Given potential disparity and limited allocation of deceased donor kidneys for transplantation, a new federal kidney allocation system was implemented in 2014. Donor organ function and estimated recipient survival in this system has implications for perioperative management of kidney transplant recipients. Early analysis suggests that many of the anticipated goals are being attained. For anesthesiologists, implications of increased dialysis duration and burdens of end-stage renal disease include increased cardiopulmonary disease, challenging fluid, hemodynamic management, and central vein access. With no recent evidence to guide anesthesia care within this new system, we describe the kidney allocation system, summarize initial data, and briefly review organ systems of interest to anesthesiologists. As additional invasive and echocardiographic monitoring may be indicated, one consideration may be development of a dedicated anesthesiology team experienced in management and monitoring of complex patients, in a similar manner as has been done for liver transplant recipients.
Balogh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
TO THE EDITORS:We read James et al.'s 1 description of using the Thrombelastograph (TEG) PlateletMapping (PM) assay (Haemonetics Corp., Braintree, MA) to monitor and guide the antithrombotic management of a complex patient with great interest. This novel approach will be useful to physicians caring for patients with the coagulation abnormalities associated with cirrhosis in addition to pharmacological anticoagulants. However, it is being increasingly appreciated that pharmacokinetic/dynamic effects with antiplatelet therapy are relevant to the interpretation of PM results.
2In this particular case, aspirin (75 mg) and clopidogrel (75 mg) therapy was instituted with low maintenance doses. Without a loading dose and at doses lower than those used for patients undergoing procedures in the catheterization laboratory (usually 325 and 150 mg, respectively, for 5 days prior to intervention), it is not surprising that PM a week later did not show platelet inhibition (see Fig. 2A in James et al.'s article 1 ; it is not noted whether the 0% inhibition in the figure is related to arachidonic acid or an adenosine diphosphate agonist). Doubling the aspirin dose and retesting the following day would not be expected to increase inhibition significantly, although Fig. 2B in the article reveals 45% inhibition; this suggests a possible accumulation of antiplatelet effects. Although the addition of tirofiban resulted in 100% inhibition of platelet function (Fig. 2C), clinical bleeding necessitated cessation of the glycoprotein IIb/IIIa antagonist with residual 70% inhibition (Fig. 2D). On the basis of a prolonged R time suggesting impaired fibrin formation, fresh frozen plasma was administered. However, according to the TEG traces presented, the R time of 9.2 minutes was the shortest recorded in comparison with all previous traces (13-13.6 minutes). Given these data, we wonder why the authors chose fresh frozen plasma instead of a platelet transfusion, which would likely have temporarily ameliorated the platelet inhibition, the most remarkable and significant TEG finding present at that time.The authors are congratulated on their innovative use of TEG PM in a complex patient, which will stimulate further evaluation of this point-of-care monitor in patients with end-stage liver disease.
The Milestones are designed only for use in evaluation of resident physicians in the context of their participation in ACGME-accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context.
Milestone ReportingThis document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as the resident moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine Milestone performance data for each program's residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing.For each reporting period, review and reporting will involve selecting the level of milestones that best describes each resident's current performance level in relation to these milestones. Milestones are arranged into numbered levels. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page v). A general interpretation of levels for anesthesiology is below:Level 1: The resident demonstrates milestones expected of a resident who has completed one post-graduate year of education in either an integrated anesthesiology program or another preliminary education year prior to entering the CA1 year in anesthesiology. Level 2: The resident demonstrates milestones expected of a resident in anesthesiology residency prior to significant experience in the subspecialties of anesthesiology. Level 3: The resident demonstrates milestones expected of a resident after having experience in the subspecialties of anesthesiology. Level 4: The resident substantially fulfills the milestones expected of an anesthesiology residency, and is ready to transition to independent practice. This level is designed as the graduation target. Level 5: The resident has advanced beyond performance targets defined for residency, and is demonstrating "aspirational" goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level for selected milestones.iii
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