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Moguilevitch M, Polaner DM, Mann G, Mauner A, Beagley B, Hendrickse A, Stoll WD, DeMarchi L, Damian D, Sridhar S, Costandi A, Tran L, Jorge LM, Mandell MS. A comparison of pediatric liver transplant anesthesia practices with new organ procurement and transplant network pediatric policy requirements: A report from the society for the advancement of transplant anesthesia and the society for pediatric anesthesia. Clin Transplant 2022; 36:e14672. [PMID: 35443083 DOI: 10.1111/ctr.14672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/17/2022] [Accepted: 04/09/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Organ Procurement and Transplant Network (OPTN) pediatric policies on knowledge and skill requirements for key personnel failed to address the Director of Anesthesia for Pediatric Liver Transplantation. A Joint Committee representing the Society for the Advancement of Transplant Anesthesia and Society for Pediatric Anesthesia (SPA) surveyed all pediatric anesthesia liver transplant practices to determine if practices were aligned with policies and what changes would be needed for compliance. METHODS A survey of the Director or equivalent at each program collected data about specialized knowledge and skill sets. Questions focused on (1) skill and knowledge of the Director and team, (2) requirements for appointment, (3) experience in pediatrics, and (4) characteristics of the program including the availability of pediatric resources. RESULTS Response rate was 73% (n = 63). Most responding programs had a Director (67%) with certification, selection committee, and continuing education credits outlined in existing policies. Team members met similar requirements. Alternate pathways for acquiring knowledge and skill sets were identified between programs. CONCLUSIONS Pediatric liver transplant anesthesiologists use knowledge and skill pathways that align with the new pediatric policies. We suggest that collaborative work with oversight agencies is needed to resolve high case volume requirements originally designed for adult programs. SUMMARY Most pediatric liver transplant anesthesiologists in the US have specialized knowledge and skills for expert care consistent with current oversight policies. Differences in pathways to acquire knowledge and skill sets were still aligned with the new policies for pediatric transplant surgeons and bylaws for the Director of Transplant Anesthesia. We conclude that minimal changes in case volume requirements to the existing Pediatric Transplant Anesthesiology Directorship criteria that authenticates the pediatric anesthesia Director's position would improve the safety of care without limiting access to transplantation.
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Affiliation(s)
- Marina Moguilevitch
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David M Polaner
- Department of Anesthesiology and Pain Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Glenn Mann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Aaron Mauner
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
| | - Britni Beagley
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
| | - William D Stoll
- Department of Anesthesiology, Medical University of South Carolina, Charlottesville, South Carolina, USA
| | - Lorenzo DeMarchi
- Department of Anesthesiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Daniela Damian
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Srikanth Sridhar
- Department of Anesthesiology, McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Andrew Costandi
- Department of Anesthesiology Critical Care Medicine, Children's hospital Los Angeles, Keck School of Medicine, Los Angeles, California, USA
| | - Lieu Tran
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lydia M Jorge
- Department of Anesthesiology, Jackson Health System, University of Miami, Miami, Florida, USA
| | - M Susan Mandell
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, USA
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Souki FG, Chadha R, Planinsic R, Zerillo J, Nguyen-Buckley C, Smith N, Mandell MS, Sakai T, Nicolau-Raducu R. Recommendations From the Society for the Advancement of Transplant Anesthesiology Fellowship Committee: Core Competencies and Milestones for the Kidney/Pancreas Component of Abdominal Organ Transplant Anesthesia Fellowship. Semin Cardiothorac Vasc Anesth 2021; 26:15-26. [PMID: 34872395 DOI: 10.1177/10892532211058574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Society for the Advancement of Transplant Anesthesia (SATA) is dedicated to improving patient care in all facets of transplant anesthesia. The anesthesia fellowship training recommendations for thoracic transplantation (heart and lungs) and part of the abdominal organ transplantation (liver) have been presented in previous publications. The SATA Fellowship Committee has completed the remaining component of abdominal transplant anesthesia (kidney/pancreas) and has assembled core competencies and milestones derived from expert consensus to guide the education and overall preparation of trainees providing care for kidney/pancreas transplant recipients. These recommendations provide a comprehensive approach to pre-operative evaluation, vascular access procedures, advanced hemodynamic monitoring, assessment of coagulation and metabolic abnormalities, operative techniques, and post-operative pain control. As such, this document supplements the current liver/hepatic transplant anesthesia fellowship training programs to include all aspects of "Abdominal Organ Transplant Anesthesia" recommended knowledge.
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Affiliation(s)
- Fouad G Souki
- Department of Anesthesiology, 12235University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Ryan Chadha
- Department of Anesthesiology, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Raymond Planinsic
- Department of Anesthesiology, 6595University of Pittsburgh Medical Center, Pittsburgh, AR, USA
| | - Jeron Zerillo
- Department of Anesthesiology, 5944Mount Sinai Medical Center, New York, NY, USA
| | | | - Natalie Smith
- Department of Anesthesiology, 5944Mount Sinai Medical Center, New York, NY, USA
| | - M Susan Mandell
- Department of Anesthesiology, 129263University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Tetsuro Sakai
- Department of Anesthesiology, 6595University of Pittsburgh Medical Center, Pittsburgh, AR, USA
| | - Ramona Nicolau-Raducu
- Department of Anesthesiology, 12235University of Miami, Jackson Memorial Hospital, Miami, FL, USA
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Mandell MS, Sakai T, Wagener G, De Marchi L, Subramaniam K, JHuang J, Hendrickse A, Deshpande R, Ryan C, Pretto EA. The Society for the Advancement of Transplant Anesthesia (SATA) enters a new partnership with Clinical Transplantation. Clin Transplant 2021; 35:e14203. [PMID: 33475197 DOI: 10.1111/ctr.14203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Anschutz Medical Center, Denver, CO, USA
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Lorenzo De Marchi
- Department of Anesthesiology, MedStar-Georgetown University Hospital, Washington, DC, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jiapeng JHuang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Anschutz Medical Center, Denver, CO, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Chadha Ryan
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| | - Ernesto A Pretto
- Department of Anesthesiology and Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL, USA
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Smith NK, Zerillo J, Kim SJ, Efune GE, Wang C, Pai SL, Chadha R, Kor TM, Wetzel DR, Hall MA, Burton KK, Fukazawa K, Hill B, Spad MA, Wax DB, Lin HM, Liu X, Odeh J, Torsher L, Kindscher JD, Mandell MS, Sakai T, DeMaria S. Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States. Anesth Analg 2021; 132:130-139. [PMID: 32167977 DOI: 10.1213/ane.0000000000004734] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.
