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This study examined the characteristics, intraoperative, and postoperative course of patients undergoing inferior vena cava tumor thrombectomy for metastatic renal cell carcinoma.A single-center case series that reported demographic data and intraoperative and postoperative outcomes for patients with renal cell carcinoma undergoing inferior vena cava thrombectomy.This investigation was performed at a large quaternary referral center.Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2005, to March 10, 2017, undergoing inferior vena cava thrombectomy for level III and IV renal cell carcinoma.No interventions were performed.Sixty-five patients who met the inclusion criteria were identified, with 31 patients diagnosed with level III and 34 with level IV renal cell carcinoma. Patients with level IV tumors were significantly more likely to have greater intraoperative blood loss, had longer surgical duration and hospital stays, and had more frequently required blood products, pressors, and cardiopulmonary bypass intraoperatively. Intraoperative transesophageal echo was more frequently used in level IV thrombectomy compared to level III (91.2% v 67.7%). Of patients with level IV thrombus, 41.2% developed postoperative atrial fibrillation compared to only 3.2% with level III thrombus. The 30-day mortality was 4.6% for both groups.Patients undergoing inferior vena cava tumor thrombectomy for renal cell carcinoma had more complex intraoperative and postoperative courses with level IV compared to level III tumor thrombus.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, with an individual lifetime risk of approximately 37% in the United States. Broadly defined as a supraventricular tachyarrhythmia with disorganized atrial activation, AF results in an increased risk of stroke, heart failure, valvular heart disease, and impaired quality of life, and confers a significant burden on the health of individuals and society. AF in the perioperative setting is common and a significant source of perioperative morbidity and mortality worldwide. The latest iteration of the European Society of Cardiology AF guidelines published in 2020 provide the clinician a valuable road map for the management of this arrythmia. This expert review will comprehensively analyze the 2020 European Society of Cardiology guidelines and provide perioperative management tools for the clinician.

High-dose heparin has been suggested to reduce consumption coagulopathy.In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements.There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups.Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.

INTRODUCTION: Transesophageal echocardiography (TEE) is increasingly used for intraoperative management during orthotopic liver transplantation. Proficient TEE use requires skill and knowledge to accurately assess the hemodynamic status and guide clinical management. Currently there are no TEE educational tracks specifically focused on perioperative liver transplant management and barriers to obtaining basic certification exist. METHODS: A 4-hour simulation-based learning (SBL) course was provided to improve liver transplant anesthesiologist TEE knowledge and skill. Learners received training and education using a TEE simulator in small groups focusing on basic image acquisition, relevant anatomy, hemodynamic calculations, and pathology germane to the liver transplant period. Knowledge assessment and survey responses were assessed at the beginning and completion of the course. Learners completed TEE examinations with simulated pathology during high-fidelity simulations following the course. RESULTS: Seventeen anesthesiologists completed the course. The median baseline knowledge assessment score was 55.0% (37–70). The median postcourse knowledge assessment score improved to 95.0% (94–100) (P < .001). All anesthesiologists were able to identify TEE pathology during high-fidelity simulation. Survey responses yielded significant median score improvement in all areas assessed using a 5-point Likert scale. CONCLUSIONS: A small group, simulation TEE course delivered over 4 hours can increase knowledge and skill in TEE use for liver transplant anesthesiologists.

PURPOSE OF REVIEW The success of the Fontan procedure has led to increased survival of patients born with certain congenital heart disease to the point that new sequlae, as a result of Fontan circulation, are being discovered. Included among these is Fontan-associated liver disease (FALD). The purpose of this review is to present available literature on the perioperative management of the combined heart--liver transplantation (CHLT) in patients with FALD. RECENT FINDINGS The perioperative management of a combined heart-liver transplant in a patient with Fontan circulation is complex. The patient is at risk for hemodynamic disturbances, significant blood loss, coagulopathies, and metabolic derangements. The maintenance of an appropriate transpulmonary pressure gradient is paramount to success. Postoperative management should be accomplished by a multidisciplinary care team. Limited series have demonstrated good outcomes in patients who have undergone CHLT. SUMMARY The perioperative management of CHLT in patients with FALD is complex and available literature is limited. Future studies are needed to further assess proper perioperative management of patients with FALD who undergo CHLT.

Platelet (PLT) transfusions are an important component of hemostatic resuscitation. The AABB has published several guidelines recommending that PLT units should not be infused through blood warming devices. STUDY DESIGN AND METHODS Thirty-one units of hospital blood bank apheresis PLTs were obtained. PLT-rich plasma (PRP) aggregometry and thromboelastography (TEG) were performed on the unit samples before and after the units were infused through a Ranger blood/fluid warming device. RESULTS There were no differences in any of the aggregometry results before and after infusion of the PLTs through the blood warmer (all P > .32). There was a significant reduction in the TEG maximum amplitude (MA) of 69.8 ± 7.9 mm before and 66.0 ± 8.8 mm after (P

Neuromuscular blockade (NMB) reversal with neostigmine and glycopyrrolate has been reported to cause cardiac arrest in patients with a history of cardiac transplantation. The purpose of this study was to examine the safety of NMB reversal with acetylcholinesterase inhibitors and muscarinic anticholinergics in these patients.We queried the medical records of a large tertiary referral center for patients with a history of prior heart transplantation who underwent anesthesia including receipt of NMB reversal. Patient records were reviewed to investigate maximal decrease in heart rate (HR) after NMB reversal and incidence of death and cardiac arrest.Seventy-seven heart transplant patients underwent 118 subsequent anesthetics during which they received neostigmine and glycopyrrolate for NMB reversal. No patients had active pacemakers at the time of their anesthetics. Mean time from heart transplantation to NMB reversal was 2.9 ± 3.2 (median, 1.9; range, 0.01- 12.5) years. After NMB reversal, no patients received atropine or epinephrine, suffered cardiac arrest, or died within 30 days. Mean HR decrease, defined as the difference between the HR immediately before NMB reversal and the lowest HR within 5 minutes thereafter, after NMB reversal was 0.5 ± 3.2 with median 0 (range, -8 to 17) beats per minute. Mean HR decrease was not associated with transplantation type (biatrial versus bicaval, P = 0.2029) or with increasing duration of time from cardiac transplantation (P = 0.0874).Although rare cases of cardiac arrest after NMB reversal have been reported, our experience would support the safety of neostigmine and glycopyrrolate in cardiac transplantation patients.

• Patients with drug-resistant epilepsy may have an implanted vagal nerve stimulator (VNS).

Successful restoration of declining anadromous species is dependent upon effective riparian buffer zone management. Natural resource managers, policy developers and local conservation groups require science-based information concerning the width at which a given buffer will be effective for its stated purpose. This paper summarizes a method developed in 1999 to determine effective riparian buffer widths for Atlantic salmon habitat protection as part of the Atlantic Salmon Conservation Plan for Seven Maine Rivers. A major assumption of the method is that no two buffers are alike with respect to their effectiveness and that various buffer characteristics dictate the required width for a given level of effectiveness. The method uses a predictive model that generates suggested riparian buffer widths as a function of specific, measurable buffer characteristics (such as slope, soil characteristics, and plant community structure and density) that affect buffer function. The method utilizes a variable-width, two-zone approach and specifies land uses that are consistent with desired buffer function within the two zones.