesthesiologists must have expertise in transesophageal echocardiography, extracorporeal life support, and cardiopulmonary anesthesia and understand the pathophysiology of end-stage lung disease and the drugs administered. In addition, communication among anesthesiologists, surgeons, and perfusionists during surgery is important to achieve optimal patient results.
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Affiliation(s)
- Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang-Wook Shin
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Seyeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Yangsan, Korea
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Murray AW, Boisen ML, Fritz A, Renew JR, Martin AK. Anesthetic considerations in lung transplantation: past, present and future. J Thorac Dis 2022; 13:6550-6563. [PMID: 34992834 PMCID: PMC8662503 DOI: 10.21037/jtd-2021-10] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/10/2021] [Indexed: 01/01/2023]
Abstract
Lung transplantation is a very complex surgical procedure with many implications for the anesthetic care of these patients. Comprehensive preoperative evaluation is an important component of the transplant evaluation as it informs many of the decisions made perioperatively to manage these complex patients effectively and appropriately. These decisions may involve pre-emptive actions like pre-habilitation and nutrition optimization of these patients before they arrive for their transplant procedure. Appropriate airway and ventilation management of these patients needs to be performed in a manner that provides an optimal operating conditions and protection from ventilatory injury of these fragile post-transplant lungs. Pain management can be challenging and should be managed in a multi-modal fashion with or without the use of an epidural catheter while recognizing the risk of neuraxial technique in patients who will possibly be systemically anticoagulated. Complex monitoring is required for these patients involving both invasive and non-invasive including the use of transesophageal echocardiography (TEE) and continuous cardiac output monitoring. Management of the patient's hemodynamics can be challenging and involves managing the systemic and pulmonary vascular systems. Some patients may require extra-corporeal lung support as a planned part of the procedure or as a rescue technique and centers need to be proficient in instituting and managing this sophisticated method of hemodynamic support.
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Affiliation(s)
- Andrew W Murray
- Department of Anesthesiology, Mayo Clinic Graduate School of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ashley Fritz
- Division of Cardiothoracic and Thoracic Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| | - J Ross Renew
- Department of Anesthesiology, Mayo Clinic Graduate School of Medicine, Mayo Clinic, Jacksonville, FL, USA
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The role of intraoperative pulmonary arterial catheterization data in determining the need for extracorporeal membrane oxygenation in lung transplantation. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:480-486. [PMID: 35096445 PMCID: PMC8762920 DOI: 10.5606/tgkdc.dergisi.2021.20485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/20/2020] [Indexed: 11/21/2022]
Abstract
Background
This study aims to investigate predictive factors of identification of the need of patients for extracorporeal membrane oxygenation support during lung transplantation.
Methods
A total of 63 patients (49 males, 14 females, mean age: 44.9±14.4 years; range, 14 to 64 years) who underwent lung transplantation in our institution between December 2016 and December 2019 were retrospectively analyzed. Demographic characteristics and perioperative clinical data of patients were recorded. After induction and pulmonary artery catheterization, cardiac output, mean pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index, pulmonary vascular resistance, systemic vascular resistance, and right atrial pressure were measured using the thermodilution technique.
Results
Thirty-three of the patients received extracorporeal membrane oxygenation support during surgery. The right atrial pressure (p<0.001), pulmonary capillary wedge pressure (p<0.002), mean pulmonary artery pressure (p<0.001), and pulmonary vascular resistance (p<0.001) were statistically significantly higher in the patients who required extracorporeal membrane oxygenation support intraoperatively. The systemic vascular resistance (p<0.032) was statistically significantly lower in the patients who required extracorporeal membrane oxygenation support intraoperatively. A mean pulmonary artery pressure of >39 mmHg (p<0.02) and a right atrial pressure of >12 mmHg (p<0.047) were independent risk factors for ECMO support intraoperatively during lung transplantation.
