Introduction: There has been a recent increase in the use of intraoperative transesophageal echoc... more Introduction: There has been a recent increase in the use of intraoperative transesophageal echocardiography (TEE) in liver transplant surgeries to identify intracardiac thrombi and pulmonary embolism (PE). These are rare but serious complications of transplant surgery that carry a high mortality risk. However, there is a lack of literature supporting the use of TEE during liver transplants, especially in pediatric cases. Case Presentation: We present a rare case of intraoperative catheter-related right atrial thrombus (CRAT) in a nine-year-old multi-visceral transplant (MVT) patient. This patient’s medical history was notable for preterm birth and gastroschisis complicated by neonatal necrotizing enterocolitis resulting in short-gut syndrome. He had a significant surgical history, including intestinal resection, Hartmann Procedure, and cholecystectomy, after which he developed non-cholestatic liver disease. He was admitted for MVT for intestinal failure associated with ESLD. The pr...
Aortic stenosis (AS) is the most common valvular disease and is reported to be present in 2%–7% o... more Aortic stenosis (AS) is the most common valvular disease and is reported to be present in 2%–7% of people over the age of 65. Risk factors for aortic stenosis and NASH overlap; thus, as the population ages, there is an increased likelihood that patients undergoing liver transplantation evaluation may have severe aortic stenosis. There is a high mortality rate associated with cardiac surgeries in patients with cirrhosis. Further, there are no guidelines that assist in the decision making process for patients with cirrhosis and AS. In this review, we highlight key studies that compare transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in patients with cirrhosis. We propose an algorithm as to how to approach the patient with aortic stenosis and considerations unique to patients with cirrhosis (i.e., anticoagulation, EGD for variceal assessment; need to determine timing after TAVI before listing).
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2021
The SATA Task Force on TEE use during Transplant Surgery thanks Dr. Wigg et al. for sharing their... more The SATA Task Force on TEE use during Transplant Surgery thanks Dr. Wigg et al. for sharing their experience of a patient death where a TEE probe was used in their letter to the editor "Is transesophageal echocardiography really safe during liver transplantation surgery in patients with high-risk varices." The authors describe a complex patient with pulmonary hypertension and speculate that bleeding caused by the probe contributed to adverse events and eventually death. Based on their experience, the authors question the safety of TEE use.
Journal of the American College of Cardiology, 2020
Background: Hepatopulmonary syndrome (HPS) is a complication of cirrhosis and is associated with ... more Background: Hepatopulmonary syndrome (HPS) is a complication of cirrhosis and is associated with increased pre-orthotopic liver transplant (OLT) mortality. Diagnosis requires intrapulmonary vascular dilatation (IPVD) and hypoxemia. The clinical significance of IPVD severity on post-OLT mortality is unknown. Methods: Echocardiograms (TTE) were retrospectively reviewed in patients who underwent OLT from 2011-2015. Pre-OLT IPVD was graded on a scale of 0 to 4 (0=no shunting, 4=severe shunting). Bivariate analysis was performed to investigate the association between shunting degree and all-cause mortality at four years post-OLT using Fisher's exact test and Wilcoxon rank-sum test. Results: 110 of 150 subjects had intrapulmonary shunting at baseline. Post-OLT, patients with no shunting had 25% mortality compared to 20% mortality for patients with any shunting (p=0.51). Severe shunting (Grade 3-4) was associated with 29% mortality compared to 21% in those with non-severe shunting (Grade 0-2) (p=0.50). Conclusion: There was no significant difference in mortality four years post OLT between patients with or without IPVD, suggesting no long term consequences of IPVD following OLT. Future research is indicated to evaluate the clinical impact of subclinical HPS on pretransplant mortality.