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Affiliation(s)
- Natalie K Smith
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jeron Zerillo
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Sang Jo Kim
- Department of Anesthesiology, Hospital for Special Surgery, New York City, New York
| | - Guy E Efune
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cynthia Wang
- Department of Anesthesiology, Greater Los Angeles VA Healthcare System, Los Angeles, California
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Todd M Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - David R Wetzel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Hall
- Department of Anesthesiology, Christiana Care Health System, Newark, Delaware
| | - Kristen K Burton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kyota Fukazawa
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Bryan Hill
- Department of Anesthesiology, The Ohio State University, Columbus, Ohio
| | | | - David B Wax
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Xiaoyu Liu
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jaffer Odeh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laurence Torsher
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - James D Kindscher
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - M Susan Mandell
- Department of Anesthesiology, University of Colorado Hospital, Aurora, Colorado.,The Center for Perioperative & Pain Quality, Safety and Outcomes-PPQiSO, University of Washington Medical Center, Seattle, Washington
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samuel DeMaria
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
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Affiliation(s)
- Wai-Kay Seto
- Department of Medicine, The University of Hong Kong and The University of Hong Kong-Shenzhen Hospital, Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
- * E-mail:
| | - M. Susan Mandell
- Department of Anaesthesiology, University of Colorado, Aurora, Colorado, United States of America
- National Yang Ming University, Taipei, Taiwan
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Subramaniam K, Rio JMD, Wilkey BJ, Kumar A, Tawil JN, Subramani S, Tani M, Sanchez PG, Mandell MS. Anesthetic management of lung transplantation: Results from a multicenter, cross-sectional survey by the society for advancement of transplant anesthesia. Clin Transplant 2020; 34:e13996. [PMID: 32484978 DOI: 10.1111/ctr.13996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/27/2020] [Accepted: 05/22/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Current protocols for the perioperative care of lung transplant (LTX) recipients lack rigorous evidence and are often empiric, based upon institutional preferences. We surveyed LTX anesthesiologists to determine the most common practices. METHODS We developed a survey of 40 questions regarding perioperative care of LTX recipients using Qualtrics software. The survey was sent out to members of the Society of Cardiovascular Anesthesiologists performing LTX at geographically diverse sites to facilitate data collection for as many practices as possible. RESULTS The responses were center-weighed (127 responses, 85% from academic settings). The clamshell approach was commonly used (70%). Cardiopulmonary bypass was preferred by 56%, ex vivo lung perfusion utilized by 43%, and 49.4% indicated they use lungs from donation after circulatory determination of death. Most (69%) used oximetric pulmonary artery catheters, 60% used tissue oximetry, and 89.3% utilized transesophageal echocardiography. Inhaled nitric oxide was preferred by 48%, restrictive fluid management by 48%, and systemic analgesia advocated by 49% of participants. Inspired oxygen concentration <30% was applied to the new lung on reperfusion by 28% of the respondents. CONCLUSION Variations in healthcare delivery and utilization for LTX recipients indicate gaps in knowledge and potential opportunities to improve the quality of care.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Barbara J Wilkey
- Department of Anesthesiology, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Akshay Kumar
- Medanta Super specialty Hospital, Gurgaon, New Delhi, India
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Medical Center, Iowa city, Iowa, USA
| | - Makiko Tani
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - M Susan Mandell
- Department of Anesthesiology, University of Colorado School of Medicine, Denver, Colorado, USA
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7
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Hendrickse A, Crouch C, Sakai T, Stoll WD, McNulty M, Pivalizza E, Sridhar S, Diaz G, Sheiner P, Nevah Rubin MI, Al-Khafaji A, Pomposelli J, Mandell MS. Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations. Liver Transpl 2020; 26:582-590. [PMID: 31883291 DOI: 10.1002/lt.25711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/13/2019] [Indexed: 12/13/2022]
Abstract
There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.
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Affiliation(s)
| | - Cara Crouch
- Department of Anesthesiology, University of Colorado, Aurora, CO
| | - Tetsuro Sakai
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - William D Stoll
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC
| | - Monica McNulty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado, Aurora, CO
| | - Evan Pivalizza
- Department of Anesthesiology, UTHealth McGovern Medical School, Houston, TX
| | - Srikanth Sridhar
- Department of Anesthesiology, UTHealth McGovern Medical School, Houston, TX
| | - Geraldine Diaz
- Department of Anesthesiology, SUNY Downstate Medical Center, State University of New York, Brooklyn, NY
| | | | | | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - M Susan Mandell
- Department of Anesthesiology, University of Colorado, Aurora, CO
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Li W, Huang J, Guo X, Zhao J, Mandell MS. Anesthesia Management and Perioperative Infection Control in Patients With the Novel Coronavirus. J Cardiothorac Vasc Anesth 2020; 35:1503-1508. [PMID: 32279934 PMCID: PMC7146651 DOI: 10.1053/j.jvca.2020.03.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/18/2020] [Indexed: 11/11/2022]
Abstract
Anesthesiologists have a high risk of infection with COVID-19 during perioperative care and as first responders to airway emergencies. The potential of becoming infected can be reduced by a systematic and integrated approach that assesses infection risk. The latter leads to an acceptable choice of materials and techniques for personal protection and prevention of cross-contamination to other patients and staff. The authors have presented a protocolized approach that uses diagnostic criteria to clearly define benchmarks from the medical history along with clinical symptoms and laboratory tests. Patients can then be rapidly assigned into 1 of 3 risk categories that direct the choice of protective materials and/or techniques. Each hospital can adapt this approach to develop a system that fits its individual resources. Educating medical staff about the proper use of high-risk areas for containment serves to protect staff and patients.
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Affiliation(s)
- Weixia Li
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | | | | | - Jing Zhao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China.
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9
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Mandell MS, Huang J, Zhao J. Enhanced recovery after surgery and practical application to liver transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:119-127. [PMID: 32334782 DOI: 10.1016/j.bpa.2020.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 12/13/2022]
Abstract
There is a growing support for the use of protocols that incorporate multiple steps aimed at reducing the time patients require to regain health. A recurring limitation is the variable outcomes of these protocols with more or less success at the sites at which they are instituted. This review examines the essential building blocks needed to launch a successful ERAS protocol. It addresses why there are differences in outcome measures between centers such as the length of stay and the cost of care even if the protocols and patient populations are similar.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado, CO, USA
| | - Jiapeng Huang
- Department of Anesthesiology, University of Louisville, Louisville, KY, USA
| | - Jing Zhao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China.
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Nguyen-Buckley C, Wray CL, Zerillo J, Gilliland S, Aniskevich S, Nicolau-Raducu R, Planinsic R, Srinivas C, Pretto EA, Mandell MS, Chadha RM. Recommendations From the Society for the Advancement of Transplant Anesthesiology: Liver Transplant Anesthesiology Fellowship Core Competencies and Milestones. Semin Cardiothorac Vasc Anesth 2019; 23:399-408. [DOI: 10.1177/1089253219868918] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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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Crouch C, Hendrickse A, Gilliland S, Mandell MS. Unexpected Complication of Hydroxocobalamin Administration for Refractory Vasoplegia in Orthotopic Liver Transplant: A Case Report. Semin Cardiothorac Vasc Anesth 2019; 23:409-412. [PMID: 30985242 DOI: 10.1177/1089253219842662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 40-year-old male with alcoholic cirrhosis and end-stage renal disease presented for simultaneous liver and kidney transplantation. Hemodialysis was utilized intraoperatively during liver transplantation. During the procedure, the patient developed refractory hypotension and ultimately received hydroxocobalamin for vasoplegia. Shortly after administration, the hemodialysis machine ceased working after a "blood leak" alarm developed. Without the ability to continue intraoperative dialysis, the kidney transplantation portion of his surgery was postponed. The patient was transferred to the intensive care unit, where he underwent continuous renal replacement therapy overnight, and his kidney transplant proceeded the following morning.
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Affiliation(s)
- Cara Crouch
- University of Colorado Hospital, Aurora, CO, USA
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12
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Zerillo J, Ramsay M, Mandell MS, Sakai T. An Update in Abdominal Organ Transplantation Anesthesia in 2018: Society for the Advancement of Transplant Anesthesia (SATA). Semin Cardiothorac Vasc Anesth 2018; 22:109-110. [PMID: 29701539 DOI: 10.1177/1089253218768558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - M Susan Mandell
- 3 University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tetsuro Sakai
- 4 University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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13
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Biancofiore G, Tomescu DR, Mandell MS. Rapid Recovery of Liver Transplantation Recipients by Implementation of Fast-Track Care Steps: What Is Holding Us Back? Semin Cardiothorac Vasc Anesth 2018; 22:191-196. [PMID: 29488444 DOI: 10.1177/1089253218761124] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A body of scientific studies has shown that early extubation is safe and cost-effective in a large number of liver transplant (LT) recipients including pediatric patients. However, fast-track practices are not universally accepted, and debate still lingers about whether these interventions are safe and serve the patients' best interest. In this article, we focus on reasons why physicians still have a persistent, although diminishing, reluctance to adopt fast-track protocols. We stress the importance of collection/analysis of perioperative data, adoption of a consensus-based standardized protocol for perioperative care, and formation of LT anesthesia focused teams and leadership. We conclude that the practice of early extubation and fast-tracking after LT surgery could help improve anesthesia performance, safety, and cost-effectiveness.
