Administering anesthesia to patients undergoing liver transplantation often yields intraoperative... more Administering anesthesia to patients undergoing liver transplantation often yields intraoperative hemodynamic instability. During this type of major surgery, many factors may contribute to hemodynamic collapse, including myocardial infarction, pulmonary embolus, bleeding, and preload reduction owing to inferior vena cava clamping. Pneumothorax, a potentially dangerous condition, can arise unexpectedly during anesthesia. Diagnosis is based on exclusion, as the initial vital sign changes, including cardiorespiratory decompensation, are non-specific. Here, we describe the case of a patient with adult polycystic kidney disease who developed intraoperative cardiovascular collapse and hypoxemia owing to tension pneumothorax during liver and kidney transplantation. We highlight the etiology of intraoperative tension pneumothorax, the sequence of hemodynamic changes, and the importance of early diagnosis and treatment.
Low-dose remifentanil during anesthesia emergence reduces the incidence and severity of coughing.... more Low-dose remifentanil during anesthesia emergence reduces the incidence and severity of coughing. Background: Coughing during emergence may provoke sympathetic stimulation resulting in hypertension and tachycardia, and can cause increased intraocular and intracranial pressure which can be harmful in certain procedures. Several techniques have been employed to prevent coughing. Opioids during emergence are avoided because they can delay awakening by causing respiratory depression. Objective: To determine whether low-dose remifentanil decreases the incidence of coughing, non-purposeful movement, hypertension, and tachycardia during anesthesia emergence. Design: Prospective randomized double-blind study. Participants/Methods: 61 adult patients, ASA I-II, scheduled to undergo nasal surgery, were randomized into 2 groups. All patients received standardized anesthesia induction with lidocaine, propofol, rocuronium, and remifentanil bolus 1 mcg/kg and were intubated with a tube maintaining the cuff pressure at 30 cm H 2 O. Anesthesia was maintained with nitrous oxide, oxygen, isoflurane, and remifentanil infusion at a rate 0.05 to 0.5 μg/kg/minute adjusted to maintain systolic blood pressure between baseline and 20% lower. At the end of the surgery the isoflurane was stopped. Remifentanil was stopped in the control group, while in the treatment group the infusion was continued at one tenth the rate of the mean infusion but not <0.01 μg/kg /minute and was stopped after extubation. The following variables were measured every 2 minutes in the emergence period: number and grade of coughing episodes, non-purposeful movement, mean arterial pressure, heart rate, end-tidal (ET) CO 2 , Ramsay Sedation Scale, and time to respond to verbal command, to eye opening, and to tracheal extubation. Results: Smoking was equally distributed in the 2 groups. The incidence, number, and severity of coughing as well as non-purposeful movements were significantly higher in the control group when compared to the remifentanil (incidence 80% vs 40%). Coughing and non-purposeful movements occurred mainly in the presence of the endotracheal tube. Mean arterial pressure was similar between the groups but heart rate was higher in the control group after administration of reversal and after extubation (2 and 5 minutes). There was no difference between groups in the sedation, ET isoflurane, time to eye opening, response to verbal command, and in the incidence of sore throat, hoarseness, pain, and postoperative nausea and vomiting. Conclusions: The antitussive properties of remifentanil are attributed to depression of the cough reflex in the brain stem and are mediated via the opioid receptors. The ultra short half-life of remifentanil provides an advantage over the other opioids by decreasing the risk and duration of respiratory depression. This technique was used in nasal surgery patients and might not be applicable in other surgeries with greater pain medication requirements. Reviewer's Comments: Several different techniques have been used to prevent coughing: deep extubation, laryngeal mask use, topical use of local anesthetics, administration of propofol, short-acting opioids, and dexmedetomidine. Remifentanil provides an alternative choice but the selection should be tailored to the individual patient's hemodynamic, respiratory, and pain condition. (Reviewer-Ioanna Apostolidou, MD).
