ObjectPatients often develop markedly elevated serum lactate levels during craniotomy although the reason for this is not entirely understood. Elevated lactate levels have been associated with poor outcomes in critically ill septic shock patients, as well as patients undergoing abdominal and cardiac surgeries. We investigated whether elevated lactate in craniotomy patients is associated with neurologic complications (new neurological deficits) as well as systemic complications.MethodsWe performed a cohort study of elective craniotomy patients. Demographic and intraoperative data were collected, as well as three timed intraoperative arterial lactate values. Additional lactate, creatinine and troponin values were collected immediately postoperatively as well as 12 and 24 hours postoperatively. Assessment for neurologic deficit was performed at 6 hours and 2 weeks postoperatively. Hospital length-of-stay and 30-day mortality were collected.ResultsInterim analysis of 81 patients showed that no patient had postoperative myocardial infarction, renal failure, or mortality within 30 days of surgery. There was no difference in the incidence of new neurologic deficit in patients with or without elevated lactate (10/26, 38.5% vs. 15/55 27.3%, p = 0.31). Median length of stay was significantly longer in patients with elevated lactate (6.5 vs. 3 days, p = 0.003). Study enrollment was terminated early due to futility (futility index 0.16).ConclusionElevated intraoperative serum lactate was not associated with new postoperative neurologic deficits, other end organ events, or 30 day mortality. Serum lactate was related to longer hospital stay.
In this report we describe the use of intraoperative venoarterial ECMO as salvage therapy in a unique case of post-reperfusion intracardiac thrombosis during liver transplantation with prolonged ACLS and coagulopathy. The limited literature on intraoperative ECMO as salvage therapy in liver transplantation is reviewed.
This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016–2020) compared with the pre‐TEE era (2011–2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End‐Stage Liver Disease–sodium (MELD‐Na) scores, pretransplant hospitalization, malignancy, drug‐induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver–kidney transplantation. The patients with ICT were similar, except patients in the pre‐TEE era had higher MELD‐Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre‐TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30‐day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p = 0.002). The 30‐day mortality rate was 36% (9/25) in the TEE era (p = 0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.
In the year 2019, we identified and screened over 400 peer-reviewed publications on pancreatic transplantation, over 200 on intestinal transplantation, and over 1900 on kidney transplantation. The liver transplantation section focuses on and features selected articles among 70 clinical trials published in 2019. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a broad range of topics, including risks for and prediction of perioperative complications, updated indications for transplantation, recommendations on perioperative management, including Enhanced Recovery After Surgery programs, and topics relevant to optimization of patient and graft outcomes and survival.
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