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14
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Zerillo J, Hill B, Kim S, DeMaria S, Mandell MS. Use, Training, and Opinions About Effectiveness of Transesophageal Echocardiography in Adult Liver Transplantation Among Anesthesiologists in the United States. Semin Cardiothorac Vasc Anesth 2018; 22:137-145. [DOI: 10.1177/1089253217750754] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Study Objective. Describe transesophageal echocardiography (TEE) use, preparatory training and opinions about clinical importance, and future training pathways in a sample of liver transplant anesthesiologists. Design. Online survey questionnaire. Setting. Liver Transplant Centers in the United States. Participants. Director of Liver Transplant Anesthesia or designated alternate respondent. Results. A total of 79 Directors or alternates from 111 (71%) centers were identified. There were 56 responses (71%) representing 433 transplant anesthesiologists who cared for 63.3% of liver transplant cases performed in 2015. Basic TEE certification was reported more frequently (64%) than advanced (53.6%). At least one team member used TEE in over 90% of responding centers. Most respondents (83.9%) agreed TEE provided unique and valuable clinical information but were equally divided about future training pathways (on the job learning vs basic TEE certification). Conclusion. TEE use in liver transplantation is growing with a substantial increase in basic TEE certified users. Transplant anesthesiologists support basic certification but an equal number believe there should be more applied training at the site of care.
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Affiliation(s)
- Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan Hill
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sang Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Chadha RM, Crouch C, Zerillo J, Pretto EA, Planinsic R, Kim S, Nicolau-Raducu R, Adelmann D, Elia E, Wray CL, Srinivas C, Mandell MS. Society for the Advancement of Transplant Anesthesia: Liver Transplant Anesthesia Fellowship—White Paper Advocating Measurable Proficiency in Transplant Specialties Training. Semin Cardiothorac Vasc Anesth 2017; 21:352-356. [DOI: 10.1177/1089253217737043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The anesthesia community has openly debated if the care of transplant patients was generalist or specialist care ever since the publication of an opinion paper in 1999 recommended subspecialty training in the field of liver transplantation anesthesia. In the past decade, liver transplant anesthesia has become more complex with a sicker patient population and evolving evidence-based practices. Transplant training is currently not required for accreditation or certification in anesthesiology, and not all anesthesia residency programs are associated with transplant centers. Yet there is evidence that patient outcome is affected by the experience of the anesthesiologist with liver transplants as part of a multidisciplinary care team. Requests for a formal review of the inequities in training opportunities and requirements led the Society for the Advancement for Transplant Anesthesia (SATA) to begin the task of developing post-graduate fellowship training recommendations. In this article, members of the SATA Working Group on Transplant Anesthesia Education present their reasoning for specialized education and conclusions about which pathways can better prepare trainees to care for complex transplant patients.
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Affiliation(s)
| | - Cara Crouch
- University of Colorado Hospital, Aurora, CO, USA
| | - Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Sang Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Elia Elia
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
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DiMartini A, Dew MA, Liu Q, Simpson MA, Ladner DP, Smith AR, Zee J, Abbey S, Gillespie BW, Weinrieb R, Mandell MS, Fisher RA, Emond JC, Freise CE, Sherker AH, Butt Z. Social and Financial Outcomes of Living Liver Donation: A Prospective Investigation Within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2). Am J Transplant 2017; 17:1081-1096. [PMID: 27647626 PMCID: PMC5359081 DOI: 10.1111/ajt.14055] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/04/2016] [Accepted: 09/07/2016] [Indexed: 01/25/2023]
Abstract
Because results from single-center (mostly kidney) donor studies demonstrate interpersonal relationship and financial strains for some donors, we conducted a liver donor study involving nine centers within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2) consortium. Among other initiatives, A2ALL-2 examined the nature of these outcomes following donation. Using validated measures, donors were prospectively surveyed before donation and at 3, 6, 12, and 24 mo after donation. Repeated-measures regression models were used to examine social relationship and financial outcomes over time and to identify relevant predictors. Of 297 eligible donors, 271 (91%) consented and were interviewed at least once. Relationship changes were positive overall across postdonation time points, with nearly one-third reporting improved donor family and spousal or partner relationships and >50% reporting improved recipient relationships. The majority of donors, however, reported cumulative out-of-pocket medical and nonmedical expenses, which were judged burdensome by 44% of donors. Lower income predicted burdensome donation costs. Those who anticipated financial concerns and who held nonprofessional positions before donation were more likely to experience adverse financial outcomes. These data support the need for initiatives to reduce financial burden.
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Affiliation(s)
- A DiMartini
- Department of Psychiatry, University of Pittsburgh, Pittsburgh PA, USA,Department of Surgery, University of Pittsburgh, Pittsburgh PA, USA
| | - MA Dew
- Department of Psychiatry, University of Pittsburgh, Pittsburgh PA, USA,Department of Psychology, University of Pittsburgh, Pittsburgh PA, USA,Department of Epidemiology, University of Pittsburgh, Pittsburgh PA, USA,Department of Biostatistics, University of Pittsburgh, Pittsburgh PA, USA
| | - Q Liu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - MA Simpson
- Lahey Hospital and Medical Center Clinical Research and Education, Burlington, MA, USA,Department of Transplantation, Burlington, MA, USA
| | - DP Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Chicago, IL, USA,Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA
| | - AR Smith
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA,Departments of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - J Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - S Abbey
- Department of Psychiatry, University of Toronto and University Health Network, Toronto ON, CA
| | - BW Gillespie
- Departments of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - R Weinrieb
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - MS Mandell
- Department of Anesthesiology, University of Colorado, Denver CO, USA
| | - RA Fisher
- Department of Transplant Surgery, Virginia Commonwealth University, Richmond, VA, USA (current affiliation, Beth Israel Deaconess Department of Surgery, Harvard University)
| | - JC Emond
- Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - CE Freise
- Department of Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - AH Sherker
- Liver Diseases Research Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Z Butt
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Chicago, IL, USA,Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA,Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago IL, USA,Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago IL, USA
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Rajakumar A, Kaliamoorthy I, Rela M, Mandell MS. Small-for-Size Syndrome: Bridging the Gap Between Liver Transplantation and Graft Recovery. Semin Cardiothorac Vasc Anesth 2017; 21:252-261. [DOI: 10.1177/1089253217699888] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In living donor liver transplantation, optimal graft size is estimated from values like graft volume/standard liver volume and graft/recipient body weight ratio but the final functional hepatic mass is influenced by other donor and recipient factors. Grafts with insufficient functional hepatic mass can produce a life-threatening condition with rapidly progressive liver failure called small-for-size syndrome (SFSS). Diagnosis of SFSS requires careful surveillance for signs of inadequate hepatocellular function, residual portal hypertension, and systemic inflammation that suggest rapidly progressive liver failure. Early diagnosis, symptom control, and addressing the cause of SFSS may prevent the need for retransplantation. With increased attention to avoiding donor risk, intensivists will be confronted with more SFSS recipients. In this review, we aim to outline a systematic approach to the medical management of patients with SFSS by providing a concise synopsis of general supportive care—neurological, cardiovascular, and renal support, mechanical ventilation, nutritional support, infection control, and tailored immunosuppression—with an aim to avoid end-organ damage or death and a review of current interventions including liver support devices, portal flow modulating drugs, and other experimental interventions that aim to preserve existing hepatic mass and improve conditions for hepatic regeneration. We examine evidence for SFSS interventions to provide the reader with information that may assist in clinical decision making. Points of controversy in care are purposefully highlighted to identify areas where additional experimental work is still needed. A full understanding of the pathophysiology of SFSS and measures to support liver regeneration will guide effective management.