Background and objective Accidental dural puncture (ADP) and consequent post-dural puncture heada... more Background and objective Accidental dural puncture (ADP) and consequent post-dural puncture headache (PDPH) related to epidural needle use have prompted the design of a pencil-point epidural needle. The aim of this prospective, randomized, single-blind pilot study was to assess the efficacy, ease of use, patient satisfaction, and adverse events associated with this newly designed pencil-point epidural needle compared to a Tuohy conventional epidural needle in parturients receiving combined spinal-epidural (CSE) anesthesia for labor. Methods After obtaining the Institutional Research Board approval, 100 parturients were randomized to receive CSE anesthesia with either the new pencil-point epidural needle (Gertie Marx, IMD Inc., Huntsville, UT) (P group) or Tuohy needle (T group). We documented patients' height, weight, loss of resistance (LOR), number of attempts required, onset time of spinal anesthesia, difficulties with insertion of spinal needle, difficulties with insertion of the epidural needle and catheter, duration of the procedure, overall satisfaction of the provider and patient, ADP, PDPH, paresthesia, and pain. Results There was no difference in body mass index (BMI), LOR, number of attempts, and onset time of spinal anesthetic between the study groups. Success in obtaining cerebrospinal fluid (CSF) on the first attempt was 50/51 (98%) in the T group vs. 44/49 (89.8%) in the P group (p=0.108). The need for subsequent epidural needle readjustment to obtain CSF was higher in the P group (16/49, 32.7%) vs. the T group (3/51, 5.9%, p<0.001). Success on the first attempt with epidural catheter threading was lower with the pencil-point epidural needle compared to the Tuohy needle (69% vs. 98%, p<0.001). The anesthesiologist switched from the assigned pencil-point epidural needle to the Tuohy needle due to technical difficulties in 8/49 (16.3%) cases. The duration of the procedure was longer in the P group (16.43 ±6.33 minutes) compared to the T group (11.49 ±1.87 minutes) (p<0.001). User satisfaction was lower in the P group compared to the T group (34.7% vs. 90.2%, p<0.001). Patient satisfaction was lower with the pencil-point epidural needle compared to the Tuohy needle (75.5% vs. 92.2%, p=0.03). There was no difference in complication rates from the CSE procedure between groups (pain, paresthesia, ADP, and PDPH). Conclusion In this pilot study, the use of the pencil-point epidural needle for CSE was associated with less successful epidural catheter placement as well as low user and patient satisfaction compared to the Tuohy epidural needle. Modifications in the pencil-point epidural needle design are needed to improve efficacy and enhance user acceptance before a larger study can be conducted to evaluate the rates of ADP and PDPH.
International Journal for Quality in Health Care, 2022
Background Anesthesia practitioners are at risk for percutaneous injuries by blood-contaminated n... more Background Anesthesia practitioners are at risk for percutaneous injuries by blood-contaminated needles and sharp objects that may result in the transmission of human immunodeficiency virus and hepatitis viruses. Reporting these injuries is important for the early prevention and management of blood-borne infections. Objective To investigate the occurrence, reporting, characteristics and outcome of contaminated percutaneous injuries (CPIs) in anesthesia residents, fellows and faculty. Method A cross-sectional anonymous survey electronically distributed to all 214 anesthesia practitioners at a large academic multihospital-based anesthesia practice in Florida, USA. Results The overall response rate was 51% (110/214) (60% (50/83) for residents, 50% (8/16) for fellows and 45% (52/115) for anesthesia faculty). Fifty-nine percent (65/110) (95% confidence interval (95% CI): 5068) of participants reported having one or more CPIs during their years of anesthesia practice (residents 42% (95% C...
BACKGROUND There is an abundant need to increase the availability of deceased donor kidney transp... more BACKGROUND There is an abundant need to increase the availability of deceased donor kidney transplantation (DDKT) to address the high incidence of kidney failure. Challenges exist in the utilization of higher risk donor organs into what appears to be increasingly complex recipients; thus the identification of modifiable risk factors associated with poor outcomes is paramount. AIM To identify risk factors associated with delayed graft function (DGF). METHODS Consecutive adults undergoing DDKT between January 2016 and July 2017 were identified with a study population of 294 patients. The primary outcome was the occurrence of DGF. RESULTS The incidence of DGF was 27%. Under logistic regression, eight independent risk factors for DGF were identified including recipient body mass index ≥ 30 kg/m2, baseline mean arterial pressure < 110 mmHg, intraoperative phenylephrine administration, cold storage time ≥ 16 h, donation after cardiac death, donor history of coronary artery disease, donor terminal creatinine ≥ 1.9 mg/dL, and a hypothermic machine perfusion (HMP) pump resistance ≥ 0.23 mmHg/mL/min. CONCLUSION We delineate the association between DGF and recipient characteristics of pre-induction mean arterial pressure below 110 mmHg, metabolic syndrome, donor-specific risk factors, HMP pump parameters, and intraoperative use of phenylephrine.
