Background and objectivesEffective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.Strategy and selection criteriaRandomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.ResultsOf 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.ConclusionsBased on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.

Background: In congenital cardiac surgery, priming cardiopulmonary bypass (CPB) with fresh frozen plasma (FFP) is performed to prevent coagulation abnormalities. The hypothesis was that CPB priming with crystalloids would be different compared with FFP in terms of bleeding and/or need for blood product transfusion. Methods: In this parallel-arm double-blinded study, patients weighing between 7 and 15 kg were randomly assigned to a CPB priming with 15 ml • kg −1 PlasmaLyte or 15 ml • kg −1 FFP in addition to a predefined amount of packed red blood cells used in all patients. The decision to transfuse was clinical and guided by point-of-care tests. The primary endpoints included postoperative bleeding tracked by chest tubes, number of patients transfused with any additional blood products, and the total number of additional blood products administered intra-and postoperatively. The postoperative period included the first 6 h after intensive care unit arrival. results: Respectively, 30 and 29 patients in the FFP and in the crystalloid group were analyzed in an intention-to-treat basis. Median postoperative blood loss was 7.1 ml • kg −1 (5.1, 9.4) in the FFP group and 5.7 ml • kg −1 (3.8, 8.5) in the crystalloid group (P = 0.219); difference (95% CI): 1.2 (−0.7 to 3.2). The proportion of patients additionally transfused was 26.7% (8 of 30) and 37.9% (11 of 29) in the FFP and the crystalloid groups, respectively (P = 0.355; odds ratio [95% CI], 1.7 [0.6 to 5.1]). The median number of any blood products transfused in addition to priming was 0 (0, 1) and 0 (0, 2) in the FFP and crystalloid groups, respectively (P = 0.254; difference [95% CI], 0 [0 to 0]). There were no study-related adverse events. conclusions: The results demonstrate that in infants and children, priming CPB with crystalloids does not result in a different risk of postoperative bleeding and need for transfusion of allogeneic blood products.

Ischemia-reperfusion injury (IRI) is an inflammatory process inherent in organ transplantation procedures. It is associated with tissue damage and, depending on its intensity, can impact early graft function. In liver transplantation (LT), strategies to alleviate IRI are essential in order to increase the use of extended criteria donor (ECD) grafts, which are more susceptible to IRI, as well as to improve postoperative graft and patient outcomes. Sevoflurane, a commonly used volatile anesthetic, has been shown to reduce IRI. This scoping review aims to give a comprehensive overview of the existing experimental and clinical data regarding the potential benefits of sevoflurane for hepatic IRI (HIRI) and to identify any gaps in knowledge to guide further research. We searched Medline and Embase for relevant articles. A total of 380 articles were identified, 45 of which were included in this review. In most experimental studies, the use of sevoflurane was associated with a significant decrease in biomarkers of acute liver damage and oxidative stress. Administration of sevoflurane before hepatic ischemia (preconditioning) or after reperfusion (postconditioning) appears to be protective. However, in the clinical setting, results are conflicting. While some studies showed a reduction of postoperative markers of liver injury, the benefit of sevoflurane on clinical outcomes and graft survival remains unclear. Further prospective clinical trials remain necessary to assess the clinical relevance of the use of sevoflurane as a protective factor against HIRI.

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Highlights With adrenocortical carcinoma, tumoral secretion is present in 25 to 75% of the cases. In the absence of excessive hormonal production, the diagnosis is often delayed. Isolated liver metastatic lesion may develop after several years of follow-up. Resection of a large intrahepatic malignant lesion may be complicated by a secondary capillary leak syndrome.

CORRESPONDENCE tracheal intubation than adults. Although the American Society of Anesthesiologists (Schaumburg, Illinois; ASA) provides definitions and clinical examples to guide the use of the ASA Physical Status system, Dr. Horvath states correctly that a patient's age is not considered. 3 Dr. Horvath's suggestion of updating the definitions for the ASA Physical Status system for pediatric patients is worthy of discussion. Assigning ASA Physical Status II to healthy infants because of higher rates of adverse events during tracheal intubation might be problematic. First, the purpose of the ASA Physical Status classification system is to communicate the patient's medical comorbidities, not their anesthetic risk. Second, if age were considered a comorbidity then one would have to assign a higher status for patients at both extremes of age, not just infants. Finally, a rapid sequence induction in a child increases the risk of hypoxemia during laryngoscopy, yet ASA Physical Status is not typically adjusted because of a plan for rapid sequence induction. There are many clinical scenarios wherein infants may be classified appropriately as ASA Physical Status I, such as a 3-month-old patient undergoing a circumcision. Although direct laryngoscopy can be challenging in infants, there are alternatives for establishing an airway, including supraglottic airways and video laryngoscopy, that may be less challenging than direct laryngoscopy.

Background and goal of the studyFew studies in infants have investigated whether the addition of FFP to the cardiopulmonary bypass (CPB) priming shows advantages in terms of bleeding and transfusion. 1,2 We hypothesized that adding FFP to CPB priming is superior when compared with Plasmalyte ® . Material and methods Results and discussion Conclusions-The preliminary results of this first double-blinded study show that in small infants priming CPB with FFP does not show beneficial effects in terms of bleeding and transfusion requirements and can be avoided. -Our results need to be interpreted with caution as the baseline characteristics of the groups were not totally comparable.

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