Conclusion
Predicting the need of intraoperative extracorporeal membrane oxygenation support is of utmost importance in timing the need for mechanical support, protecting the new graft from high mechanical ventilator pressures, and adequately maintaining hemodynamic stability.
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Subramaniam K, Gelzinis TA, Lazar S, Bains S, Ball RD, Metro DG. Basic Transesophageal Echocardiography Education for Senior Anesthesiology Residents-Institutional Experience. J Cardiothorac Vasc Anesth 2021; 36:155-162. [PMID: 34489152 DOI: 10.1053/j.jvca.2021.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/07/2021] [Accepted: 08/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The use of basic transesophageal echocardiography (TEE) in critically ill and older surgical patients can change patient management and improve outcomes after noncardiac surgery. The authors hypothesized that educating the future generation on basic TEE skills by an intense two-month rotation will help them achieve basic TEE certification by the National Board of Echocardiography (NBE) and facilitate good use of their skills for patient care during their practice. DESIGN This is a descriptive report of graduating anesthesiology residents who completed two months basic TEE rotation at the authors' residency program between 2013 and 2019. The authors report the clinical training goals, NBE testamur and certification status, and a survey report on the use of basic TEE skills in their practice SETTINGS: University medical center. PARTICIPANTS Residents who completed two months basic TEE rotation during their Clinical Anesthesia (CA)-3 year. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of a total of 115 residents, 67 (58%) elected basic TEE rotation. The NBE basic TEE certification and testamur status were achieved by 12 (21%) and 14 (24%) eligible residents, respectively. Residents (n = 43) personally performed 73 ± 21 (mean ± standard deviation) and reviewed 72 ± 28 (mean ± standard deviation basic TEE studies before graduation. The survey indicated that 63.4% of residents trained in basic TEE did not use their skills in their practice. CONCLUSIONS Two months' basic TEE rotation was able to fulfill its educational goals (testamur status and clinical training) but fell short on achieving NBE certification rate and its ultimate impact on practice and patient care.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Theresa A Gelzinis
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sofiane Lazar
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Semerjit Bains
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ryan D Ball
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - David G Metro
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
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Anesthetic management in lung transplantation: Our single-center experience. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:191-200. [PMID: 34104513 PMCID: PMC8167475 DOI: 10.5606/tgkdc.dergisi.2021.9490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/16/2020] [Indexed: 11/25/2022]
Abstract
Background
In this study, we aimed to discuss our anesthesia management strategies, experiences, and outcomes in patients undergoing lung transplantation.
Methods
Between December 2016 and December 2018, a total of 53 patients (43 males, 10 females; mean age: 46.1±13 years; range, 14 to 64 years) undergoing lung transplantation in our center were included. The anesthesia technique, patients" characteristics, and perioperative clinical and follow-up data were recorded. The stage of lung disease was assessed using the New York Heart Association functional classification.
Results
Two patients underwent single lung transplantation, while 51 patients underwent double lung transplantation. Idiopathic pulmonary fibrosis was the most common indication in 41.5% of the patients. All patients had end-stage lung disease (Class IV) and 79% were oxygen-dependent. The extracorporeal membrane oxygenation support was given to 32 patients.
Conclusion
The anesthetic management of lung transplantation is challenging, either due to the deterioration of the recipient"s physical performance and the complexity of the surgical techniques used. In general, a kind of mechanical support may be needed and extracorporeal membrane oxygenation is the first choice in the majority of patients. A close communication should be maintained between the surgeons, perfusion technicians, and anesthesiologists to ensure an optimal multidisciplinary approach and to achieve successful outcomes.
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Anaesthesia for Liver Transplantation: An Update. ACTA ACUST UNITED AC 2020; 6:91-100. [PMID: 32426515 PMCID: PMC7216023 DOI: 10.2478/jccm-2020-0011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 01/30/2020] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the patho-physiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.