Cardiac arrest occurs only about once in every 30.000 late pregnancy, and survival from such an e... more Cardiac arrest occurs only about once in every 30.000 late pregnancy, and survival from such an event is exceptional. Not only is cardiac arrest a feared entity in this population, but it is also unexpected and catastrophic. For this reason, it is necessary that the obstetric anesthesiologist be knowledgeable about the risk factors for cardiac arrest, the physical changes in the parturient and the management of CPR during pregnancy.
BackgroundAnesthesia practitioners are at inherent risk for percutaneous injuries by blood-contam... more BackgroundAnesthesia practitioners are at inherent risk for percutaneous injuries by blood-contaminated needles and sharp objects. These exposures may result in transmission of HIV and hepatitis viruses. Data about this occupational hazard from contaminated needles and sharp devices is limited and decades old. We conducted a web-based survey to assess the occurrence, reporting, characteristics, and outcome of contaminated percutaneous injuries (CPI) in anesthesia residents, fellows, and attendings.MethodsAfter institutional research board approval, an email was sent to 217 anesthesia practitioners requesting their participation in an online survey about contaminated percutaneous injuries. Responses were collected from February through March 2020. Results are reported as absolute numbers and proportions with 95% confidence interval (CI).ResultsThe overall survey response rate was 51% (110/217). 59% (65/110) (95% CI, 50–68) of participants reported having one or more contaminated perc...
Spondylothoracic dysostosis is a rare congenital disorder characterised by multiple vertebral mal... more Spondylothoracic dysostosis is a rare congenital disorder characterised by multiple vertebral malformations, shortening of the spine and fusion of the ribs at the costovertebral junction. These abnormalities create anaesthetic challenges due to difficult airway, severe restrictive lung disease and spine deformity necessitating a multidisciplinary approach and careful perioperative planning. We present the perianaesthetic management of a parturient with spondylothoracic dysostosis who successfully underwent preterm caesarean delivery under general anaesthesia with awake videolaryngoscopy-assisted tracheal intubation.
INTRODUCTION Complexity of combined heart-liver transplantation has resulted in low adoption rate... more INTRODUCTION Complexity of combined heart-liver transplantation has resulted in low adoption rates. We report a case series of adult patients receiving en-bloc heart-liver transplantation (HLTx), describe technical aspects, and discuss benefits of the technique. METHODS Retrospective review of patients receiving en-bloc HLTx over 18 months, with clinical follow up to 1 year. Primary outcomes included postoperative mortality and major complications. Secondary outcomes included 1-year survival, cardiac or hepatic allograft rejection, and infection. RESULTS Five patients received en-bloc HLTx. Mean recipient age was 43 years (26-63), and 3 patients were male. Total operative time was 430 minutes (393-480), cold and warm ischemic times of 85 (32-136) and 37.5 (31-47) minutes. Hospital survival was 80%. One patient died on postoperative day 55 due to fungal sepsis. Major postoperative complications included prolonged mechanical ventilation in 2 of 5 patients (40%), and renal insufficiency requiring hemodialysis in 2 of 5 patients (40%). Among patients discharged from hospital 1-year survival was 100%, with no evidence of rejection or infectious complications. CONCLUSION En-bloc HLTx technique is a safe and effective strategy, decreasing operative times, and allograft ischemic times, whereas offering protection of implanted allografts during early stages of reperfusion while patient is hemodynamically supported on cardiopulmonary bypass.
Seminars in Cardiothoracic and Vascular Anesthesia, 2019
Liver transplantation is a complex procedure performed on critically ill patients with multiple c... more Liver transplantation is a complex procedure performed on critically ill patients with multiple comorbidities, which requires the anesthesiologist to be facile with complex hemodynamics and physiology, vascular access procedures, and advanced monitoring. Over the past decade, there has been a continuing debate whether or not liver transplant anesthesia is a general or specialist practice. Yet, as significant data have come out in support of dedicated liver transplant anesthesia teams, there is not a guarantee of liver transplant exposure in domestic residencies. In addition, there are no standards for what competencies are required for an individual seeking fellowship training in liver transplant anesthesia. Using the Accreditation Council for Graduate Medical Education guidelines for residency training as a model, the Society for the Advancement of Transplant Anesthesia Fellowship Committee in conjunction with the Liver Transplant Anesthesia Fellowship Task Force has developed the ...
