Living liver donors for adult liver transplant recipients undergo extensive liver resection. Partial donor hepatectomies may alter postoperative drug metabolism and hemostasis; thus, the risks and the benefits of pain management for this unique patient population may need to be reassessed. The safety and efficacy of combined epidural analgesia and field infiltration in our initial living liver donor group are presented. A thoracic epidural catheter was placed before general anesthesia in 2 female and 6 male donors (44.2 ؎ 11.3 years old, mean ؎ standard deviation [SD], range 26 -56). At the end of surgery, incisions were infiltrated (bupivacaine 0.25%), and an epidural infusion was used (bupivacaine 0.1% ؉ hydromorphone hydrochloride 0.02%). Clinical outcomes were followed for 5 days. The time sequence of pain intensity on a 0 -10 visual analog scale clustered into 3 phases, the intensity of which differed significantly from each other (2.2 ؎ 0.6, 0.69 ؎ 0.2, and 2.37 ؎ 0.3 respectively, P ‫؍‬ 0.028). Right shoulder pain was observed in 75% of the donors. Sedation, pruritus, and nausea were minimal. Consistently maximal international normalized ratio elevation occurred at 17.6 ؎ 7 hours postoperatively, then slowly declined. Platelet counts were lowest on day 3. No neurologic injury or local anesthetic toxicity was observed. This 2-site approach provided effective, safe, postoperative analgesia for our donors. Universally, coagulopathy ensued, indicating a potentially increased risk for epidural hemorrhage at epidural catheter removal and mandating close postoperative neurologic and laboratory monitoring. Research is needed to advance the understanding of postoperative coagulopathy and hepatic dysfunction in these donors to further optimize their perioperative management, including that of analgesia. (Liver Transpl 2004;10:363-368.) M inimization of perioperative pain enhances many surgical outcomes, 1 and safe, effective postoperative pain management is a clinical goal, an ethical mandate, and a standard of the Joint Commission on Accreditation of Healthcare Organizations. 2 Large liver resections may result in transient metabolic impairment [3][4][5][6] and temporary disturbances in hemostasis. 3,4,[7][8][9][10][11] Hence, development of an optimal perioperative pain management strategy for donors is a complex clinical challenge. Although epidural pain management has been recommended, 12 and used successfully in living liver donor surgery, 8,9,12 a systematic assessment of its efficacy and safety in living donors for adult liver transplantation, who typically donate approximately 60% of their liver, 13,14 is not available.Reports in operations other than liver donation suggest that epidural pain management, in combination with local anesthetic field infiltration, offers effective, opioid-sparing analgesia [15][16][17] as an alternative to systemic opioids with their potential hepatotoxicity 18,19 and risk of sedation. In the current case series, we evaluated the efficacy and safety of this 2-site approach and ...

Children with cyanotic congenital heart disease (CCHD) have complex alterations in their whole blood composition and coagulation profile due to long-standing hypoxemia. Secondary erythrocytosis is an associated physiological response intended to increase circulating red blood cells and oxygen carrying capacity. However, this response is frequently offset by an increase in whole blood viscosity that paradoxically reduces blood flow and tissue perfusion. In addition, the accompanying reduction in plasma volume leads to significant deficiencies in multiple coagulation proteins including platelets, fibrinogen and other clotting factors. On the one hand, these patients may suffer from severe hyperviscosity and subclinical 'sludging' in the peripheral vasculature with an increased risk of thrombosis. On the other hand, they are at an increased risk for postoperative hemorrhage due to a complex derangement in their hemostatic profile. Anesthesiologists caring for children with CCHD and secondary erythrocytosis need to understand the pathophysiology of these alterations and be aware of available strategies that lessen the risk of bleeding and/or thrombosis. The aim of this review is to provide an updated analysis of the systemic effects of long-standing hypoxemia in children with primary congenital heart disease with a specific focus on secondary erythrocytosis and hemostasis.

AAOCA = anomalous aortic origin of a coronary artery; ACS = American College of Surgeons; AGMP = aerosol-generating medical procedures; ASE = American Society of Echocardiography; CCAS = Congenital Cardiac Anesthesia Society; CHD = congenital heart disease; CICU = cardiac intensive care unit; CMS = Center for Medicare and Medicaid Services; COVID-19 = coronavirus disease 2019; CPB = cardiopulmonary bypass; CT = clotting time; EACA = epsilon amino caproic acid; ECMO = extracorporeal membrane oxygenation; EXTEM = extrinsic test from thromboelastometry; FC = fibrinogen concentrate; FEIBA = factor eight inhibitor bypassing activity; FFP = fresh frozen plasma; FIBTEM = fibrinogen test from thromboelastometry; HEPA = high-efficiency particulate air; IDA = iron-deficiency anemia; MUF = modified ultrafiltration; PCC = prothrombin complex concentrate; PDA = patent ductus arteriosus; PLT = platelets; PPE = personal protective equipment; RBC = red blood cell; RT-PCR = reverse transcription-polymerase chain reaction; RV-PA = right ventricle to pulmonary artery; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; TEE = transesophageal echocardiography; TXA = tranexamic acid; VAD = ventricular assist device