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Affiliation(s)
| | - Tetsuro Sakai
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Mandell MS, Smith AR, Dew MA, Gordon DB, Holtzman S, Howell T, DiMartini AF, Butt Z, Simpson MA, Ladner DP, Freise CE, McCluskey SA, Fisher RA, Guarrera JV, Olthoff KM, Pomfret EA. Early Postoperative Pain and its Predictors in the Adult to Adult Living Donor Liver Transplantation Cohort Study. Transplantation 2016; 100:2362-2371. [PMID: 27517726 PMCID: PMC5077637 DOI: 10.1097/tp.0000000000001442] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Little is known about how well postoperative pain is managed in living liver donors, despite pain severity being the strongest predictor of persistent pain with long-lasting disability. METHODS We conducted a prospective multicenter study of 172 living liver donors. Self-reported outcomes for pain severity, activity interference, affective (emotional) reactions, adverse effects to treatment, and perceptions of care were collected using the American Pain Society Patient Outcomes Questionnaire-Revised. Mixed-effects linear regression was used to identify demographic and psychosocial predictors of subscale scores. RESULTS Donors were young (36.8 ± 10.6) and healthy. Of 12 expert society analgesic recommendations for postoperative pain management, 49% received care conforming to 3 guidelines, and only 9% to 4 or 5. More than half reported adverse effects to analgesic treatment for moderate to severe pain that interfered with functional activity; however, emotional distress to pain was unexpectedly minimal. Female donors had higher affective (β = 0.88, P = 0.005) and adverse effects scores (β = 1.33, P < 0.001). Donors with 2 or more medical concerns before surgery averaged 1 unit higher pain severity, functional interference, adverse effects, and affective reaction subscale scores (β range 1.06-1.55, all P < 0.05). Receiving information about pain treatment options increased perception of care subscale scores (β = 1.24, P = 0.001), whereas depressive symptoms before donation were associated with lower scores (β = -1.58, P = 0.01). CONCLUSIONS Donors have a distinct profile of pain reporting that is highly influenced by psychological characteristics. Interventions to improve pain control should consider modifying donor behavioral characteristics in addition to optimizing pain care protocols.
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Affiliation(s)
| | - Abigail R. Smith
- Department of Biostatistics, University of Michigan
- Arbor Research Collaborative for Health, University of Pittsburgh
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh
- Department of Psychology, University of Pittsburgh
- Department of Epidemiology, University of Pittsburgh
- Department of Biostatistics, University of Pittsburgh
| | | | - Susan Holtzman
- Department of Psychology, University of British Columbia
| | | | - Andrea F. DiMartini
- Department of Psychiatry, University of Pittsburgh
- Department of Surgery, University of Pittsburgh
| | - Zeeshan Butt
- Department of Medical Social Sciences, Northwestern University
| | | | - Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Robert A. Fisher
- Department of Transplant Surgery, Virginia Commonwealth University, Richmond, VA (current affiliation, Beth Israel Deaconess Department of Surgery, Harvard University)
| | - James V. Guarrera
- Department of Surgery, Columbia University College of Physicians and Surgeons
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21
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Chirichella TJ, Dunham CM, Zimmerman MA, Phelan EM, Mandell MS, Conzen KD, Kelley SE, Nydam TL, Bak TE, Kam I, Wachs ME. Donor preoperative oxygen delivery and post-extubation hypoxia impact donation after circulatory death hypoxic cholangiopathy. World J Gastroenterol 2016; 22:3392-3403. [PMID: 27022221 PMCID: PMC4806197 DOI: 10.3748/wjg.v22.i12.3392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 10/06/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate donation after circulatory death (DCD) orthotopic liver transplant outcomes [hypoxic cholangiopathy (HC) and patient/graft survival] and donor risk-conditions.
METHODS: From 2003-2013, 45 DCD donor transplants were performed. Predonation physiologic data from UNOS DonorNet included preoperative systolic and diastolic blood pressure, heart rate, pH, SpO2, PaO2, FiO2, and hemoglobin. Mean arterial blood pressure was computed from the systolic and diastolic blood pressures. Donor preoperative arterial O2 content was computed as [hemoglobin (gm/dL) × 1.37 (mL O2/gm) × SpO2%) + (0.003 × PaO2)]. The amount of preoperative donor red blood cell transfusions given and vasopressor use during the intensive care unit stay were documented. Donors who were transfused ≥ 1 unit of red-cells or received ≥ 2 vasopressors in the preoperative period were categorized as the red-cell/multi-pressor group. Following withdrawal of life support, donor ischemia time was computed as the number-of-minutes from onset of diastolic blood pressure < 60 mmHg until aortic cross clamping. Donor hypoxemia time was the number-of-minutes from onset of pulse oximetry < 80% until clamping. Donor hypoxia score was (ischemia time + hypoxemia time) ÷ donor preoperative hemoglobin.
RESULTS: The 1, 3, and 5 year graft and patient survival rates were 83%, 77%, 60%; and 92%, 84%, and 72%, respectively. HC occurred in 49% with 16% requiring retransplant. HC occurred in donors with increased age (33.0 ± 10.6 years vs 25.6 ± 8.4 years, P = 0.014), less preoperative multiple vasopressors or red-cell transfusion (9.5% vs 54.6%, P = 0.002), lower preoperative hemoglobin (10.7 ± 2.2 gm/dL vs 12.3 ± 2.1 gm/dL, P = 0.017), lower preoperative arterial oxygen content (14.8 ± 2.8 mL O2/100 mL blood vs 16.8 ± 3.3 mL O2/100 mL blood, P = 0.049), greater hypoxia score >2.0 (69.6% vs 25.0%, P = 0.006), and increased preoperative mean arterial pressure (92.7 ± 16.2 mmHg vs 83.8 ± 18.5 mmHg, P = 0.10). HC was independently associated with age, multi-pressor/red-cell transfusion status, arterial oxygen content, hypoxia score, and mean arterial pressure (r2 = 0.6197). The transplantation rate was greater for the later period with more liberal donor selection [era 2 (7.1/year)], compared to our early experience [era 1 (2.5/year)]. HC occurred in 63.0% during era 2 and in 29.4% during era 1 (P = 0.03). Era 2 donors had longer times for extubation-to-asystole (14.4 ± 4.7 m vs 9.3 ± 4.5 m, P = 0.001), ischemia (13.9 ± 5.9 m vs 9.7 ± 5.6 m, P = 0.03), and hypoxemia (16.0 ± 5.1 m vs 11.1 ± 6.7 m, P = 0.013) and a higher hypoxia score > 2.0 rate (73.1% vs 28.6%, P = 0.006).
CONCLUSION: Easily measured donor indices, including a hypoxia score, provide an objective measure of DCD liver transplantation risk for recipient HC. Donor selection criteria influence HC rates.