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Assaad S, Perrino AC. Lung Transplantation: Can PiCCO2 Navigate Perioperative Safe Harbor? J Cardiothorac Vasc Anesth 2018. [PMID: 29525188 DOI: 10.1053/j.jvca.2018.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sherif Assaad
- Yale University School of Medicine, New Haven, CT; Cardiothoracic Anesthesia Service, VA Connecticut Healthcare System, West Haven, CT
| | - Albert C Perrino
- Yale University School of Medicine, New Haven, CT; Cardiothoracic Anesthesia Service, VA Connecticut Healthcare System, West Haven, CT
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Tomasi R, Betz D, Schlager S, Kammerer T, Hoechter DJ, Weig T, Slinger P, Klotz LV, Zwißler B, Marczin N, von Dossow V. Intraoperative Anesthetic Management of Lung Transplantation: Center-Specific Practices and Geographic and Centers Size Differences. J Cardiothorac Vasc Anesth 2018; 32:62-69. [DOI: 10.1053/j.jvca.2017.05.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Indexed: 12/16/2022]
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Konur H, Erdogan Kayhan G, Toprak HI, Bucak N, Aydogan MS, Yologlu S, Durmus M, Yılmaz S. Evaluation of pleth variability index as a predictor of fluid responsiveness during orthotopic liver transplantation. Kaohsiung J Med Sci 2016; 32:373-80. [PMID: 27450027 DOI: 10.1016/j.kjms.2016.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/18/2016] [Accepted: 05/25/2016] [Indexed: 11/17/2022] Open
Abstract
Fluid management is challenging and still remains controversial in orthotopic liver transplantation (OLT). The pleth variability index (PVI) has been shown to be a reliable predictor of fluid responsiveness of perioperative and critically ill patients; however, it has not been evaluated in OLT. This study was designed to examine whether the PVI can reliably predict fluid responsiveness in OLT and to compare PVI with other hemodynamic indexes that are measured using the PiCCO2 monitoring system. Twenty-five patients were enrolled in this study. Each patient was monitored using the noninvasive Masimo and PiCCO2 monitoring system. PVI was obtained with a Masimo pulse oximeter. Cardiac index was obtained using a transpulmonary thermodilution technique (CITPTD). Stroke volume variation (SVV), pulse pressure variation, and systemic vascular resistance index were measured using the PiCCO2 system. Fluid loading (10 mL/kg colloid) was performed at two different phases during the operation, and fluid responsiveness was defined as an increase in CITPTD ≥ 15%. During the dissection phase and the anhepatic phase, respectively, 14 patients (56%) and 18 patients (75%) were classified as responders. There were no differences between the baseline values of the PVI of responders and nonresponders. Area under the curve for PVI was 0.56 (sensitivity 35%, specificity 90%, p = 0.58) at dissection phase, and was 0.55 (sensitivity 55%, specificity 66%, p = 0.58) at anhepatic phase. Of the parameters, a higher area under the curve value was found for SVV. We conclude that PVI was unable to predict fluid responsiveness with sufficient accuracy in patients undergoing OLT, but the SVV parameter was reliable.
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Affiliation(s)
- Huseyin Konur
- Department of Anesthesiology and Reanimation, Goztepe Education and Research Hospital, Medeniyet University, Istanbul, Turkey
| | - Gulay Erdogan Kayhan
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey.
| | - Huseyin Ilksen Toprak
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Nizamettin Bucak
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Mustafa Said Aydogan
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Saim Yologlu
- Department of Biostatistics, Inonu University Medical Faculty, Malatya, Turkey
| | - Mahmut Durmus
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Sezai Yılmaz
- Department of General Surgery, Inonu University Medical Faculty, Malatya, Turkey
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De Pietri L, Mocchegiani F, Leuzzi C, Montalti R, Vivarelli M, Agnoletti V. Transoesophageal echocardiography during liver transplantation. World J Hepatol 2015; 7:2432-2448. [PMID: 26483865 PMCID: PMC4606199 DOI: 10.4254/wjh.v7.i23.2432] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/22/2015] [Accepted: 09/09/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver transplant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the procedures as a result of both the disease process and the surgery. Transoesophageal echocardiography (TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. Moreover, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.