Ultrasound (US) performed at the point of care has found fertile ground in perioperative medicine... more Ultrasound (US) performed at the point of care has found fertile ground in perioperative medicine. In the hands of anesthesiologists, transesophageal echocardiography (TEE) has become established as a powerful diagnostic and monitoring tool in the perioperative care of cardiac and non-cardiac patients. A number of point-of-care US (POCUS) applications are relevant to perioperative care, including airway, cardiac, lung and gastric US. Although guidelines exist to define the scope of practice for basic and advanced TEE, there remains a lack of such guidelines for perioperative point-of-care ultrasound (POCUS), despite a number of recent calls for action in the academic anesthesia community. POCUS training has been integrated into anesthesia residency curricula in Canada and the United States of America (USA). However, a nation-wide curriculum is still lacking. Many limitations to the development of perioperative POCUS curricula exist, including the need to define the scope of practice...
The safe administration of conscious sedation in a patient with a critical airway who underwent a... more The safe administration of conscious sedation in a patient with a critical airway who underwent awake tracheotomy using dexmedetomidine, a selective alpha 2-agonist with sympatholytic, anxiolytic, analgesic, and sedative properties, is presented. Unlike other commonly used sedative agents, dexmedetomidine provided adequate sedation with minimal respiratory depression.
INTRODUCTION: Liver transplant anesthesiology is an evolving and expanding subspecialty, and prog... more INTRODUCTION: Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors. This article is protected by copyright. All rights reserved. METHODS: Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%). RESULTS: Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of venovenous bypass, routine placement of pulmonary artery catheters and the intraoperative use of antifibrinolytics when compared to prior surveys. CONCLUSION: The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.
BACKGROUND: The presence of an endotracheal tube is the main cause for developing ventilator-asso... more BACKGROUND: The presence of an endotracheal tube is the main cause for developing ventilator-associated pneumonia (VAP), but pneumonia can still develop in hospitalized patients after endotracheal tube removal (postextubation pneumonia [PEP]). We hypothesized that short-term intubation (24 hours) can play a role in the pathogenesis of PEP. To test such hypothesis, we initially evaluated the occurrence of lung colonization and VAP in sheep that were intubated and mechanically ventilated for 24 hours. Subsequently, we assessed the incidence of lung colonization and PEP at 48 hours after extubation in sheep previously ventilated for 24 hours. METHODS: To simulate intubated intensive care unit patients placed in semirecumbent position, 14 sheep were intubated and mechanically ventilated with the head elevated 30° above horizontal. Seven of them were euthanized after 24 hours (Control Group), whereas the remaining were euthanized after being awaken, extubated, and left spontaneously brea...
IntroductionOrgan Procurement and Transplant Network (OPTN) pediatric policies on knowledge and s... more IntroductionOrgan 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.MethodsA 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.ResultsResponse rate was 73% (n = 63). Most responding programs had a Director (67%) with certification, selection committee, and continuing edu...
Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (M... more Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (MG) as well as the management of small thymomas and other benign thymic pathology has been gaining in acceptance and popularity as an alternative to the traditional median sternotomy approach. Although VATS thymectomy has been described in several variations, our current preference is a left sided VATS approach due to the exposure it provides in critical areas of dissection. Here we describe our technique for the left sided VATS thymectomy including patient selection, preoperative preparation, operative steps, and postoperative care. We also share pitfalls and tips to prevent them at each step of the procedure learned from our experience with this approach.
Interactive cardiovascular and thoracic surgery, Jun 1, 2017
The purpose of this research is to compare liposomal bupivacaine and bupivacaine/epinephrine for ... more The purpose of this research is to compare liposomal bupivacaine and bupivacaine/epinephrine for intercostal blocks related to analgesic use and length of stay following video-assisted thoracoscopic wedge resection. A retrospective study of patients undergoing video-assisted thoracoscopic wedge resection from 2010 to 2015 was performed. We selected patients who stayed longer than 24 h in hospital. Primary outcomes were length of stay and postoperative analgesic use at 12-h intervals from 24 to 72 h. Intercostal blocks were performed with liposomal bupivacaine in 62 patients and bupivacaine/epinephrine in 51 patients. A Wilcoxon signed-rank test evaluated differences in median postoperative analgesic use and length of stay. Those who received liposomal bupivacaine consumed fewer analgesics than those who received bupivacaine/epinephrine, with a statistically significant difference from 24 to 36 h (20.25 vs 45.0 mg; P = 0.0059) and from 60 to 72 h postoperatively (15.0 vs 33.75 mg; P...
