Episode 68: Liver transplant with Meera Gupta

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We learn about liver transplant with Dr. Meera Gupta, transplant surgeon at the University of Kentucky Healthcare Transplant Center, and surgical director of the Kidney and Pancreas Transplant Program. We discuss eligibility, triage, the peri-operative course, and important post-op complications.

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Takeaway lessons

  1. Liver transplant eligibility is based on need, not time on the list. The MELD score (MELD 3 now, including albumin) is used for this, with MELD >9 (historically >15) considered the cutoff for transplant potentially exceeding the risk of not transplanting.
  2. Livers can now be placed on warm perfusion pumps, allowing continued viability for much longer. This is mainly used in donors who died from cardiac death, those with high BMI or similar risks for primary non-function (i.e. the transplanted liver never starts working), and longer transport distances or expected operative times.
  3. Incision is a large right subcostal incision, extended as needed. The liver hilum is dissected, preserving the feeding vessels. Caval clamping may be tested, then the liver is removed. This anhepatic phase in minimized to <60 minutes, preferably <45 minutes. The new liver is then anastomosed to the portal veins, vena cava, hepatic artery, and the bile duct. Some instability can occur during reperfusion, such as right heart strain, electrolyte abnormalities, or volume shifts.
  4. Patients will usually remain intubated post-op, lines in place. Sedation ideally is limited so the patient can rouse and confirm the absence of encephalopathy. Systolic BP is closely watched (goal >90), as diastolic BP tends to be low in most liver failure patients. Hepatopulmonary patients can rest on the vent a little longer and are expected to remain on oxygen for the time being. Patients can be fed once extubated and stable.
  5. High-dose steroids are loaded up front and then tapered, and oral immunosuppression initiated soon after.
  6. Some AKI is common. Colloid like albumin is favored early.
  7. Chronic thrombocytopenia is common and is monitored to determine when DVT prophylaxis can be started. Platelets >20k are targeted.
  8. If INR >2, vitamin K is given empirically. FFP is usually not given prophylactically. Bleeding is usually considered a little preferable to clotting, in terms of ease of treatment.
  9. A liver duplex is performed in the first 24 hours to ensure the new vascular supply is patent.

Lightning rounds #34: … When?

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When should you…

  • Update family on clinical changes
  • Call a consult
  • Notify a nurse about new orders
  • Communicate with an attending

Episode 67: Whipples with Michael Cavnar

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We learn about pancreaticoduodenectomy (the Whipple) with Michael Cavnar (@DrMikeCavnar), surgical oncologist at University of Kentucky, with a fellowship in Complex General Surgical Oncology from Sloan Kettering. He specializes in GI surgical oncology (liver, pancreas, stomach, etc), with ongoing research in GI stromal tumors and hepatic artery infusion pump chemotherapy.

