Transplantation proceedings
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Randomized Controlled Trial
Perioperative management in patients undergoing pancreatic surgery: the anesthesiologist's point of view.
A high rate of mortality and morbidity has been associated with pancreaticoduodenectomy; the 5-year survival rate is 15% to 25% compared with 1% to 5% among those who did not have any cancer-directed treatment. Systemic rather than surgical complications cause the majority of perioperative deaths, so the anesthesiologist has a crucial role in the management of these patients. This work sought to evaluate an improved approach to perioperative pain management, postsurgical complications as well as outcomes. ⋯ Adequate perioperative treatment included suitable nutritional support and pain management using loco-regional techniques, which seem to improve the surgical outcomes among pancreatic cancer patients.
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A patient undergoing renal transplantation presents unique problems to the anesthetist, as almost every body system is affected. The combined spinal-epidural technique has become popular in lower abdominal surgeries because it offers the advantages of both spinal and epidural techniques. We review our experience of combined spinal-epidural technique in patients undergoing renal transplantation with respect to demographics, intraoperative anesthesia, hemodynamics, postoperative analgesia, and untoward adverse events. ⋯ Combined spinal-epidural anesthesia proved to be a useful regional anesthetic technique, combining the reliability of spinal block and versatility of epidural block for renal transplantation.
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Previous studies have suggested that retroperitoneal and transperitoneal approaches for laparoscopic donor nephrectomy are associated with variable carbon dioxide (CO(2)) absorption, which can cause significant morbidity. The approach that results in greater CO(2) absorption is a matter of debate. We studied patients undergoing transperitoneal/retroperitoneal donor nephrectomy to determine relative CO(2) absorption, incidence of subcutaneous emphysema, pneumothorax, and pneumomediastinum, seeking to establish a correlation between the incidence of subcutaneous emphysema and CO(2) elimination. ⋯ CO(2) absorption during laparoscopy did not depend on the route of surgery. Subcutaneous emphysema was strongly and independently associated with a greater degree of CO(2) absorption during laparoscopic surgery.
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Organ transplantation as a substitute for diseased organs in end-stage organ failure has led to a worldwide increase in this treatment modality, but donation has not kept pace with the demand, despite scientific, social, and government efforts. For many years, Hispanic donation in Puerto Rico was meager and lagged behind major centers in North America and Europe. Studies signaled mostly cultural factors in this limited donation. We report a 16-fold increase in organ donation with the development of a formal procurement organization tailored to a local culture. ⋯ Cultural and educational obstacles in a given country may be overridden by aggressive administrative and educational approaches and strategic planning tailored to local realities, with improvement in organ transplantation.
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Parenteral analgesics are still diffusely administered for postoperative pain after major liver resection, while epidural analgesia is widely criticized because of possible changes in the postoperative coagulation profile. The safety of regional anesthesia in liver resections is based on appropriate timing of needle placement and catheter removal and on the individual's skill in performing both the puncture and the catheterization. In the absence of liver failure or in cases of only moderate hepatic dysfunction, the risk of neurologic complications and spinal hematomas does not appear greater than when an epidural is performed for routine abdominal or thoracic surgery. ⋯ However, a low CVP may not be tolerated by all patients: intraoperative hemodynamic instability may, in fact, easily ensue because of the cardiovascular depressant effects of anesthetics, surgical blood losses, and manipulation of the inferior vena cava. We suggest combining intraoperative epidural anesthesia with general (light) anesthesia as a useful strategy to keep the CVP low during liver resection without vasodilators or diuretics. Epidural anesthesia does not lead to changes in intravascular volume, but only promotes redistribution of blood, decreasing both venous return and portal vein pressure, thus contributing to reduced hepatic congestion and surgical blood loss.