To design and fabricate crush-proof polyurethane tracheal tubes for the newborn with the lowest r... more To design and fabricate crush-proof polyurethane tracheal tubes for the newborn with the lowest resistance, least dead space, and thinnest wall. Test and evaluation of a novel, low-resistance, and low-dead-space tracheal tube for newborns. National Institutes of Health Research Laboratory. The short orotracheal portion of the tracheal tube was fabricated of polyurethane, reinforced with flat nickel-titanium shape-memory alloy (Nitinol) to render the tube crush-proof, of a wall thickness about one half of a standard tracheal tube. To the oral part of the tracheal tube, which is the sole dead-space, we attached a Y piece. We connected to one arm of the Y a nonreinforced (inspiratory) tube of larger internal diameter, and a similar tube (expiratory) to the other. The computed air flow resistance, as derived from the pressure/flow curves, is about one half to one third the resistance of a comparable standard tracheal tube at flow rates up to 8 L/min, with a tubing, connector, and adapter dead space three to seven times smaller, depending on the tracheal tube connector piece, the ventilator tube connector piece, and size of the tracheal tube. The novel tracheal tube design has a resistance to gas flow one half to one third that of a standard tracheal tube and a dead-space volume three to seven times lower, including tubing and connector dead space. In addition, it offers a means for potential accurate, continuous online monitoring of expiratory oxygen and Co(2) concentration and gas flow, in both the inspiratory and the expiratory lines, without contributing to dead-space ventilation or gas flow resistance.
Introduction: There has been a recent increase in the use of intraoperative transesophageal echoc... more Introduction: There has been a recent increase in the use of intraoperative transesophageal echocardiography (TEE) in liver transplant surgeries to identify intracardiac thrombi and pulmonary embolism (PE). These are rare but serious complications of transplant surgery that carry a high mortality risk. However, there is a lack of literature supporting the use of TEE during liver transplants, especially in pediatric cases. Case Presentation: We present a rare case of intraoperative catheter-related right atrial thrombus (CRAT) in a nine-year-old multi-visceral transplant (MVT) patient. This patient’s medical history was notable for preterm birth and gastroschisis complicated by neonatal necrotizing enterocolitis resulting in short-gut syndrome. He had a significant surgical history, including intestinal resection, Hartmann Procedure, and cholecystectomy, after which he developed non-cholestatic liver disease. He was admitted for MVT for intestinal failure associated with ESLD. The pr...
Aortic stenosis (AS) is the most common valvular disease and is reported to be present in 2%–7% o... more Aortic stenosis (AS) is the most common valvular disease and is reported to be present in 2%–7% of people over the age of 65. Risk factors for aortic stenosis and NASH overlap; thus, as the population ages, there is an increased likelihood that patients undergoing liver transplantation evaluation may have severe aortic stenosis. There is a high mortality rate associated with cardiac surgeries in patients with cirrhosis. Further, there are no guidelines that assist in the decision making process for patients with cirrhosis and AS. In this review, we highlight key studies that compare transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in patients with cirrhosis. We propose an algorithm as to how to approach the patient with aortic stenosis and considerations unique to patients with cirrhosis (i.e., anticoagulation, EGD for variceal assessment; need to determine timing after TAVI before listing).
Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2021
The SATA Task Force on TEE use during Transplant Surgery thanks Dr. Wigg et al. for sharing their... more The SATA Task Force on TEE use during Transplant Surgery thanks Dr. Wigg et al. for sharing their experience of a patient death where a TEE probe was used in their letter to the editor "Is transesophageal echocardiography really safe during liver transplantation surgery in patients with high-risk varices." The authors describe a complex patient with pulmonary hypertension and speculate that bleeding caused by the probe contributed to adverse events and eventually death. Based on their experience, the authors question the safety of TEE use.