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Gong CSA, Lin SP, Mandell MS, Tsou MY, Chang Y, Ting CK. Portable optical epidural needle-a CMOS-based system solution and its circuit design. PLoS One 2014; 9:e106055. [PMID: 25162150 PMCID: PMC4146568 DOI: 10.1371/journal.pone.0106055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 07/26/2014] [Indexed: 11/19/2022] Open
Abstract
Epidural anesthesia is a common anesthesia method yet up to 10% of procedures fail to provide adequate analgesia. This is usually due to misinterpreting the tactile information derived from the advancing needle through the complex tissue planes. Incorrect placement also can cause dural puncture and neural injury. We developed an optic system capable of reliably identifying tissue planes surrounding the epidural space. However the new technology was too large and cumbersome for practical clinical use. We present a miniaturized version of our optic system using chip technology (first generation CMOS-based system) for logic functions. The new system was connected to an alarm that was triggered once the optic properties of the epidural were identified. The aims of this study were to test our miniaturized system in a porcine model and describe the technology to build this new clinical tool. Our system was tested in a porcine model and identified the epidural space in the lumbar, low and high thoracic regions of the spine. The new technology identified the epidural space in all but 1 of 46 attempts. Experimental results from our fabricated integrated circuit and animal study show the new tool has future clinical potential.
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Affiliation(s)
- Cihun-Siyong Alex Gong
- Department of Electrical Engineering, School of Electrical and Computer Engineering, College of Engineering, Chang Gung University, Taoyuan, Taiwan
- Portable Energy System Group, Green Technology Research Center, College of Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - M. Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Aurora, Colorado, United States of America
| | - Mei-Yung Tsou
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Yin Chang
- Institute of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan
| | - Chien-Kun Ting
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
- * E-mail:
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Mandell MS, Pomfret EA, Steadman R, Hirose R, Reich DJ, Schumann R, Walia A. Director of anesthesiology for liver transplantation: existing practices and recommendations by the United Network for Organ Sharing. Liver Transpl 2013; 19:425-30. [PMID: 23447113 DOI: 10.1002/lt.23610] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 12/23/2012] [Indexed: 02/07/2023]
Abstract
A new Organ Procurement and Transplantation Network/United Network for Organ Sharing bylaw recommends that all centers appoint a director of liver transplant anesthesia with a uniform set of criteria. We obtained survey data from the Liver Transplant Anesthesia Consortium so that we could compare existing criteria for a director in the United States with the current recommendations. The data set included responses from adult academic liver transplant programs before the new bylaw. The respondent rates were within statistical limits to exclude sampling bias. All centers had a director of liver transplant anesthesia. The criteria varied between institutions, and the data suggest that the availability of resources influenced the choice of criteria. The information suggests that the criteria used in the new bylaw reflect existing practices. The bylaw plays an important role in supporting emerging leadership roles in liver transplant anesthesia and brings greater uniformity to the directorship position.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Aurora, CO 80045, USA.
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Wang SC, Teng WN, Chang KY, Susan Mandell M, Ting CK, Chu YC, Loong CC, Chan KH, Tsou MY. Fluid management guided by stroke volume variation failed to decrease the incidence of acute kidney injury, 30-day mortality, and 1-year survival in living donor liver transplant recipients. J Chin Med Assoc 2012; 75:654-9. [PMID: 23245482 DOI: 10.1016/j.jcma.2012.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 05/30/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Low central venous pressure (CVP) produced by fluid restriction has been applied to liver transplant recipients in order to decrease blood loss. However, CVP is not reliable for monitoring intravascular volume and ventricular filling. In addition, doubts remain over the association between fluid restriction and acute kidney injury (AKI). We tested the utility of stroke volume variation (SVV), derived from the FloTrac/Vigileo system, as a decision-making tool in fluid management. We examined the differences in fluid administration, urine output, postoperative AKI, and 30-day and 1-year survival rates between liver transplant recipients with fluid management guided by SVV and CVP. METHODS We retrospectively collected data on our liver transplant recipients with a Model for End-stage Liver Disease score less than 30 and serum creatinine lower than 1.5 mg/dL from 2007 to 2010. Recipients in 2007 and 2008 who received CVP-guided fluid management served as the control group. Recipients in 2009 and 2010 who received fluid administration triggered by SVV were recruited as the study group. The estimated blood loss, urine output, and fluid administered during the operation were recorded. Renal function was assessed using the RIFLE criteria on postoperative days 1 and 5. We also recorded the 30-day and 1-year survival. RESULTS Significantly more diuretic use and urine output were noted in the control group in spite of similar fluid administration. However, there was no significant difference in blood loss, AKI, or 30-day and 1-year survival rates. CONCLUSION The outcomes of living donor liver transplant patients who had fluid therapy guided by an SVV less than 10% were similar to those of patients who were given fluids to reach a CVP of 10 mmHg. Our findings suggest that the two measures of vascular filling are similar in liver transplant recipients with demographic characteristics similar to those of our patients.
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Affiliation(s)
- Shen-Chih Wang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Wang SC, Lin HT, Chang KY, Mandell MS, Ting CK, Chu YC, Loong CC, Chan KH, Tsou MY. Use of higher thromboelastogram transfusion values is not associated with greater blood loss in liver transplant surgery. Liver Transpl 2012; 18:1254-8. [PMID: 22730210 DOI: 10.1002/lt.23494] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Plasma-containing products are given during the pre-anhepatic stage of liver transplant surgery to correct abnormal thromboelastogram (TEG) values and prevent blood loss due to coagulation defects. However, evidence suggests that abnormal TEG results do not always predict bleeding. We questioned what effect using higher TEG values to initiate treatment would have on blood loss. A single transfusion protocol was used for all patients who underwent liver transplantation between 2007 and 2010. Thirty-eight patients received coagulation products when standard TEG cutoff values were exceeded, whereas another 39 patients received coagulation products when the TEG values were 35% greater than normal. The results of postoperative coagulation tests for total blood loss and the use of blood products were compared for the 2 groups. When the critical TEG values for transfusion were higher, significantly fewer units of fresh frozen plasma (5.58 ± 6.49 versus 11.53 ± 6.66 U) and pheresis platelets (1.84 ± 1.33 versus 3.55 ± 1.43 U) were used. There were no differences in blood loss or postoperative blood product use. In conclusion, the use of higher critical TEG values to initiate the transfusion of plasma-containing products is not associated with increased blood loss. Further testing is necessary to identify what TEG value predicts bleeding due to a deficit in coagulation factors.
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Affiliation(s)
- Shen-Chih Wang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
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Cheng SS, Berman GW, Merritt GR, Hendrickse A, Fiegel MJ, Teitelbaum I, Campsen J, Wachs M, Zimmerman M, Mandell MS. The response to methylene blue in patients with severe hypotension during liver transplantation. J Clin Anesth 2012; 24:324-8. [DOI: 10.1016/j.jclinane.2011.10.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 09/22/2011] [Accepted: 10/09/2011] [Indexed: 11/28/2022]
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Walia A, Mandell MS, Mercaldo N, Michaels D, Robertson A, Banerjee A, Pai R, Klinck J, Weinger M, Pandharipande P, Schumann R. Anesthesia for liver transplantation in US academic centers: institutional structure and perioperative care. Liver Transpl 2012; 18:737-43. [PMID: 22407934 DOI: 10.1002/lt.23427] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Investigators at a single institution have shown that the organization of the anesthesia team influences patient outcomes after liver transplant surgery. Little is known about how liver transplant anesthesiologists are organized to deliver care throughout the United States. Therefore, we collected quantitative survey data from adult liver transplant programs in good standing with national governing agencies so that we could describe team structure and duties. Information was collected from 2 surveys in a series of quantitative surveys conducted by the Liver Transplant Anesthesia Consortium. All data related to duties, criteria for team membership, interactions/communication with the multidisciplinary team, and service availability were collected and summarized. Thirty-four of 119 registered transplant centers were excluded (21 pediatric centers and 13 centers not certified by national governing agencies). Private practice sites (26) were later excluded because of a poor response rate. There were minimal changes in the compositions of the programs between the 2 surveys. All academic programs had distinct liver transplant anesthesia teams. Most had set criteria for membership and protocols outlining the preoperative evaluation, attended selection committees, and were always available for transplant surgery. Fewer were involved in postoperative care or were available for patients needing subsequent surgery. Most trends were associated with the center volume. In conclusion, some of the variance in team structure and responsibilities is probably related to resources available at the site of practice. However, similarities in specific duties across all teams suggest some degree of self-initiated specialization.
