Anesthesia and surgical intensive care

BackgroundManagement of COVID-19 in transplant patients is a big challenge. Data on immunosuppression management, clinical picture, and outcomes are lacking.ObjectivesTo summarize the current literature on COVID-19 in transplant patients especially the data regarding the immunosuppression protocols, clinical presentation, and outcomes.Search strategyA systematic search of MEDLINE, EBSCO, CENTRAL, CINAHL, LitCovid, Web of Science, and Scopus electronic databases. The references of the relevant studies were also searched. The search was last updated on June 3, 2020.Selection CriteriaPrimary reports of solid organ transplant patients who developed COVID-19. An overlap of cases in different reports was checked.Data collection and analysisA descriptive summary of immunosuppression therapy (before and after COVID-19), clinical presentation (symptoms, imaging, laboratory, and disease severity), management (oxygen therapy, antiviral, and antibacterial), major outcomes (Intensive care admiss...

Introduction: Living-donor liver transplantation (LDLT) is a complex procedure requiring a special perioperative patients' care. Despite the improvements in the operative techniques and perioperative care, early postoperative mortality remains a disappointing event. The current study is conducted to determine the incidence, causes and potential predictive factors of early postoperative mortality after LDLT. Methods: We reviewed the data of patients who underwent LDLT during the period between May 2004 till October 2020. Results: During the study period, 780 cases underwent LDLT. Early Mortality occurred in 109 cases (14%). We divided our cases into two groups, Early Mortality group (n=109) and Survivors group (n=671). Higher preoperative INR, creatinine, and MELD score were found in Early Mortality group. More blood loss and perioperative transfusions were found in Early Mortality group. Longer ICU stay with higher incidence of pulmonary and vascular complications were found in Early Mortality group. Preoperative MELD score, blood transfusion, pulmonary complications, and vascular complications were significant predictors of early mortality in multivariate analysis. Conclusion: Reduction of perioperative transfusions together with early detection and management of vascular and respiratory complications are essential to reduce early mortality after LDLT.

Biliary reconstruction is a cornerstone of living-donor liver transplantation (LDLT). The routine uses of trans-anastomotic biliary catheters in biliary reconstruction had been a controversial issue. We describe a rare complication related to the use of trans-anastomotic biliary catheter after LDLT. In this case, intestinal obstruction occurred early after LDLT due to internal herniation of the small bowel around trans-anastomotic biliary catheter. A 42 years male patient with end stage liver disease underwent LDLT utilizing a right hemi-liver graft. Biliary reconstruction was done by single duct-to-duct anastomosis over trans-anastomotic biliary catheter. The patient was doing well apart from early postoperative ascites that was managed medically. Three weeks after surgery, the patient developed severe agonizing central abdominal pain not responding to anti-spasmodics and analgesics. The decision was to proceed for surgical exploration. Exploration revealed internal herniation of t...

Background: Hypotension is a common problem during spinal anesthesia for cesarean delivery. Intravenous fluid loading is used to correct preoperative dehydration and reduce the incidence and severity of hypotension. Different fluid regimens have been studied but colloid preload and crystalloid co-load have not been compared. Methods: In this randomized double-blind study, 210 patients scheduled for elective cesarean section under spinal anesthesia were randomly allocated to receive either 6% hydroxyethyl starch 130/0.4 500 mL before spinal anesthesia (colloid preload) or Ringer's acetate solution 1000 mL administered rapidly starting with intrathecal injection (crystalloid co-load). Maternal hypotension (systolic blood pressure <80% of baseline or <90 mmHg) and severe hypotension (systolic blood pressure <80 mmHg) were treated with 5 and 10 mg ephedrine boluses, respectively. The primary outcome was the incidence of hypotension. Secondary outcomes included the incidence of severe hypotension, total ephedrine dose, nausea and vomiting and neonatal outcome assessed by Apgar scores and umbilical artery blood gas analysis. Results: Data analysis was performed on 205 patients; 103 in the colloid preload group and 102 in the crystalloid co-load group. There were no significant differences in the incidence of hypotension (52.4% vs. 42.2%; P=0.18) or severe hypotension (15.5% vs. 9.8%; P=0.31) between colloid preload and crystalloid co-load groups, respectively. The median [range] ephedrine dose was 5 [0-45] mg in the colloid preload group and 0 [0-35] mg in the crystalloid co-load group (P=0.065). There were no significant differences in maternal nausea or vomiting or neonatal outcomes between groups. Conclusion: The use of 1000 mL crystalloid co-load has similar effect to 500 mL colloid preload in reducing the incidence of hypotension after spinal anesthesia for elective cesarean delivery. Neither technique can totally prevent hypotension and should be combined with vasopressor use.