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Comparison of an advanced minimally invasive cardiac output monitoring with a continuous invasive cardiac output monitoring during lung transplantation. J Clin Monit Comput 2015. [PMID: 26223864 DOI: 10.1007/s10877-015-9741-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The aim of this study was to compare a continuous non-calibrated left heart cardiac index (CI) measurement by arterial waveform analysis (FloTrac(®)/Vigileo(®)) with a continuous calibrated right heart CI measurement by pulmonary artery thermodilution (CCOmbo-PAC(®)/Vigilance II(®)) for hemodynamic monitoring during lung transplantation. CI was measured simultaneously by both techniques in 13 consecutive lung transplants (n = 4 single-lung transplants, n = 9 sequential double-lung transplants) at distinct time points perioperatively. Linear regression analysis and Bland-Altman analysis with percentage error calculation were used for statistical comparison of CI measurements by both techniques. In this study the FloTrac(®) system underestimated the CI in comparison with the continuous pulmonary arterial thermodilution (p < 0.000). For all measurement pairs we calculated a bias of -0.55 l/min/m(2) with limits of agreement between -2.31 and 1.21 l/min/m(2) and a percentage error of 55 %. The overall correlations before clamping a branch oft the pulmonary artery (percentage error 41 %) and during the clamping periods of a branch oft the pulmonary artery (percentage error 66 %) failed to reached the required percentage error of less than 30 %. We found good agreement of both CI measurements techniques only during the measurement point "15 min after starting the second one-lung ventilation period" (percentage error 30 %). No agreement was found during all other measurement points. This pilot study shows for the first time that the CI of the FloTrac(®) system is not comparable with the continuous pulmonary-artery thermodilution during lung transplantation including the time periods without clamping a branch of the pulmonary artery. Arterial waveform and continuous pulmonary artery thermodilution are, therefore, not interchangeable during these complex operations.
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Tan TC, Dudzinski DM, Hung J, Mehta V. Peri-operative assessment of right heart function: role of echocardiography. Eur J Clin Invest 2015; 45:755-66. [PMID: 25989109 DOI: 10.1111/eci.12462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 05/13/2015] [Indexed: 01/10/2023]
Abstract
The right heart contributes significantly to overall cardiac function. Right ventricular (RV) haemodynamics and function have been defined to be physiologically different from the left ventricle, and yet independently associated with outcomes in a spectrum of conditions. In particular, RV function has been shown to influence prognosis of patients undergoing surgery. The assessment of right heart function during the intra-operative and immediate postoperative periods plays an important role in the clinical management of patients having surgery. While a number of techniques are available for the assessment of the right heart intra-operatively, echocardiography remains the prime choice being least invasive, relatively safe, readily accessible and cost-effective. Advancements in the field of echocardiographic have improved ability to assess right heart function. This review examines the role echocardiography and advances in this imaging modality in the assessment of right heart function within the peri-operative setting.
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Affiliation(s)
- Timothy C Tan
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David M Dudzinski
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Vipin Mehta
- Department of Anesthesia, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Perioperative management of pulmonary hypertension during lung transplantation (a lesson for other anaesthesia settings). ACTA ACUST UNITED AC 2014; 61:434-45. [PMID: 25156939 DOI: 10.1016/j.redar.2014.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 04/19/2014] [Accepted: 05/12/2014] [Indexed: 11/21/2022]
Abstract
Patients with pulmonary hypertension are some of the most challenging for an anaesthesiologist to manage. Pulmonary hypertension in patients undergoing surgical procedures is associated with high morbidity and mortality due to right ventricular failure, arrhythmias and ischaemia leading to haemodynamic instability. Lung transplantation is the only therapeutic option for end-stage lung disease. Patients undergoing lung transplantation present a variety of challenges for anaesthesia team, but pulmonary hypertension remains the most important. The purpose of this article is to review the anaesthetic management of pulmonary hypertension during lung transplantation, with particular emphasis on the choice of anaesthesia, pulmonary vasodilator therapy, inotropic and vasopressor therapy, and the most recent intraoperative monitoring recommendations to optimize patient care.
