SATA

Society for the Advancement of Transplant Anesthesia

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Midwest Regional Meeting Registration Information

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The MidWEST SATA Meeting

Saturday, JANUARY, 21, 2023

08:55 Am – 12:30 PM (CST)

 

Course Syllabus

Program overview:

This SATA regional meeting will provide discussion of novel areas of interest in liver, heart, and lung transplantation.

 

Learning objectives:

At the end of this session participants will be able to:

 

  1. Determine the potential benefits and challenges of veno-venous bypass in liver transplantation
  2. Understand intraoperative management of recipients of DCD donation in liver transplantation
  3. Analyze the various vascular complications in the early postoperative period in lung transplantation
  4. Identify the role of new technology, including ex-vivo perfusion, in lung transplantation
  5. Understand changes in allocation policy in heart transplantation
  6. Assess intraoperative transesophageal echocardiography in patients undergoing heart transplantation
  7. Define the current state of DCD donation in heart transplantation

 

Target audience:

Anesthesiologists, intensivists, surgeons, fellows, resident, medical students, nurse anesthetists, advanced practice nurses, anesthesiologist assistants, physician assistants, and nursing staff who are involved in the perioperative care of transplant patients.

Faculty listing

 

Richa Dhawan, MD MPH                                           Michael Essandoh, MD

Associate Professor                                                               Clinical Professor

Department of Anesthesia and Critical Care                   Department of Anesthesiology

University of Chicago, Chicago, IL                                    Ohio State University, Columbus, OH

 

 

Mariya Geube, MD FASE                                           Ivan Kangrga, MD PhD

Assistant Professor                                                              Professor

Department of Anesthesiology                                         Department of Anesthesiology

Cleveland Clinic, Cleveland, OH                                       Washington University, St.Louis, MO

 

 

Choy R. Lewis, MD                                                     Maria Lucia Madariaga, MD

Associate Professor                                                            Assistant Professor

Department of Anesthesiology                                       Department of Surgery

Northwestern Medicine, Chicago, IL                             University of Chicago, Chicago, IL

 

 

Anthony L. Panos, MD                                               Sudhakar Subramani, MD, MMed, FASE

Professor                                                                               Clinical Associate Professor

Department of Surgery                                                      Department of Anesthesiology

University of Iowa, Iowa City, IA                                    University of Iowa, Iowa City, IA

 

 

Tetsuro Sakai, MD, PhD, MHA, FASA                    Jeffrey Leighton Tong, MBChB

President SATA                                                              Associate Professor

Professor                                                                                  Department of Anesthesia and Critical Care

Department of Anesthesiology                                            University of Chicago, Chicago, IL

University of Pittsburgh, Pittsburgh, PA

 

 

Kristin Trela, MD                                                        Andrea Vannucci, MD

Assistant Professor                                                          Associate Professor

Department of Anesthesia and Critical Care             Department of Anesthesia and Critical Care

University of Chicago, Chicago, IL                              University of Chicago, Chicago, IL

 

 

Accreditation and CME credit designation:

SATA (The Society for the Advancement of Transplant Anesthesia), University of Pittsburgh Medical Center

 

Program organizing institution 

University of Chicago (Meeting Chair: Richa Dhawan, MD MPH, FASE)

 

Platform:

https://us02web.zoom.us/j/88691487271?pwd=alhoNEsyRUdZYW1jcVN3SmRBa3NjZz09

Password will be provided upon registration below

 

Registration:  Online Registration (Please complete your registration form for attendance purposes and to receive the hybrid link.)  

 

Registration Fee:

  • US $30.00 at registration to SATA (via above), if you need CME credits
  • Free registration for:
    • Current SATA members and members of the Society of Cardiovascular Anesthesiologists (SCA)
    • Lecturers and moderators of the meeting
    • Trainees, medical students, international medical personals, or nursing specialist who do not need CME credits

 

PROGRAM

 

8:55 – 9:00 AM            Welcome and Introduction

                                    Richa Dhawan MD, MPH

 

9:00 – 9:50 AM            Liver Transplantation Session

                                      (Moderator: Jeffrey Leighton Tong MBChB)

 

9:00 – 9:25 AM                        Use of veno-venous bypass in liver transplantation

                                    Andrea Vannucci MD

 

9:25 – 9:50 AM                        Intraoperative management of a DCD liver transplant recipient

                                    Ivan Kangrga MD, PhD

 

9:50 – 10:40 AM           Lung Transplantation Session

                                      (Moderator: Sudhakar Subramani MD, MMed)

 

9:50 – 10:15 AM          The future of lung transplantation: New technology, ex-vivo perfusion and bioengineered lungs

                                    Maria Lucia Madariaga MD

 

10:15 – 10:40 AM        Vascular complications in lung transplantation

                                    Michael Essandoh MD

 

10:40 – 10:50 AM        SATA President Address

                                    Tetsuro Sakai MD, PhD, MHA, FASA

 