Background: Post-reperfusion syndrome (PRS) is a serious hemodynamic event during liver transplantation, which increases early graft dysfunction and mortality. Many vasoactive drugs have been used, but norepinephrine boluses are new during PRS. Our study aimed to test the efficacy and safety of Norepinephrine boluses to prevent PRS during orthotopic liver transplantation. Methods: This feasibility phase II trial included 40 patients undergoing living donor liver transplantation. The intervention was an escalated protocol of higher than usual Norepinephrine boluses. The primary outcome was the incidence of PRS. The main secondary outcomes were arrhythmia, ECG ischemic changes, mean pulmonary pressure, 3-month survival, and one-year survival. Results: PRS occurred in 28 (70%) cases, (95% CI 54% to 83%, P-value &lt; 0.001), with a relative risk reduction of 0.22 when compared to our previous results (90%). Twelve cases (30%) developed transient ECG ischemic changes (95% CI, 17% to 47%)...

Background: Hypotension is a common problem during spinal anesthesia for cesarean delivery. Intravenous fluid loading is used to correct preoperative dehydration and reduce the incidence and severity of hypotension. Different fluid regimens have been studied but colloid preload and crystalloid co-load have not been compared. Methods: In this randomized double-blind study, 210 patients scheduled for elective cesarean section under spinal anesthesia were randomly allocated to receive either 6% hydroxyethyl starch 130/0.4 500 mL before spinal anesthesia (colloid preload) or Ringer's acetate solution 1000 mL administered rapidly starting with intrathecal injection (crystalloid co-load). Maternal hypotension (systolic blood pressure <80% of baseline or <90 mmHg) and severe hypotension (systolic blood pressure <80 mmHg) were treated with 5 and 10 mg ephedrine boluses, respectively. The primary outcome was the incidence of hypotension. Secondary outcomes included the incidence of severe hypotension, total ephedrine dose, nausea and vomiting and neonatal outcome assessed by Apgar scores and umbilical artery blood gas analysis. Results: Data analysis was performed on 205 patients; 103 in the colloid preload group and 102 in the crystalloid co-load group. There were no significant differences in the incidence of hypotension (52.4% vs. 42.2%; P=0.18) or severe hypotension (15.5% vs. 9.8%; P=0.31) between colloid preload and crystalloid co-load groups, respectively. The median [range] ephedrine dose was 5 [0-45] mg in the colloid preload group and 0 [0-35] mg in the crystalloid co-load group (P=0.065). There were no significant differences in maternal nausea or vomiting or neonatal outcomes between groups. Conclusion: The use of 1000 mL crystalloid co-load has similar effect to 500 mL colloid preload in reducing the incidence of hypotension after spinal anesthesia for elective cesarean delivery. Neither technique can totally prevent hypotension and should be combined with vasopressor use.

Heart rate, mean arterial pressure, and FLACC score were significantly lower in the dexmedetomidine group compared with the control group after 4 and 8 h in ICU. Duration of intubation and ICU stay were signifi cantly shorter in the dexmedetomidine group compared with the control group. Ramsay sedation score was lower in the dexmedetomidine group compared with the control group at 4 h in ICU. Bradycardia and hypotension incidence were higher in the dexmedetomidine group compared with that in the control group.

A total of 70 pediatric patients submitted for open heart surgery by median sternotomy were randomized into two groups. The control group (n = 35) received 0.4 ml/kg normal saline with fentanyl 2 μg/ml, whereas for the bupivacaine group (n = 35) 0.4 ml/kg bupivacaine 0.25% with fentanyl 2 μg/ml was injected down each side of the paravertebral space. Heart rate, mean arterial blood pressure, perioperative opioid requirements, operating room extubation, time to extubation, postextubation PaO 2 , PaCO 2 , postoperative objective pain discomfort score, ICU length of stay, and postoperative complications were recorded.

A total of 70 pediatric patients submitted for open heart surgery by median sternotomy were randomized into two groups. The control group (n = 35) received 0.4 ml/kg normal saline with fentanyl 2 μg/ml, whereas for the bupivacaine group (n = 35) 0.4 ml/kg bupivacaine 0.25% with fentanyl 2 μg/ml was injected down each side of the paravertebral space. Heart rate, mean arterial blood pressure, perioperative opioid requirements, operating room extubation, time to extubation, postextubation PaO 2 , PaCO 2 , postoperative objective pain discomfort score, ICU length of stay, and postoperative complications were recorded.