Journal of the American College of Cardiology, 2020
Background: Hepatopulmonary syndrome (HPS) is a complication of cirrhosis and is associated with ... more Background: Hepatopulmonary syndrome (HPS) is a complication of cirrhosis and is associated with increased pre-orthotopic liver transplant (OLT) mortality. Diagnosis requires intrapulmonary vascular dilatation (IPVD) and hypoxemia. The clinical significance of IPVD severity on post-OLT mortality is unknown. Methods: Echocardiograms (TTE) were retrospectively reviewed in patients who underwent OLT from 2011-2015. Pre-OLT IPVD was graded on a scale of 0 to 4 (0=no shunting, 4=severe shunting). Bivariate analysis was performed to investigate the association between shunting degree and all-cause mortality at four years post-OLT using Fisher's exact test and Wilcoxon rank-sum test. Results: 110 of 150 subjects had intrapulmonary shunting at baseline. Post-OLT, patients with no shunting had 25% mortality compared to 20% mortality for patients with any shunting (p=0.51). Severe shunting (Grade 3-4) was associated with 29% mortality compared to 21% in those with non-severe shunting (Grade 0-2) (p=0.50). Conclusion: There was no significant difference in mortality four years post OLT between patients with or without IPVD, suggesting no long term consequences of IPVD following OLT. Future research is indicated to evaluate the clinical impact of subclinical HPS on pretransplant mortality.
Ultrasound (US) performed at the point of care has found fertile ground in perioperative medicine... more Ultrasound (US) performed at the point of care has found fertile ground in perioperative medicine. In the hands of anesthesiologists, transesophageal echocardiography (TEE) has become established as a powerful diagnostic and monitoring tool in the perioperative care of cardiac and non-cardiac patients. A number of point-of-care US (POCUS) applications are relevant to perioperative care, including airway, cardiac, lung and gastric US. Although guidelines exist to define the scope of practice for basic and advanced TEE, there remains a lack of such guidelines for perioperative point-of-care ultrasound (POCUS), despite a number of recent calls for action in the academic anesthesia community. POCUS training has been integrated into anesthesia residency curricula in Canada and the United States of America (USA). However, a nation-wide curriculum is still lacking. Many limitations to the development of perioperative POCUS curricula exist, including the need to define the scope of practice...
The safe administration of conscious sedation in a patient with a critical airway who underwent a... more The safe administration of conscious sedation in a patient with a critical airway who underwent awake tracheotomy using dexmedetomidine, a selective alpha 2-agonist with sympatholytic, anxiolytic, analgesic, and sedative properties, is presented. Unlike other commonly used sedative agents, dexmedetomidine provided adequate sedation with minimal respiratory depression.
INTRODUCTION: Liver transplant anesthesiology is an evolving and expanding subspecialty, and prog... more INTRODUCTION: Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors. This article is protected by copyright. All rights reserved. METHODS: Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%). RESULTS: Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of venovenous bypass, routine placement of pulmonary artery catheters and the intraoperative use of antifibrinolytics when compared to prior surveys. CONCLUSION: The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.
BACKGROUND: The presence of an endotracheal tube is the main cause for developing ventilator-asso... more BACKGROUND: The presence of an endotracheal tube is the main cause for developing ventilator-associated pneumonia (VAP), but pneumonia can still develop in hospitalized patients after endotracheal tube removal (postextubation pneumonia [PEP]). We hypothesized that short-term intubation (24 hours) can play a role in the pathogenesis of PEP. To test such hypothesis, we initially evaluated the occurrence of lung colonization and VAP in sheep that were intubated and mechanically ventilated for 24 hours. Subsequently, we assessed the incidence of lung colonization and PEP at 48 hours after extubation in sheep previously ventilated for 24 hours. METHODS: To simulate intubated intensive care unit patients placed in semirecumbent position, 14 sheep were intubated and mechanically ventilated with the head elevated 30° above horizontal. Seven of them were euthanized after 24 hours (Control Group), whereas the remaining were euthanized after being awaken, extubated, and left spontaneously brea...