10:50 – 11:05 AM        BREAK

 

11:05 AM-12:20 PM   Heart Transplantation Session

(Moderator: Kristin Trela MD & Richa Dhawan MD, MPH)

 

11:05 – 11: 30 AM      Allocation policy, past, present, future

                                    Anthony Panos MD

 

11:30 – 11: 50 AM      Echocardiography assessment for heart transplantation

                                    Mariya Geube MD

 

11:50 AM–12:20 PM   Update on DCD donor donation

                                    Choy Lewis MD

 

12:20-12:30 PM          Closing Remarks

Richa Dhawan MD, MPH

 

Continuing Education Credit

In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 

Physician (CME)

The University of Pittsburgh designates this live activity for a maximum of TBA AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

Other Health Care Professionals

Other health care professionals will receive a certification of attendance confirming the number of contact hours commensurate with the extent of participation in this activity. 

 

Faculty Disclosure- TBD

All individuals in a position to control the content of this education activity including members of the planning committee, speakers, presenters, authors, and/or content reviewers have disclosed all relevant financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients.

The following relevant financial relationships were disclosed:

 

  • Tetsuro Sakai, MD, PhD, MHA (Haemonetics Inc. Research Grant)

 

No other planners, members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships to disclose.

  

Disclaimer Statement

The information presented at this CME program represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses.

 

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SATA Southeastern Regional Meeting – Thoracic Transplantation

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SATA Southeastern Regional Meeting – SATA Presidential Address

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SATA Southeastern Regional Meeting – Abdominal Transplantation

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SATA MidState Regional Meeting – Case Presentations

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SATA MidState Regional Meeting – Current Dilemmas in Transplantation Session

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SATA MidState Regional Meeting – Cardiopulmonary Considerations in Transplantation Session

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SATA MidState Regional Meeting – SATA Address

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September 2022 – Article of the Month

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Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study

Abstract

Background: Postreperfusion syndrome (PRS) after portal vein reperfusion during liver transplantation (LT) has been reported to cause rapid hemodynamic changes and is associated with a prolonged postoperative hospital stay, renal failure, and increased mortality. Although there are some reports on risk factors for PRS in brain-dead donor LT, there are a few reports on those in living donor LT. Therefore, we retrospectively reviewed the factors associated with PRS to contribute to the anesthetic management so as to reduce PRS during living donor LT.

Methods: After approval by the ethics committee of our institution, 250 patients aged ≥20 years who underwent living donor LT at our institution between January 2013 and September 2018 were included in the study. A decrease in mean arterial pressure of ≥30% within 5 minutes after portal vein reperfusion was defined as PRS, and estimates and odds ratio (OR) for PRS were calculated using logistic regression. The backward method was used for variable selection in the multivariable analysis.

Results: Serum calcium ion concentration before reperfusion (per 0.1 mmol/L increase; OR, 0.74; 95% confidence interval (CI), 0.60-0.95; P < .001), preoperative echocardiographic left ventricular end-diastolic diameter (per 1-mm increase: OR, 0.90; 95% CI, 0.85-0.95; P < .001, men [versus women: OR, 2.45; 95% CI, 1.26-4.75; P = .008]), mean pulmonary artery pressure before reperfusion (restricted cubic spline, P = .003), anhepatic period (restricted cubic spline, P = .02), and graft volume to standard liver volume ratio (restricted cubic spline, P = .03) were significantly associated with PRS.

Conclusions: In living donor LT, male sex and presence of small left ventricular end-diastolic diameter, large graft volume, and long anhepatic period are associated with PRS, and a high calcium ion concentration and low pulmonary artery pressure before reperfusion are negatively associated with PRS.

Comments by Scott Byram M.D.

Summary:

Hemodynamic management is often difficult and complex during orthotopic liver transplantation (OLT).  One stage that can be particularly challenging to the anesthesiologist is the initiation of the neohepatic stage signaled by reperfusion of the liver graft.  Post reperfusion syndrome (PRS) is known to cause rapid hemodynamic changes and is seen within minutes of opening the portal vein.  The exact mechanism of PRS is still not understood, but is most likely multifactorial.  PRS has been associated with several poor postoperative outcomes including renal failure, increased length of stay, and increased mortality. 

                In this retrospective study, the authors sought to identify risk factors for developing PRS after  living donor (LD) OLT.  Most prior studies on this topic have examined PRS with brain death donors.  For this study, PRS was defined as a decrease in mean arterial pressure by more than 30% within 5 minutes of reperfusion that persisted for longer than 1 minute.  250 charts of LD OLT recipients were reviewed.  Of these patients, 73 (29%) met the criteria for PRS. There were no significant baseline differences in sex, age, liver function, general condition, comorbidities, blood pressure, or medication between the two groups (PRS vs. non-PRS).  Through multi-variable statistical analysis, the authors identified five significant risk factors for developing PRS.  Characteristics associated with increased risk for PRS were: male sex, low left ventricular end-diastolic diameter on pre-op TTE, prolonged anhepatic duration, large graft volume, low ionized calcium just prior to reperfusion, and high mean pulmonary artery pressure (mPAP) just prior to reperfusion.    These last two risk factors are particularly interesting because the anesthesiologist is able to modify both calcium concentration and mPAP prior to reperfusion, therefore potentially decreasing the risk for PRS.