There is a critical shortage of donor organs. According to the United Network for Organ Sharing (UNOS), 20% of organs are discarded after procurement. Many of these may be potentially salvageable. Brain death is particularly detrimental to cardiac function. The initial sympathetic storm can produce direct myocardial injury. The ensuing spinal shock reduces global oxygen delivery. There is a change to anaerobic metabolism due to global mitochondrial dysfunction. Diabetes insipidus worsens hypovolemia and thyroid deficiency impairs cardiac function. Inadequate replacement of blood loss from trauma and coagulopathy worsens anemia and oxygen delivery. In the mid-1990s, the Papworth Hospital group in the UK advocated early invasive hemodynamic monitoring and administration of a 'hormonal cocktail', consisting of triiodothyronine (T3), vasopressin, methylprednisolone and insulin. This has been widely accepted and is endorsed by UNOS. Ventricular function, volume status and adequacy of resuscitation should be guided by invasive monitoring and serial echocardiography. Dopamine or epinephrine is used for inotropic support. If hypotension persists, vasopressin should be added which may allow reduction of inotropes. Donor lung function and ventilation should be optimized. Recently, two large retrospective studies have shown that, with aggressive pharmacological and hormonal resuscitation, a significant increase in the number and quality of organs harvested can be achieved.

BACKGROUND: Mid-frequency ventilation (MFV) is a mode of pressure control ventilation based on an optimal targeting scheme that maximizes alveolar ventilation and minimizes tidal volume (V T ). This study was designed to compare the effects of conventional mechanical ventilation using a lung-protective strategy with MFV in a porcine model of lung injury. Our hypothesis was that MFV can maximize ventilation at higher frequencies without adverse consequences. We compared ventilation and hemodynamic outcomes between conventional ventilation and MFV. METHODS: This was a prospective study of 6 live Yorkshire pigs (10 ؎ 0.5 kg). The animals were subjected to lung injury induced by saline lavage and injurious conventional mechanical ventilation. Baseline conventional pressure control continuous mandatory ventilation was applied with V T ‫؍‬ 6 mL/kg and PEEP determined using a decremental PEEP trial. A manual decision support algorithm was used to implement MFV using the same conventional ventilator. We measured P aCO 2 , P aO 2 , end-tidal carbon dioxide, cardiac output, arterial and venous blood oxygen saturation, pulmonary and systemic vascular pressures, and lactic acid. RESULTS: The MFV algorithm produced the same minute ventilation as conventional ventilation but with lower V T (؊1 ؎ 0.7 mL/kg) and higher frequency (32.1 ؎ 6.8 vs 55.7 ؎ 15.8 breaths/min, P < .002). There were no differences between conventional ventilation and MFV for mean airway pressures (16.1 ؎ 1.3 vs 16.4 ؎ 2 cm H 2 O, P ‫؍‬ .75) even when auto-PEEP was higher (0.6 ؎ 0.9 vs 2.4 ؎ 1.1 cm H 2 O, P ‫؍‬ .02). There were no significant differences in any hemodynamic measurements, although heart rate was higher during MFV. CONCLUSIONS: In this pilot study, we demonstrate that MFV allows the use of higher breathing frequencies and lower V T than conventional ventilation to maximize alveolar ventilation. We describe the ventilatory or hemodynamic effects of MFV. We also demonstrate that the application of a decision support algorithm to manage MFV is feasible.

Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease ranging in age from neonates to adults. Training in pediatric cardiac anesthesia is a second-year fellowship with variability in both training duration and content and is not accredited by the Accreditation Council on Graduate Medical Education. Consequently, in this article and based on the Accreditation Council on Graduate Medical Education Milestones Model, an expert panel of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, defines 18 milestones as competency-based developmental outcomes for training in the pediatric cardiac anesthesia fellowship.

Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG.

This study confirms the feasibility of obtaining 2-dimensional images of kidney parenchyma and Doppler-derived measurements using TEE in children. Angle-independent TEE Doppler-derived indices show significant concordance with those derived by TAU. Further studies are required to assess whether this correlation holds true in the presence of renal pathology. This technique has the potential to help modulate intraoperative interventions based on their impact on renal variables and may prove helpful in the perioperative period for children at risk of acute kidney injury.