A total of 70 pediatric patients submitted for open heart surgery by median sternotomy were randomized into two groups. The control group (n = 35) received 0.4 ml/kg normal saline with fentanyl 2 μg/ml, whereas for the bupivacaine group (n = 35) 0.4 ml/kg bupivacaine 0.25% with fentanyl 2 μg/ml was injected down each side of the paravertebral space. Heart rate, mean arterial blood pressure, perioperative opioid requirements, operating room extubation, time to extubation, postextubation PaO 2 , PaCO 2 , postoperative objective pain discomfort score, ICU length of stay, and postoperative complications were recorded.

Abstract
Objective: The aim of the present study was to evaluate the efficy of extrathoracic jugulo-femoral venous shunt (JFVS) in avoiding the need
for cardiopulmonary bypass (CPB) during the bi-directional Glenn shunt (BDGS) procedure.
Methods: A total of 40 patients aged between 9 and 36 months were enrolled in the present study. The patients were classifid into two groups,
group A (n=20) in which the patients had no veno-venous shunt and group B (n=20) in which the patients had extrathoracic JFVS. Patients
requiring CPB, arterial oxygen saturation (SaO2), heart rate, mean arterial pressure (MAP) and central venous pressure (CVP) were recorded
during surgery. Postoperative time of intubation, intensive care unit (ICU) and hospital length of stays and neurological complications were also
recorded.
Results: The number of patients who needed urgent CPB was greater in group A than in group B. Intraoperative MAP was signifiantly lower
in group A than in group B 10 min after clamping of the superior vena cava (SVC) and 30 min after declamping of the SVC. The CVP was
signifiantly lower, and arterial SaO2 was signifiantly higher in group B than in group A 10 min after clamping of the SVC. The duration of
postoperative intubation was signifiantly shorter in group B than in group A, and the ICU length of stay was shorter in group B than in group
A. The hospital length of stay was similar in both groups. Postoperative neurological defiits were comparable in both groups.
Conclusion: The use of extrathoracic JFVS during the BDGS procedure avoided the use of CPB, maintained MAP and prevented any significant increase in SVC pressure.
Keywords: Cardiopulmonary bypass, cyanotic congenial heart diseases, jugulo-femoral venous shunt, superior vena cava

Abstract
Objective: The aim of the present study was to evaluate the efficy of inhaled milrinone in controlling pulmonary arterial hypertension (PAH)
in paediatric cardiac surgery and its effct on weaning from cardiopulmonary bypass (CPB).
Methods: A total of 40 patients with congenital heart diseases complicated by PAH submitted to cardiac surgery requiring CPB were included
in the present study and were randomly classifid into the control group (n=20) who received intravenous milrinone 0.5 μg kg-1 min-1 and the
inhaled group (n=20) who received inhaled milrinone 50 μg kg-1 before initiation and just before weaning of CPB. Mean pulmonary artery
pressure (mPAP), mean systemic arterial pressure (MAP), heart rate (HR), MAP/mPAP ratio, vasoactive drug requirements and time needed to
wean the patients from CPB were collected.
Results: mPAP and HR were signifiantly lower, and MAP and MAP/mPAP ratio were signifiantly higher in the inhaled group than in the
control group. Vasoactive drug requirements were signifiantly lesser, and the time needed to wean the patients was signifiantly shorter in the
inhaled group than in the control group.
Conclusion: Milrinone inhalation facilitated the weaning from CPB as it signifiantly reduced mPAP and maintained MAP with subsequently
less needs for vasoactive drugs.
Keywords: Cardiopulmonary bypass, congenial heart diseases, milrinone inhalation, pulmonary hypertension, vasoactive drugs

Sternum is the main source of pain after cardiac surgery. The use of high doses of opioid are associated with prolonged mechanical ventilation.
Regional anesthetic techniques facilitate early recovery. Transversus thoracis plane (TTP) block is a newly developed analgesic technique that can
provide adequate analgesia for surgeries associated with sternotomy. In pediatric cardiac surgery, the dose of local anesthetics for TTP block is
not described in any of literature. In our hospital (Mansoura University Children Hospital), we perform bilateral TTP block for most of children
submitted for cardiac surgery via median sternotomy in a dose of 0.2-0.3mL/kg 0.2 to 0.25 % bupivacaine on each side of sternum. We found that,
the above dose provides effective perioperative analgesia without any signs of local anesthetic toxicity. The aim of this work is to highlight the
analgesic efficacy of TTP block and the dose of local anesthetic in children undergoing open heart surgery via median sternotomy.
Keywords: Transversus thoracis; Pediatric cardiac; Sternotomy; Block; Surgery