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Affiliation(s)
- Ann Walia
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Campsen J, Ray C, Zimmerman M, Mandell MS, Kaplan M, Kam I. Diagnosis and correction of hepatic vena caval obstruction following liver transplantation. Indian Journal of Transplantation 2012. [DOI: 10.1016/s2212-0017(12)60108-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lin SP, Mandell MS, Chang Y, Chen PT, Tsou MY, Chan KH, Ting CK. Discriminant analysis for anaesthetic decision-making: an intelligent recognition system for epidural needle insertion. Br J Anaesth 2011; 108:302-7. [PMID: 22157847 DOI: 10.1093/bja/aer369] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Incorrect placement of epidural catheters causes medical complications. We used linear discriminant analysis (LDA) to develop an intelligent recognition system (i-RS) in order to guide epidural placement and reduce physician error. METHODS We analysed real-time dual-wavelength fibreoptic data recorded from the end of an epidural needle in a live porcine model. Two categories of tissue layers were necessary for correct placement of catheter: epidural space and ligamentum flavum. The data were tested using linear, quadratic and logistic parametric analysis to identify which method could distinguish the two anatomical structures. RESULTS LDA was the best fit for our model. There was ∼80% sensitivity and specificity for correct anatomical identification. Error rates based on cross-validation were 17.0% for the epidural space and 18.6% for ligamentum flavum. Error rates were greater with the 532 nm compared with 650 nm wavelength. CONCLUSIONS The sensitivity and specificity of LDA for identifying the correct anatomical structure was similar to a physician who is an expert in epidural placement. Overall performance of an i-RS could be improved by expanding the database for decision-making and adding a category of uncertainty. This would reduce complications caused by incorrect epidural placement.
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Affiliation(s)
- S P Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
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Zimmerman MA, Kelly MA, Campsen J, Mandell MS, Wachs M, Bak T, Skibba A, Lancaster B, Kam I. The influence of OKT3 therapy on hepatocellular carcinoma recurrence following liver transplantation. Clin Transplant 2010; 24:E103-8. [DOI: 10.1111/j.1399-0012.2009.01179.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Mandell MS, Zimmerman M, Campsen J, Kam I. Bariatric Surgery in Liver Transplant Patients: Weighing the Evidence. Obes Surg 2008; 18:1515-6. [DOI: 10.1007/s11695-008-9712-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 09/12/2008] [Indexed: 12/23/2022]
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Mandell MS, Stoner TJ, Barnett R, Shaked A, Bellamy M, Biancofiore G, Niemann C, Walia A, Vater Y, Tran ZV, Kam I. A multicenter evaluation of safety of early extubation in liver transplant recipients. Liver Transpl 2007; 13:1557-63. [PMID: 17969193 DOI: 10.1002/lt.21263] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Small single-institutional studies performed prior to the introduction of organ allocation using the Model for End-Stage Liver Disease (MELD) suggest that early airway extubation of liver transplant recipients is a safe practice. We designed a multicenter study to examine adverse events associated with early extubation in patients selected for liver transplantation using MELD score. A total of 7 institutions extubated all patients meeting study criteria and reported adverse events that occurred within 72 hours following surgery. Adverse events were uncommon: occurring in only 7.7% of 391 patients studied. Most adverse events were pulmonary or surgically related. Pulmonary complications were usually minor, requiring only an increase in ambient oxygen concentration. The majority of surgical adverse events required additional surgery. Analysis of a limited set of perioperative variables suggest that blood transfusions and technical factors were associated with an increased risk of adverse events. In conclusion, while early extubation appears to be safe under specified circumstances, there are performance differences between institutions that remain to be explained.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO, USA.
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Mandell MS. Clinical controversies surrounding the diagnosis and treatment of hepatopulmonary syndrome. Minerva Anestesiol 2007; 73:347-55. [PMID: 17464272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a clinical syndrome which complicates liver disease but remains poorly defined. To date there is no consensus on the definition of hypoxemia or the best diagnostic test that provides evidence of intrapulmonary shunting. Furthermore, it is reasonable to question whether the role of intrapulmonary shunting has been overplayed in the etiology of HPS and if echocardiographic intrapulmonary shunts could simply be nonspecific markers of the hyperdynamic circulation of liver disease. These inquiries lend support to theories that HPS is primarily a manifestation of profound pulmonary vascular autoregulatory failure that occurs in predisposed patients. Because there is little experience with clinical interventions for HPS other than liver transplantation, there are few accepted, efficacious therapeutic options for these patients. Because liver transplantation remains the only treatment known to effectively ''treat'' HPS, many medical communities have increased the priority of HPS patients over others who are waiting for life saving organs. Until there is further evidence that effectively identifies patients with HPS and that predicts outcomes, the preferential allocation of organs to patients with suspected HPS may unjustly cause the death of others waiting for transplantation.
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Affiliation(s)
- M S Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center Denver, CO 80262, USA.
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Hendrickse A, Azam F, Mandell MS. Hepatopulmonary syndrome and portopulmonary hypertension. Curr Treat Options Cardiovasc Med 2007; 9:127-36. [PMID: 17484815 DOI: 10.1007/s11936-007-0006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The incidence of pulmonary vascular disorders is significantly increased in patients with liver disease. Intrapulmonary shunting with hypoxemia in patients with liver disease is diagnosed as hepatopulmonary syndrome (HPS), whereas precapillary pulmonary vessel obliteration is identified as portopulmonary hypertension (PPHTN). Because the symptoms of liver disease can mimic those of pulmonary vascular disease, all patients with hepatic failure should be screened for these two diseases. Pulse oximetry effectively screens for hypoxemia associated with HPS, whereas an elevated right ventricular systolic pressure estimated by echocardiography identifies patients at risk of having PPHTN. Liver transplantation is the only effective medical therapy for HPS. However, those who have a resting arterial oxygenation less than 50 mm Hg or a shunt measured by scintigraphic perfusion greater than 20% have an unacceptably high mortality rate following surgery. Compared with HPS, there are more therapeutic options that can bridge patients with PPHTN to transplantation. Drugs used to manage idiopathic pulmonary hypertension have shown promise in the treatment of PPHTN. Prostanoids, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors have improved transplant survival. Despite treatment, however, perioperative mortality for patients with PPHTN remains high. Even with successful transplantation, HPS and PPHTN can persist or develop de novo. Long-term follow-up and surveillance of liver transplant recipients is thus indicated to identify HPS and PPHTN following surgery.