IntroductionOrgan Procurement and Transplant Network (OPTN) pediatric policies on knowledge and s... more IntroductionOrgan 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.MethodsA 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.ResultsResponse rate was 73% (n = 63). Most responding programs had a Director (67%) with certification, selection committee, and continuing edu...
Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (M... more Video-assisted thoracic surgery (VATS) for the management of non-thymomatous myasthenia gravis (MG) as well as the management of small thymomas and other benign thymic pathology has been gaining in acceptance and popularity as an alternative to the traditional median sternotomy approach. Although VATS thymectomy has been described in several variations, our current preference is a left sided VATS approach due to the exposure it provides in critical areas of dissection. Here we describe our technique for the left sided VATS thymectomy including patient selection, preoperative preparation, operative steps, and postoperative care. We also share pitfalls and tips to prevent them at each step of the procedure learned from our experience with this approach.
Interactive cardiovascular and thoracic surgery, Jun 1, 2017
The purpose of this research is to compare liposomal bupivacaine and bupivacaine/epinephrine for ... more The purpose of this research is to compare liposomal bupivacaine and bupivacaine/epinephrine for intercostal blocks related to analgesic use and length of stay following video-assisted thoracoscopic wedge resection. A retrospective study of patients undergoing video-assisted thoracoscopic wedge resection from 2010 to 2015 was performed. We selected patients who stayed longer than 24 h in hospital. Primary outcomes were length of stay and postoperative analgesic use at 12-h intervals from 24 to 72 h. Intercostal blocks were performed with liposomal bupivacaine in 62 patients and bupivacaine/epinephrine in 51 patients. A Wilcoxon signed-rank test evaluated differences in median postoperative analgesic use and length of stay. Those who received liposomal bupivacaine consumed fewer analgesics than those who received bupivacaine/epinephrine, with a statistically significant difference from 24 to 36 h (20.25 vs 45.0 mg; P = 0.0059) and from 60 to 72 h postoperatively (15.0 vs 33.75 mg; P...
To design and fabricate crush-proof polyurethane tracheal tubes for the newborn with the lowest r... more To design and fabricate crush-proof polyurethane tracheal tubes for the newborn with the lowest resistance, least dead space, and thinnest wall. Test and evaluation of a novel, low-resistance, and low-dead-space tracheal tube for newborns. National Institutes of Health Research Laboratory. The short orotracheal portion of the tracheal tube was fabricated of polyurethane, reinforced with flat nickel-titanium shape-memory alloy (Nitinol) to render the tube crush-proof, of a wall thickness about one half of a standard tracheal tube. To the oral part of the tracheal tube, which is the sole dead-space, we attached a Y piece. We connected to one arm of the Y a nonreinforced (inspiratory) tube of larger internal diameter, and a similar tube (expiratory) to the other. The computed air flow resistance, as derived from the pressure/flow curves, is about one half to one third the resistance of a comparable standard tracheal tube at flow rates up to 8 L/min, with a tubing, connector, and adapter dead space three to seven times smaller, depending on the tracheal tube connector piece, the ventilator tube connector piece, and size of the tracheal tube. The novel tracheal tube design has a resistance to gas flow one half to one third that of a standard tracheal tube and a dead-space volume three to seven times lower, including tubing and connector dead space. In addition, it offers a means for potential accurate, continuous online monitoring of expiratory oxygen and Co(2) concentration and gas flow, in both the inspiratory and the expiratory lines, without contributing to dead-space ventilation or gas flow resistance.
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Papers by Lorenzo Marchi