Administering anesthesia to patients undergoing liver transplantation often yields intraoperative... more Administering anesthesia to patients undergoing liver transplantation often yields intraoperative hemodynamic instability. During this type of major surgery, many factors may contribute to hemodynamic collapse, including myocardial infarction, pulmonary embolus, bleeding, and preload reduction owing to inferior vena cava clamping. Pneumothorax, a potentially dangerous condition, can arise unexpectedly during anesthesia. Diagnosis is based on exclusion, as the initial vital sign changes, including cardiorespiratory decompensation, are non-specific. Here, we describe the case of a patient with adult polycystic kidney disease who developed intraoperative cardiovascular collapse and hypoxemia owing to tension pneumothorax during liver and kidney transplantation. We highlight the etiology of intraoperative tension pneumothorax, the sequence of hemodynamic changes, and the importance of early diagnosis and treatment.
Low-dose remifentanil during anesthesia emergence reduces the incidence and severity of coughing.... more Low-dose remifentanil during anesthesia emergence reduces the incidence and severity of coughing. Background: Coughing during emergence may provoke sympathetic stimulation resulting in hypertension and tachycardia, and can cause increased intraocular and intracranial pressure which can be harmful in certain procedures. Several techniques have been employed to prevent coughing. Opioids during emergence are avoided because they can delay awakening by causing respiratory depression. Objective: To determine whether low-dose remifentanil decreases the incidence of coughing, non-purposeful movement, hypertension, and tachycardia during anesthesia emergence. Design: Prospective randomized double-blind study. Participants/Methods: 61 adult patients, ASA I-II, scheduled to undergo nasal surgery, were randomized into 2 groups. All patients received standardized anesthesia induction with lidocaine, propofol, rocuronium, and remifentanil bolus 1 mcg/kg and were intubated with a tube maintaining the cuff pressure at 30 cm H 2 O. Anesthesia was maintained with nitrous oxide, oxygen, isoflurane, and remifentanil infusion at a rate 0.05 to 0.5 μg/kg/minute adjusted to maintain systolic blood pressure between baseline and 20% lower. At the end of the surgery the isoflurane was stopped. Remifentanil was stopped in the control group, while in the treatment group the infusion was continued at one tenth the rate of the mean infusion but not <0.01 μg/kg /minute and was stopped after extubation. The following variables were measured every 2 minutes in the emergence period: number and grade of coughing episodes, non-purposeful movement, mean arterial pressure, heart rate, end-tidal (ET) CO 2 , Ramsay Sedation Scale, and time to respond to verbal command, to eye opening, and to tracheal extubation. Results: Smoking was equally distributed in the 2 groups. The incidence, number, and severity of coughing as well as non-purposeful movements were significantly higher in the control group when compared to the remifentanil (incidence 80% vs 40%). Coughing and non-purposeful movements occurred mainly in the presence of the endotracheal tube. Mean arterial pressure was similar between the groups but heart rate was higher in the control group after administration of reversal and after extubation (2 and 5 minutes). There was no difference between groups in the sedation, ET isoflurane, time to eye opening, response to verbal command, and in the incidence of sore throat, hoarseness, pain, and postoperative nausea and vomiting. Conclusions: The antitussive properties of remifentanil are attributed to depression of the cough reflex in the brain stem and are mediated via the opioid receptors. The ultra short half-life of remifentanil provides an advantage over the other opioids by decreasing the risk and duration of respiratory depression. This technique was used in nasal surgery patients and might not be applicable in other surgeries with greater pain medication requirements. Reviewer's Comments: Several different techniques have been used to prevent coughing: deep extubation, laryngeal mask use, topical use of local anesthetics, administration of propofol, short-acting opioids, and dexmedetomidine. Remifentanil provides an alternative choice but the selection should be tailored to the individual patient's hemodynamic, respiratory, and pain condition. (Reviewer-Ioanna Apostolidou, MD).