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Affiliation(s)
- Adrian Hendrickse
- Department of Anesthesiology, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA
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Serkova NJ, Zhang Y, Coatney JL, Hunter L, Wachs ME, Niemann CU, Mandell MS. Early detection of graft failure using the blood metabolic profile of a liver recipient. Transplantation 2007; 83:517-21. [PMID: 17318087 PMCID: PMC2709529 DOI: 10.1097/01.tp.0000251649.01148.f8] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In this case report we describe the blood metabolic profile ("metabolomics") by nuclear magnetic resonance (NMR) spectroscopy and principle component analysis (PCA) from a patient who underwent two consecutive liver transplantations. The first graft from a living-related donor failed and was followed by a second successful transplant from a deceased donor. Using quantitative high-resolution H-NMR spectroscopy, 48 endogenous metabolites were analyzed in whole blood samples at baseline and different time points after each transplantation. From 48 analyzed metabolites, six metabolites were identified by PCA as metabolic markers consistent with a non-functional liver after first transplantation. Importantly, this distinctive metabolic profile was present as early as two hours after first transplant surgery when no other variable or conventional laboratory tests indicated poor graft function. This article reports the potential usefulness of quantitative H-NMR based metabolomics to diagnose early graft dysfunction in liver transplantation.
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Affiliation(s)
- Natalie J Serkova
- Department of Anesthesiology and Radiology, Biomedical MRI/MRS Cancer Center Core, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Mandell MS, Zamudio S, Seem D, McGaw LJ, Wood G, Liehr P, Ethier A, D'Alessandro AM. National evaluation of healthcare provider attitudes toward organ donation after cardiac death. Crit Care Med 2006; 34:2952-8. [PMID: 17075366 DOI: 10.1097/01.ccm.0000247718.27324.65] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Organ donation after cardiac death will save lives by increasing the number of transplantable organs. But many healthcare providers are reluctant to participate when the withdrawal of intensive care leads to organ donation. Prior surveys indicate ethical concerns as a barrier to the practice of organ donation after cardiac death, but the specific issues that characterize these concerns are unknown. We thus aimed to identify what barriers healthcare providers perceive. DESIGN We conducted a qualitative analysis of focus group transcripts to identify issues of broad importance. SETTING Healthcare setting. PARTICIPANTS Participants included 141 healthcare providers representing critical care and perioperative nurses, transplant surgeons, medical examiners, organ procurement personnel, neurosurgeons, and neurologists. INTERVENTIONS Collection and analysis of information regarding healthcare providers' attitudes and beliefs. MEASUREMENTS AND MAIN RESULTS All focus groups agreed that increased organ availability is a benefit but questioned the quality of organs recovered. Study participants identified a lack of standards for patient prognostication and cardiopulmonary death and a failure to prevent a conflict between patient and donor interests as obstacles to acceptance of organ donation after cardiac death. They questioned the practices and motives of colleagues who participate in organ donation after cardiac death, apprehensive that real or perceived impropriety would affect public perception. CONCLUSIONS Healthcare providers are uncomfortable at the clinical juncture where end-of-life care and organ donation interface. Our findings are consistent with theories that care providers are hesitant to perform medical tasks that they consider to be outside the focus of their practice, especially when there is potential conflict of interest. This conflict appears to impose moral distress on healthcare providers and limits acceptance of organ donation after cardiac death. Future research is warranted to examine the effect of standardized procedures on reducing moral distress. The hypothesis generated by this qualitative study is that use of neutral third parties to broach the subject of organ donation may improve acceptance of organ donation after cardiac death.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO, USA
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Abstract
Few prognostic indicators and outcomes reported for patients who have hepatopulmonary syndrome can be consistently reproduced between institutions. The lack of practice recommendations based upon consistent and predictable outcomes creates uncertainty for physicians trying to make the best patient choices. With the scarcity of donor organs, these issues are of particular importance when transplantation in considered as a treatment option. Much uncertainty arises from the basic tasks of making an accurate diagnosis in patients who have symptoms suggestive of hepatopulmonary syndrome. This article focuses on problems that underlie diagnostic accuracy and uses this information to appraise critically outcomes literature.
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Affiliation(s)
- M Susan Mandell
- University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA.
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Abstract
1. How do physicians decide which patients with pulmonary vascular disease will benefit from liver transplantation? 2. Studies on patients with pulmonary vascular disease are limited and the findings and recommendations may not apply to all practice sites. 3. All patients with hypoxemia, liver disease, and pulmonary vasodilation do not have hepatopulmonary syndrome (HPS). 4. Not all patients with hepatopulmonary syndrome will benefit from liver transplantation. 5. The mean pulmonary artery pressure (mPAP) may not be an accurate predictor of mortality in patients with portopulmonary hypertension. 6. The effects of pulmonary vasodilators on the outcome of patients with portopulmonary hypertension (PPHTN) is still unconfirmed but promising.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences, Denver, CO, USA.
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Krowka MJ, Mandell MS, Ramsay MAE, Kawut SM, Fallon MB, Manzarbeitia C, Pardo M, Marotta P, Uemoto S, Stoffel MP, Benson JT. Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. Liver Transpl 2004; 10:174-82. [PMID: 14762853 DOI: 10.1002/lt.20016] [Citation(s) in RCA: 348] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PortoPH) are pulmonary vascular consequences of advanced liver disease associated with significant mortality after orthotopic liver transplantation (OLT). Data from 10 liver transplant centers were collected from 1996 to 2001 that characterized the outcome of patients with either HPS (n = 40) or PortoPH (n = 66) referred for OLT. Key variables (PaO2 for HPS, mean pulmonary artery pressure [MPAP], pulmonary vascular resistance [PVR], and cardiac output [CO] for PortoPH) were analyzed with respect to 3 definitive outcomes (those denied OLT, transplant hospitalization survivors, and transplant hospitalization nonsurvivors). OLT was denied in 8 of 40 patients (20%) with HPS and 30 of 66 patients (45%) with PortoPH. Patients with HPS who were denied OLT had significantly worse PaO2 compared with patients who underwent transplantation (47 vs. 52 mm Hg, P <.005). Transplant hospitalization survival was associated with higher pre-OLT PaO2 (55 vs. 37 mm Hg; P <.005). MPAP was significantly higher (53 vs. 45 mm Hg; P <.015) and PVR was significantly worse (614 vs. 335 dynes. s. cm(-5); P <.05) in patients with PortoPH who were denied OLT compared with patients who underwent transplantation. Transplant hospitalization mortality was 16% (5/32) in patients with HPS and 36% (13/36) in patients with PortoPH. All of the deaths in patients with PortoPH occurred within 18 days of OLT; 5 of the 13 deaths in patients with PortoPH occurred intraoperatively. We concluded that patients with HPS (based on a combination of low PaO2 and nonpulmonary factors) and patients with PortoPH (based on pulmonary hemodynamics) were frequently denied OLT because of pre-OLT test results and comorbidities. For patients who subsequently underwent OLT, transplant hospitalization mortality remained significant for both those with HPS (16%) and PortoPH (36%).
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Mandell MS, Durham J, Kumpe D, Trotter JF, Everson GT, Niemann CU. The effects of desflurane and propofol on portosystemic pressure in patients with portal hypertension. Anesth Analg 2003; 97:1573-1577. [PMID: 14633521 DOI: 10.1213/01.ane.0000090741.63156.1b] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
UNLABELLED Physicians perform hepatic venous pressure measurements to guide medical therapy aimed at reducing portal hypertension. These measurements are frequently performed during general anesthesia. Since most general anesthetic drugs reduce liver blood flow, it is likely that hepatic venous pressures will be altered. We therefore examined the effects of two frequently used anesthetic drugs on hepatic venous pressure in a prospective randomized study to determine if pressure measurements taken during general anesthesia were similar to awake values. We studied 21 patients with hepatitis C, excluding patients with hepatofugal flow and portal vein thrombosis. All patients had free and wedged hepatic venous pressures measured awake with sedation and after anesthesia with either propofol or desflurane. Desflurane significantly increased free hepatic venous pressure (11.9 +/- 4.4 to 23.5 +/- 4.1 mm Hg; P < 0.05) and decreased hepatic venous pressure gradient (21.6 +/- 7.4 to 14.7 +/- 5.2 mm Hg; P < 0.05), whereas propofol did not change these variables. We conclude that desflurane, but not propofol, alters hepatic venous pressure measurements from the awake state, significantly increasing free hepatic venous pressure and decreasing the hepatic venous pressure gradient, an indirect measure of portosystemic pressure. Changes in the hepatic venous pressure gradient must be interpreted with caution during desflurane general anesthesia. IMPLICATIONS Desflurane reduces the blood pressure difference between the portal and systemic circulations. This can cause errors in assessment of the success of medical therapy of portal hypertension. Propofol has less effect on the difference between the portal and systemic circulation.