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Oniscu GC, Diaz G, Levitsky J. Meeting report of the 19th Annual International Congress of the International Liver Transplantation Society (Sydney Convention and Exhibition Centre, Sydney, Australia, June 12-15, 2013). Liver Transpl 2014; 20:7-14. [PMID: 24136728 DOI: 10.1002/lt.23767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 09/24/2013] [Indexed: 12/21/2022]
Abstract
The International Liver Transplantation Society held its annual meeting from June 12 to 15 in Sydney, Australia. More than 800 registrants attended the congress, which opened with a conference celebrating 50 years of liver transplantation (LT). The program included series of featured symposia, focused topic sessions, and oral and poster presentations. This report is by no means all-inclusive and focuses on specific abstracts on key topics in LT. Similarly to previous reports, this one presents data in the context of the published literature and highlights the current direction of LT.
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Affiliation(s)
- Gabriel C Oniscu
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Robertson AC, Eagle SS. Transesophageal echocardiography during orthotopic liver transplantation: maximizing information without the distraction. J Cardiothorac Vasc Anesth 2013; 28:141-154. [PMID: 23642888 DOI: 10.1053/j.jvca.2012.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Indexed: 12/17/2022]
Affiliation(s)
- Amy C Robertson
- Vanderbilt University School of Medicine, Department of Anesthesiology, Nashville, TN.
| | - Susan S Eagle
- Vanderbilt University School of Medicine, Department of Anesthesiology, Nashville, TN
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Singh S, Nasa V, Tandon M. Perioperative monitoring in liver transplant patients. J Clin Exp Hepatol 2012; 2:271-8. [PMID: 25755443 PMCID: PMC3940305 DOI: 10.1016/j.jceh.2012.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/26/2012] [Indexed: 02/06/2023] Open
Abstract
Liver transplant (LT) is a major surgical undertaking involving major fluid shifts, hemodynamic instability and metabolic derangements in a patient with preexisting liver failure and multisystemic derangements. Monitoring and organ support initiated in the preoperative phase is continued intraoperatively and into the postoperative phase to ensure an optimal outcome. As cardiovascular events are the leading cause of non-graft related death among LT recipients, major emphasis is placed on cardiovascular monitoring. The other essential monitoring are the continuous assessment of coagulapathy, extent of metabolic derangements, dyselectrolytemis and intracranial pressure monitoring in patients with fulminant hepatic failure. The type and extent of monitoring differs with need according to preexisting child status of the patient and the extent of systemic derangements. It also varies among transplant centers and is mainly determined by individual or institutional practices.
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Key Words
- ACT, activated clotting time
- ALF
- ALF, acute liver failure
- APTT, activated partial thromboplastin time
- ARDS, acute respiratory distress syndrome
- CCO, continuous CO
- CCTs, conventional coagulation tests
- CI, cardiac index
- CL, clot lysis
- CO, cardiac output
- CR, clot rate
- CVP, central venous pressure
- ESLD, end stage liver disease
- EVLWI, extra vascular lung water index
- ICG, indocyanine green
- ICH, intracranial hypertension
- ICP, intracranial pressure
- LT, liver transplant
- MA, maximum amplitude
- ONSD, optic nerve sheath diameter
- PAC, pulmonary artery catheter
- PAOP, pulmonary arterial occlusion pressure
- PF, platelet function
- PI, pulsatility index
- PT, prothrombin time
- ROTEM, rotation thrombelastometry
- RVEDV, right ventricular end-diastolic volume
- SV, stroke volume
- SVR, systemic vascular resistance
- TCD, transcranial Doppler
- TDCO, thermodilution principle
- TEE, transesophageal echocardiography
- TEG, thrombelastography
- cirrhosis
- coagulopathy
- intracranial pressure monitoring
- liver transplant
- mPAP, mean pulmonary artery pressure
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Affiliation(s)
- Shweta Singh
- Address for correspondence: Shweta Singh, Associate Professor, Dept. of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India. Tel.: +91 9810625177.