Background and objective Accidental dural puncture (ADP) and consequent post-dural puncture heada... more Background and objective Accidental dural puncture (ADP) and consequent post-dural puncture headache (PDPH) related to epidural needle use have prompted the design of a pencil-point epidural needle. The aim of this prospective, randomized, single-blind pilot study was to assess the efficacy, ease of use, patient satisfaction, and adverse events associated with this newly designed pencil-point epidural needle compared to a Tuohy conventional epidural needle in parturients receiving combined spinal-epidural (CSE) anesthesia for labor. Methods After obtaining the Institutional Research Board approval, 100 parturients were randomized to receive CSE anesthesia with either the new pencil-point epidural needle (Gertie Marx, IMD Inc., Huntsville, UT) (P group) or Tuohy needle (T group). We documented patients' height, weight, loss of resistance (LOR), number of attempts required, onset time of spinal anesthesia, difficulties with insertion of spinal needle, difficulties with insertion of the epidural needle and catheter, duration of the procedure, overall satisfaction of the provider and patient, ADP, PDPH, paresthesia, and pain. Results There was no difference in body mass index (BMI), LOR, number of attempts, and onset time of spinal anesthetic between the study groups. Success in obtaining cerebrospinal fluid (CSF) on the first attempt was 50/51 (98%) in the T group vs. 44/49 (89.8%) in the P group (p=0.108). The need for subsequent epidural needle readjustment to obtain CSF was higher in the P group (16/49, 32.7%) vs. the T group (3/51, 5.9%, p<0.001). Success on the first attempt with epidural catheter threading was lower with the pencil-point epidural needle compared to the Tuohy needle (69% vs. 98%, p<0.001). The anesthesiologist switched from the assigned pencil-point epidural needle to the Tuohy needle due to technical difficulties in 8/49 (16.3%) cases. The duration of the procedure was longer in the P group (16.43 ±6.33 minutes) compared to the T group (11.49 ±1.87 minutes) (p<0.001). User satisfaction was lower in the P group compared to the T group (34.7% vs. 90.2%, p<0.001). Patient satisfaction was lower with the pencil-point epidural needle compared to the Tuohy needle (75.5% vs. 92.2%, p=0.03). There was no difference in complication rates from the CSE procedure between groups (pain, paresthesia, ADP, and PDPH). Conclusion In this pilot study, the use of the pencil-point epidural needle for CSE was associated with less successful epidural catheter placement as well as low user and patient satisfaction compared to the Tuohy epidural needle. Modifications in the pencil-point epidural needle design are needed to improve efficacy and enhance user acceptance before a larger study can be conducted to evaluate the rates of ADP and PDPH.
International Journal for Quality in Health Care, 2022
Background Anesthesia practitioners are at risk for percutaneous injuries by blood-contaminated n... more Background Anesthesia practitioners are at risk for percutaneous injuries by blood-contaminated needles and sharp objects that may result in the transmission of human immunodeficiency virus and hepatitis viruses. Reporting these injuries is important for the early prevention and management of blood-borne infections. Objective To investigate the occurrence, reporting, characteristics and outcome of contaminated percutaneous injuries (CPIs) in anesthesia residents, fellows and faculty. Method A cross-sectional anonymous survey electronically distributed to all 214 anesthesia practitioners at a large academic multihospital-based anesthesia practice in Florida, USA. Results The overall response rate was 51% (110/214) (60% (50/83) for residents, 50% (8/16) for fellows and 45% (52/115) for anesthesia faculty). Fifty-nine percent (65/110) (95% confidence interval (95% CI): 5068) of participants reported having one or more CPIs during their years of anesthesia practice (residents 42% (95% C...
BACKGROUND There is an abundant need to increase the availability of deceased donor kidney transp... more BACKGROUND There is an abundant need to increase the availability of deceased donor kidney transplantation (DDKT) to address the high incidence of kidney failure. Challenges exist in the utilization of higher risk donor organs into what appears to be increasingly complex recipients; thus the identification of modifiable risk factors associated with poor outcomes is paramount. AIM To identify risk factors associated with delayed graft function (DGF). METHODS Consecutive adults undergoing DDKT between January 2016 and July 2017 were identified with a study population of 294 patients. The primary outcome was the occurrence of DGF. RESULTS The incidence of DGF was 27%. Under logistic regression, eight independent risk factors for DGF were identified including recipient body mass index ≥ 30 kg/m2, baseline mean arterial pressure < 110 mmHg, intraoperative phenylephrine administration, cold storage time ≥ 16 h, donation after cardiac death, donor history of coronary artery disease, donor terminal creatinine ≥ 1.9 mg/dL, and a hypothermic machine perfusion (HMP) pump resistance ≥ 0.23 mmHg/mL/min. CONCLUSION We delineate the association between DGF and recipient characteristics of pre-induction mean arterial pressure below 110 mmHg, metabolic syndrome, donor-specific risk factors, HMP pump parameters, and intraoperative use of phenylephrine.