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Affiliation(s)
- M Susan Mandell
- Departments of *Anesthesiology, †Radiology, and ‡Hepatology, University of Colorado Health Sciences Center, Denver; and §Department of Anesthesia and Perioperative Care, University of California, San Francisco
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Mandell MS, Taylor GJ, D'Alessandro A, McGaw LJ, Cohen E. Executive summary from the Intraoperative Advisory Council on Donation After Cardiac Death of the United Network for Organ Sharing: practice guidelines. Liver Transpl 2003; 9:1120-3. [PMID: 14526412 DOI: 10.1053/jlts.2003.50189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The number of organs recovered from asystolic donors is less than anticipated and is explained partially by negative attitudes held by health care providers. To understand the reasons for these beliefs and find solutions, the United Network for Organ Sharing under contract with the Department of Health and Human Services convened the Intraoperative Advisory Council on Donation After Cardiac Death in September, 2001. The Council found that, unlike other medical specialties, operating room health care providers were uncertain of their roles and duties in the care of donors declared dead with cardiopulmonary criteria, known as donation after cardiac death. They were reluctant to care for terminally ill patients in whom death was an expected outcome. Council members deliberated these issues, seeking solutions to repatriate operating room health care providers with the national effort to provide reliable and compassionate care to organ donors and their families. The Council requested the construction of practice guidelines, believing that the structure provided by guidelines will improve health provider confidence in donation after cardiac death and thus improve the quality of care. Physician and nonphysician health care providers from the operating room met to create the Guidelines for the United Network for Organ Sharing, which they believe will improve the quality of care of asystolic organ donors.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Abstract
IMPLICATIONS The authors describe the intraoperative use of indocyanine green dye elimination to detect critical reductions in donor liver function.
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Affiliation(s)
- M Susan Mandell
- Department of Anesthesiology, Division of Transplantation, University of Colorado Health Sciences Center, 4200 E. Ninth Avenue, Denver, CO 80262, USA.
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Abstract
Postoperative ventilation and admission to the intensive care unit (ICU) is the standard of care in liver transplantation and comprises a significant proportion of transplantation costs. Because immediate postoperative extubation has been reported previously in a selected group of liver transplant recipients, we questioned whether this protocol could be extended to a larger group of patients. We also sought to determine the proportion of patients extubated immediately after surgery that could be transferred to the surgical ward without intervening ICU care. Of 147 patients studied in a prospective trial of sequential liver transplant recipients (who were not second-transplant recipients, United Network for Organ Sharing status 1, living donor transplant recipients, or dead before the end of surgery), 13 patients did not meet postsurgical criteria for early extubation and 111 patients were successfully extubated. Eighty-three extubated patients were transferred to the surgical ward after a routine admission to the postoperative care unit. Only 3 patients who were transferred to the surgical ward experienced complications that required a greater intensity of nursing care. A learning curve detected during the 3-year study period showed that attempts to extubate increased from 73% to 96% and triage to the surgical ward increased from 52% to 82% without compromising patient safety. The use of this protocol in our institution resulted in a 1-day reduction in ICU use in 75.5% of study subjects. We therefore conclude that the majority of liver transplant recipients can be extubated safely and admitted to the surgical ward after liver transplantation surgery, thus decreasing the cost associated with ICU care.
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Affiliation(s)
- M Susan Mandell
- Departments of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Mandell MS, Lezotte D, Kam I, Zamudio S. Reduced use of intensive care after liver transplantation: patient attributes that determine early transfer to surgical wards. Liver Transpl 2002; 8:682-7. [PMID: 12149760 DOI: 10.1053/jlts.2002.34380] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Part 1 of our report, presented in the same issue of the Journal, shows that immediate postoperative extubation and direct transfer to the surgical ward is safe and reduces reliance on the intensive care unit in most liver transplant recipients. However, there is no method to preoperatively predict which patients will need ventilatory support after surgery. To address this issue, we examined the relationship between perioperative patient attributes and extubation outcome in patients entered into our immediate postoperative extubation study from 1996 to 1998. Variables chosen stemmed from considerations in the literature. We examined the influence of 13 preoperative and 6 intraoperative factors on extubation outcome. Preoperative attributes included sex, race, diagnosis, United Network for Organ Sharing status, Child-Pugh score, presence of a portosystemic shunt, ascites, encephalopathy, coagulation, age, body mass index (BMI), creatinine level, and year of surgery. Intraoperative factors were type of surgery, surgeon, anesthesiologist, number of red blood cells administered, length of surgery, and surgical start time. Female sex (P =.02), BMI of 32 or greater (P =.015), portosystemic shunt (P =.022), and encephalopathy (P =.041) were associated with no attempt by the physician to extubate, whereas encephalopathy (P =.01) and BMI of 34 or greater (P =.002) were associated with failure to meet criteria for postoperative extubation (described in part 1 of this study). We conclude there are limited factors that predict an increased risk for postoperative respiratory failure in liver transplant recipients. Our results indicate that physicians are conservative in their approach to extubation immediately after surgery, and sole reliance on physician judgment to determine suitability for postoperative extubation leads to unnecessary use of postoperative cardiopulmonary support.
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Affiliation(s)
- M Susan Mandell
- Departments of Anesthesiology, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Affiliation(s)
- M S Mandell
- Department of Anesthesiology, The University of Colorado Health Sciences Center, Denver, CO 80264, USA.
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Mandell MS, Henthorn T. Fibrinolysis in patients with fulminant hepatic failure. Liver Transpl Surg 1999; 5:464. [PMID: 10523124 DOI: 10.1002/lt.500050506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Affiliation(s)
- M S Mandell
- Department of Anesthesiology, University of Colorado, Health Sciences Center, CO 80262, USA
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Wachs ME, Bak TE, Karrer FM, Everson GT, Shrestha R, Trouillot TE, Mandell MS, Steinberg TG, Kam I. Adult living donor liver transplantation using a right hepatic lobe. Transplantation 1998; 66:1313-6. [PMID: 9846514 DOI: 10.1097/00007890-199811270-00008] [Citation(s) in RCA: 270] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Living donor liver transplantation has gained wide acceptance as an alternative for children with end-stage liver disease. The standard left lateral segment used in this operation does not provide adequate parenchymal mass to broaden its application to larger children or adults. METHODS We report two cases of adult to adult living donor liver transplantation using a right hepatic lobe in patients with chronic liver disease. RESULTS Both recipients experienced excellent initial graft function and have normal liver function 4 and 9 months postoperatively. Both donors are alive and well and returned to normal life 4 weeks postoperatively. CONCLUSIONS Our initial experience suggests that this technique is a safe and reliable option for adults with chronic end-stage liver disease. A conservative application of this procedure in the adult population could significantly reduce the mortality on the adult waiting list.
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Affiliation(s)
- M E Wachs
- Division of Transplant Surgery, University of Colorado Health Sciences Center, Denver, USA
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