Anesthetic and perioperative management of intestinal and multivisceral allograft recipient in nontransplant surgery

Review of anaesthetic management for cataract surgery in transplant recipients

The prevalence of transplantation is on the increase worldwide. Corneal transplantation is the most common form of human donor transplantation. Transplantation of other organs and bone marrow is established treatment for various end-organ failure and many haematological conditions, respectively. Success and survival of these patients have increased with advances in immunosuppression. Unfortunately, these patients are susceptible to cataract formation as a consequence of immunosuppressive therapy and accelerated progression of several diseases. Topical anaesthesia and regional ophthalmic blocks are ideal for cataract surgery in cooperative adults. General anaesthesia may be required in children, for extremely anxious or claustrophobic adults and for complex surgery such as simultaneous cataract and corneal transplantation. The perioperative anaesthetic management of cataract surgery in a transplant recipient is no different to a standard technique in a healthy adult, but additional challenges are posed by the underlying pathology necessitating transplantation, function of the transplanted organ, physiological and pharmacological problems of allograft denervation, side-effects of immunosuppression, risk of infection and potential for rejection. This narrative review summarises optimal anaesthetic management in transplant recipients undergoing cataract surgery.

Effects of dexmedetomidine on inflammatory factors, T lymphocyte subsets and expression of NF-κB in peripheral blood mononuclear cells in patients receiving radical surgery of colon carcinoma

The effects of dexmedetomidine on inflammatory factors, T lymphocyte subsets and expression of nuclear factor-κB (NF-κB) in peripheral blood mononuclear cells in patients receiving radical surgery of colon carcinoma were investigated. A total of 141 patients receiving radical surgery of colon carcinoma from January 2014 to April 2017 were divided into two groups randomly. The patients in the treatment group were given dexmedetomidine, while the patients in the control group were treated with saline. Results showed that there were no significant differences in preoperative levels of NF-κB, sICAM-1 and IL-8 between the two groups. However, the above three indexes of the groups were all significantly increased at 0.5 and 24 h after operation, and the results showed that the control group had a higher degree of increase (P<0.05). It was also found that the changes in levels of IL-6 and CRP in patients were the same as those of the above three indexes; in other words, the degree of the increase in the control group was significantly higher than that in the treatment group after operation. Moreover, it was found that there was little difference in the preoperative Ramsay score of patients between the two groups. The scores at 0.5 and 12 h after operation in the treatment group were significantly higher than those in the control group (P<0.05). It was also found that the intraoperative and postoperative dosages of fentanyl in the treatment group were significantly less than those in the control group (P<0.05). We can conclude that the application of dexmedetomidine during anesthesia in patients receiving radical operation of colon carcinoma has a better clinical treatment effect, which can reduce the secretion of inflammatory factors, decrease the inhibition of immunity and reduce the use of fentanyl.

Intestinal transplantation: The anesthesia perspective

Intestinal transplantation is a complex and challenging surgery. It is very effective for treating intestinal failure, especially for those patients who cannot tolerate parenteral nutrition nor have extensive abdominal disease. Chronic parental nutrition can induce intestinal failure associated liver disease (IFALD). According to United Network for Organ Sharing (UNOS) data, children with intestinal failure affected by liver disease secondary to parenteral nutrition have the highest mortality on a waiting list when compared with all candidates for solid organ transplantation. Intestinal transplant grafts can be isolated or combined with the liver/duodenum/pancreas. Organ Procurement and Transplantation Network (OPTN) has defined intestinal donor criteria. Living donor intestinal transplant (LDIT) has the advantages of optimal timing, short ischemia time and good human leukocyte antigen matching contributing to lower postoperative complications in the recipient. Thoracic epidurals provide excellent analgesia for the donors, as well as recipients. Recipient management can be challenging. Thrombosis and obstruction of venous access maybe common due to prolonged parenteral nutrition and/or hypercoaguability. Thromboelastography (TEG) is helpful for managing intraoperative product therapy or thrombosis. Large fluid shifts and electrolyte disturbances may occur due to massive blood loss, dehydration, third spacing etc. Intestinal grafts are susceptible to warm and cold ischemia and ischemia-reperfusion injury (IRI). Post-reperfusion syndrome is common. Cardiac or pulmonary clots can be monitored with transesophageal echocardiography (TEE) and treated with recombinant tissue plasminogen activator. Vasopressors maybe used to ensure stable hemodynamics. Post-intestinal transplant patients may need anesthesia for procedures such as biopsies for surveillance of rejection, bronchoscopy, endoscopy, postoperative hemorrhage, anastomotic leaks, thrombosis of grafts etc. Asepsis, drug interactions between anesthetic and immunosuppressive agents and venous access are some of the anesthetic considerations for this group.

Patients with immunodeficiency

Patients presenting in an immunocompromised state merit special consideration when being evaluated for fitness to undergo surgery. A variety of immunodeficient conditions and their respective therapies, including human immunodeficiency virus, cancer, and transplantation, exert numerous systemic effects that may lead to multiorgan dysfunction. Understanding the potential impact of these disease manifestations, and their proper evaluation, is essential in achieving optimal perioperative outcomes for these patients.

Preoperative assesment of the immunocompromised patient

In some surgical patients immunosuppression is easily apparent and directly caused by known underlying disease or treatment. In others, although induced by the underlying disease, immunosuppression may be less obvious. Perioperative management of immunocompromised patient is mostly directed by the fact that immunosuppression itself does not cause pathology, but does leave the patient prone to infection. Immunodeficiency can be broadly characterized as congenital (primary) or acquired (secondary). The majority of immune deficiencies that are of interest to the anaesthetist are acquired. They can be present both in children and adults, in a huge variety of patients that are presented preoperatively. Most of them do not require different than usual perioperative anaesthetic management. However, in some of them specific aspects of treatment should be considered, such as HIV infected, cancer, transplant patients, and those scheduled for organ transplantation.

[Perioperative management of long-term medication]

Anesthesiologists and surgeons are increasingly faced with patients who are under long-term medication. Some of these drugs can interact with anaesthetics or anaesthesia and/or surgical interventions. As a result, patients may experience complications such as bleeding, ischemia, infection or severe circulatory reactions. On the other hand, perioperative discontinuation of medication is often more dangerous. The proportion of outpatient operations has increased dramatically in recent years and will probably continue to increase. Since the implementation of DRGs (pending in Switzerland, introduced in Germany for some time), the patient enters the hospital the day before operation. This means that the referring physician as well as anesthesiologists and surgeons at an early stage must deal with issues of perioperative pharmacotherapy. This review article is about the management of the major drug classes during the perioperative period. In addition to cardiac and centrally acting drugs and drugs that act on hemostasis and the endocrine system, special cases such as immunosuppressants and herbal remedies are mentioned.