                The authors went on to speculate as to why these risk factors play a role in the development of PRS.  However, they strongly cautioned readers not to assume that these associations were causative given the retrospective nature of this study.  The ultimate conclusion of this paper was that these five factors could aid in predicting the probability of PRS, but randomized control trials would be needed to establish preventative strategies.

References

  1. Umehara K, Karashima Y, Yoshizumi T, Yamaura K. Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study. Anesth Analg. 2022 Aug 1;135(2):354-361. doi: 10.1213/ANE.0000000000006002. Epub 2022 Jul 5. PMID: 35343925.

 

Article of the Month July 2022

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Hyponatremia and Liver Transplantation: A Narrative Review.

Abstract:

Hyponatremia is a common electrolyte disorder in patients with end-stage liver disease (ESLD) and is associated with increased mortality on the liver transplantation (LT) waiting list. The impact of hyponatremia on outcomes after LT is unclear. Ninety-day and one-year mortality may be increased, but the data are conflicting. Hyponatremic patients have an increased rate of complications and longer hospital stays after transplant. Although rare, osmotic demyelination syndrome (ODS) is a feared complication after LT in the hyponatremic patient. The condition may occur when the serum sodium (sNa) concentration increases excessively during or after LT. This increase in sNa concentration correlates with the degree of preoperative hyponatremia, the amount of intraoperative blood loss, and the volume of intravenous fluid administration. The risk of developing ODS after LT can be mitigated by avoiding large perioperative increases in sNa concentration. This can be achieved through measures such as carefully increasing the sNa pretransplant, and by limiting the intravenous intra- and postoperative amounts of sodium infused. SNa concentrations should be monitored regularly throughout the entire perioperative period.

Comments made by Cale Kassel M.D., FASA  

Summary:

Anesthesiologists encounter hyponatremia in LT patients frequently. This review outlines the multiple factors that contribute to the development and management of hyponatremia.[1] While the risk of hyponatremia is well-known for patients on the waiting list, the effect on post-operative outcomes remains unclear. A few early studies on hyponatremia in LT showed increased 90-day mortality but more recent studies listed show no difference. However, some research does show increased ICU length of stay and morbidity. Of note, one study of over 40,000 patients did show increased mortality for patients with serum sodium less than 120 mmol/L indicating perhaps serve or profound hyponatremia may carry more risk.

Osmotic demyelination syndrome (ODS) is the biggest concern with rapid serum sodium correction. This potentially lethal condition can occur when serum sodium is increased more than 8 mmol/L in 24 hours. Incidence of ODS is 0.8-1.4% in LT patients compared to 0.6% in the general population and carries a higher risk of morbidity and mortality (77% for LT patients vs. 45% for non-LT patients).

Perioperative management of hyponatremia requires attention from the pre-operative evaluation through the post-operative period. While time is often limited pre-LT, there are a few options to increase serum sodium. Holding loop diuretics, free-water restriction, and high-concentration albumin (25%) can be used. Consulting with the nephrology team can be of great value as well.

Intra-operative management certainly can be challenging. Close monitoring is essential and understanding the sodium concentration of the fluids, medications, and blood products use can guide your treatment. The use of viscoelastic testing should be considered to limit the use of blood products such as plasma (with a sodium concentration of 172 mmol/L). The use of CRRT can typically uses a dialysate solution with 140 mmol/L of sodium so in patients with hyponatremia, discussion with the nephrologists is needed to explore ways to decrease sodium concentration. The authors cite a suggestion that adds sterile water (in predefined amounts) to create hyponatremic dialysate solutions.

Many solutions and blood products we administer contain significant sodium concentrations. The authors provide a great table with the recommended amount of D5W you can add to reduce the sodium concentration to 125 mmol/L. For example, a liter of normal saline would require the addition of 232 mL of D5W. In lieu of fresh frozen plasma or cryoprecipitate, the use of factor concentrates can help improve the coagulation profile without significant increases in sodium concentration.

Post-operatively, continued monitoring is important as the fluid shifts can continue despite the new graft. Again, limiting the increase of serum sodium to less than 4-6 mmol/L per 24 hours is important as is monitoring for signs of ODS.

Overall, this review was a great summary of the current state of knowledge while also providing several useful clinical suggestions for anesthesiologists.

References:

[1] Verbeek TA, Saner FH, Bezinover D. Hyponatremia and Liver Transplantation: A Narrative Review. Journal of cardiothoracic and vascular anesthesia 2022;36(5):1458-1466. DOI: https://doi.org/10.1053/j.jvca.2021.05.027.