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Maddali MM, Al-Jadidi AM, Zacharias S. Novel anaesthetic approach for surgical access and haemodynamic management during off-pump coronary artery bypass through a left thoracotomy. Indian J Anaesth 2012; 56:75-8. [PMID: 22529427 PMCID: PMC3327079 DOI: 10.4103/0019-5049.93351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
For myocardial revascularization on a beating heart through a thoracotomy, a properly deployed endobronchial blocker (EBB) provides ideal conditions for surgical access. In addition, adequate volume replacement to achieve optimal cardiac performance is a primary goal of haemodynamic management in patients undergoing off-pump coronary artery bypass grafting. To achieve both these ends, this case report describes the combined use of a left-sided EBB along with a volumetric pulmonary artery catheter in a patient who underwent a successful off-pump coronary artery bypass surgery through an anterolateral thoracotomy.
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Greenhalgh DL, Patrick MR. Perioperative transoesophageal echocardiography: past, present & future. Anaesthesia 2012; 67:343-6. [DOI: 10.1111/j.1365-2044.2012.07103.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sabaté A, Acosta Villegas F, Dalmau A, Koo M, Sansano Sánchez T, García Palenciano C. [Anesthesia in the patient with impaired liver function]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 58:574-81. [PMID: 22279877 DOI: 10.1016/s0034-9356(11)70142-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.
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Affiliation(s)
- A Sabaté
- Servicio de Anestesiología y Reanimación, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona.
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Cowie BS. Does the Pulmonary Artery Catheter Still Have a Role in the Perioperative Period? Anaesth Intensive Care 2011; 39:345-55. [DOI: 10.1177/0310057x1103900305] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The pulmonary artery catheter (PAC) was introduced into clinical practice in the early 1970s. Its use quickly expanded beyond patients with acute myocardial infarction to critically ill patients in the intensive care unit. Increasingly, it was used in the perioperative period in patients having major cardiac and noncardiac surgery. Publication of large observational studies suggested that patients with a PAC were more likely to suffer major morbidity or mortality, but this was difficult to assess because patients who had a PAC inserted were often sicker, with more severe pathology, and were therefore more likely to die. The PAC is a monitoring device and information alone is unlikely to influence outcome unless it is linked to a proven therapy. Several thousand articles on the use of the PAC now exist, but in general, the quality of this literature is poor. Much of the data are not randomised, have small sample sizes and include patients with greatly differing pathological states. It is unclear which, if any, of the PAC-guided therapies are actually beneficial for patients. Despite these flaws, there is no clear evidence of benefit, nor harm, in cardiac, intensive care or perioperative patients. Selected indications for the PAC may remain, such as complex cardiac surgery or solid organ transplantation. However, its routine use is difficult to justify and increasingly, most of the haemodynamic data available from the PAC can be obtained less invasively with echocardiography.
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Affiliation(s)
- B. S. Cowie
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia
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Della Rocca G, De Flaviis A, Costa M, Chiarandini P, Pompei L, Venettoni S. Liver Transplant Quality and Safety Plan in Anesthesia and Intensive Care Medicine. Transplant Proc 2010; 42:2229-32. [DOI: 10.1016/j.transproceed.2010.05.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Robertson A. Intraoperative Management of Liver Transplantation in Patients with Hypertrophic Cardiomyopathy: A Review. Transplant Proc 2010; 42:1721-3. [DOI: 10.1016/j.transproceed.2010.02.091] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 02/26/2010] [Indexed: 11/25/2022]
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