Cardiac arrest occurs only about once in every 30.000 late pregnancy, and survival from such an e... more Cardiac arrest occurs only about once in every 30.000 late pregnancy, and survival from such an event is exceptional. Not only is cardiac arrest a feared entity in this population, but it is also unexpected and catastrophic. For this reason, it is necessary that the obstetric anesthesiologist be knowledgeable about the risk factors for cardiac arrest, the physical changes in the parturient and the management of CPR during pregnancy.
BackgroundAnesthesia practitioners are at inherent risk for percutaneous injuries by blood-contam... more BackgroundAnesthesia practitioners are at inherent risk for percutaneous injuries by blood-contaminated needles and sharp objects. These exposures may result in transmission of HIV and hepatitis viruses. Data about this occupational hazard from contaminated needles and sharp devices is limited and decades old. We conducted a web-based survey to assess the occurrence, reporting, characteristics, and outcome of contaminated percutaneous injuries (CPI) in anesthesia residents, fellows, and attendings.MethodsAfter institutional research board approval, an email was sent to 217 anesthesia practitioners requesting their participation in an online survey about contaminated percutaneous injuries. Responses were collected from February through March 2020. Results are reported as absolute numbers and proportions with 95% confidence interval (CI).ResultsThe overall survey response rate was 51% (110/217). 59% (65/110) (95% CI, 50–68) of participants reported having one or more contaminated perc...
Spondylothoracic dysostosis is a rare congenital disorder characterised by multiple vertebral mal... more Spondylothoracic dysostosis is a rare congenital disorder characterised by multiple vertebral malformations, shortening of the spine and fusion of the ribs at the costovertebral junction. These abnormalities create anaesthetic challenges due to difficult airway, severe restrictive lung disease and spine deformity necessitating a multidisciplinary approach and careful perioperative planning. We present the perianaesthetic management of a parturient with spondylothoracic dysostosis who successfully underwent preterm caesarean delivery under general anaesthesia with awake videolaryngoscopy-assisted tracheal intubation.
INTRODUCTION Complexity of combined heart-liver transplantation has resulted in low adoption rate... more INTRODUCTION Complexity of combined heart-liver transplantation has resulted in low adoption rates. We report a case series of adult patients receiving en-bloc heart-liver transplantation (HLTx), describe technical aspects, and discuss benefits of the technique. METHODS Retrospective review of patients receiving en-bloc HLTx over 18 months, with clinical follow up to 1 year. Primary outcomes included postoperative mortality and major complications. Secondary outcomes included 1-year survival, cardiac or hepatic allograft rejection, and infection. RESULTS Five patients received en-bloc HLTx. Mean recipient age was 43 years (26-63), and 3 patients were male. Total operative time was 430 minutes (393-480), cold and warm ischemic times of 85 (32-136) and 37.5 (31-47) minutes. Hospital survival was 80%. One patient died on postoperative day 55 due to fungal sepsis. Major postoperative complications included prolonged mechanical ventilation in 2 of 5 patients (40%), and renal insufficiency requiring hemodialysis in 2 of 5 patients (40%). Among patients discharged from hospital 1-year survival was 100%, with no evidence of rejection or infectious complications. CONCLUSION En-bloc HLTx technique is a safe and effective strategy, decreasing operative times, and allograft ischemic times, whereas offering protection of implanted allografts during early stages of reperfusion while patient is hemodynamically supported on cardiopulmonary bypass.
Seminars in Cardiothoracic and Vascular Anesthesia, 2019
Liver transplantation is a complex procedure performed on critically ill patients with multiple c... more Liver transplantation is a complex procedure performed on critically ill patients with multiple comorbidities, which requires the anesthesiologist to be facile with complex hemodynamics and physiology, vascular access procedures, and advanced monitoring. Over the past decade, there has been a continuing debate whether or not liver transplant anesthesia is a general or specialist practice. Yet, as significant data have come out in support of dedicated liver transplant anesthesia teams, there is not a guarantee of liver transplant exposure in domestic residencies. In addition, there are no standards for what competencies are required for an individual seeking fellowship training in liver transplant anesthesia. Using the Accreditation Council for Graduate Medical Education guidelines for residency training as a model, the Society for the Advancement of Transplant Anesthesia Fellowship Committee in conjunction with the Liver Transplant Anesthesia Fellowship Task Force has developed the ...
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