Liver transplantation(LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver trans-plant candi...Liver transplantation(LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver trans-plant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the pro-cedures as a result of both the disease process and the surgery. Transoesophageal echocardiography(TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. More-over, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.展开更多
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase...Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase life expectancy in what was previously considered a "terminal condition". Anyway patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Despite the need of an advanced organ monitoring and support all these derangements seem to be mild and short-lived when timely addressed, at least in the majority of patients. Intensive care physicians are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover, the anesthesiologist as perioperative physician is involved in pain control, metabolic and nutritional support of this cohort of patients. This task can be challenging considering that part of the patients are already on a long list of pain control medication after previous surgery or chemotherapy. A malnourished state is common too and it is secondary to diffi cult feeding, wasting syndrome from the tumor and massive ascites. The last issue the anesthesiologists need to be aware of is the impact over the quality of life(Qo L) of this procedure. The patient's underlying pathology is unlikely to be defi nitively cured so no treatment is an acceptable choice. The possibility to withhold the treatments must be part of the consultation process like the discussion about the Qo L in the immediate, as well as in the long-term, after the operation. Careful monitoring and treatment of every aspect that can impact the Qo L must be taken and the efforts to be poured into an effective preservation of the Qo L must be doubled when compared with a patient scheduled for major abdominal surgery.展开更多
文摘Liver transplantation(LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver trans-plant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the pro-cedures as a result of both the disease process and the surgery. Transoesophageal echocardiography(TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. More-over, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.
文摘Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase life expectancy in what was previously considered a "terminal condition". Anyway patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Despite the need of an advanced organ monitoring and support all these derangements seem to be mild and short-lived when timely addressed, at least in the majority of patients. Intensive care physicians are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover, the anesthesiologist as perioperative physician is involved in pain control, metabolic and nutritional support of this cohort of patients. This task can be challenging considering that part of the patients are already on a long list of pain control medication after previous surgery or chemotherapy. A malnourished state is common too and it is secondary to diffi cult feeding, wasting syndrome from the tumor and massive ascites. The last issue the anesthesiologists need to be aware of is the impact over the quality of life(Qo L) of this procedure. The patient's underlying pathology is unlikely to be defi nitively cured so no treatment is an acceptable choice. The possibility to withhold the treatments must be part of the consultation process like the discussion about the Qo L in the immediate, as well as in the long-term, after the operation. Careful monitoring and treatment of every aspect that can impact the Qo L must be taken and the efforts to be poured into an effective preservation of the Qo L must be doubled when compared with a patient scheduled for major abdominal surgery.