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Takeaway lessons

  1. The Whipple involves an aggressive resection and reconstruction of pancreatic head tumors. Along with the head of the pancreas, the entire duodenum, the bile duct (up to near the entry of the cystic duct), the gallbladder, and usually the distal third of the stomach, along with the nearby lymph nodes, are all removed. There are then anastomoses at the small intestine, the bile duct, and the stomach.
  2. The pylorus of the stomach is generally removed, but can be left in a pylorus-sparing Whipple. The benefit of this is not well-established.
  3. It is almost always done for malignancy (or occasionally for other conditions like pre-malignant changes or pancreatitis with stricture). Mortality in high-volume centers is a few percent, and usually involves deaths in the first 90 days due to various complications more than death in the OR.
  4. Hypotension in the first 24 hours is a poor sign, as it may lead to bowel ischemia, portal vein thrombosis, anastomotic ischemia, or other injuries to vulnerable areas. If getting behind on hemodynamics, consider holding an epidural if present.
  5. NG tubes are often placed to around 55 cm. They should not be advanced or replaced by the ICU staff, as the stomach has been shortened, and advancing the tube may traumatize the anastomosis. Bilious gastric drainage is normal in anyone with post-Whipple anatomy. Patients will generally remain NPO for several days.
  6. Patients will emerge with 1-2 surgical drains. Output should be serosanguinous (sparsely bloody at most), less than 200ml/hr or so. It may occasionally be lymphatic (clear to lightly serosanguinous), which can be somewhat higher volume. Output should not be bilious or feculent.
  7. Early bleeding requiring surgical take-back is uncommon and usually obvious in the drains, unless they clot, which can occur. A pancreatic leak can also dribble onto the stump of the gastroduodenal artery, causing erosion, and subsequent bleeding usually tracks back up into the bowel lumen and hence GI bleeding.
  8. Respiratory distress can be treated with oxygen or high-flow nasal cannula, but positive pressure (eg. BiPAP) should be used with caution and consultation with the surgical team, particularly within the first two weeks post-op, as aerophagy can apply pressure to the bowel anastomosis.
  9. A leaking pancreatic anastomosis causing fistula will tend to marinate the gastroduodenal artery’s anastomosis in pancreatic juices, creating a pseudoaneurysm; this can be managed early before it turns into massive hemorrhage. Any streak of fresh blood in the drainage should be considered a sentinel marker of this and immediately evaluated, usually involving CTA or pancreas-protocol CT. The treatment of choice is IR embolization and stent, not open repair.
  10. Glucose control in diabetics will usually be worse post-operatively, both due to stress and due to removing a portion of the pancreas. SGLT inhibitors can cause strange metabolic effects as well if not fully washed out.
  11. Exocrine pancreatic insufficiency can be discovered once feeding begins, usually manifesting as diarrhea (steatorrhea), and can be treated with pancreatic enzyme supplements.
  12. A proton pump inhibitor should generally be used post-operatively.

Lightning rounds #33: Transitioning to academics with Janelle Bludorn

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We chat with Janelle Bludorn (@JanelleRBlu), former emergency medicine PA, Assistant Professor and Academic Coordinator at the Duke PA program, about transitioning from clinical work into teaching and academia.

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Resources

  1. Harvard Macy Institute
  2. Duke Ahead
  3. UNC Center for Faculty Excellence
  4. PAEA Jobs board
  5. NONPF Jobs board

Episode 66: Aortic dissection with Travis Hughes

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We explore aortic dissection with Travis Hughes, vascular surgery fellow from the University of Kentucky, including classification, medical management, and nuances of the surgical perspective.

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Takeaway lessons

  1. Type B dissections do not involve the heart or coronaries, but Type A vs B nomenclature is falling out of favor versus more anatomically specific labeling; this system helps characterize the gray area between the innominate and the left subclavian.
  2. The main sequelae of concern in type B dissection in end organ ischemia. This may be dynamic, due to movement of the flap to obstruct the feeding artery, or static, due to occlusion by thrombosis.
  3. Hypotension is unusual in type B dissection and should be a red flag for another factor, such as involvement of the heart (coronary dissection, tamponade), or rupture.
  4. Rupture is not a common event in dissection (as compared to aortic aneurysm), but can occur.
  5. Medical management of type B dissection involves controlling the impulse against the dissection flap by reducing heart rate and blood pressure. SBP <120 and HR <80 are reasonable standard goals, but should be customized somewhat to the patient; allowing higher goals in a pain-free patient, particularly one who is experiencing sequelae of relative hypotension may be reasonable.
  6. During initial presentation, impulse control may prevent dissection from extending over a period of hours. Later, once it has thrombosed and scarred, risk may be somewhat less.
  7. Dissection involving the renal arteries can be explored using doppler ultrasound in skilled hands.
  8. Focal neurologic deficit should prompt concern for both stroke, and (in the lower extremities) thrombosis.
  9. First line is usually an IV beta blocker for heart rate and either IV beta or calcium channel blocker for BP. Esmolol is a classic beta blocker, although involves a large volume of infusate, and is not always very effective. Labetalol and nicardipine are nice choices. Nitroprusside is usually a rescue.
  10. Favor the right radial artery for an arterial catheter, as the left arm will sometimes be needed for the repair.
  11. Transition to oral agents as they stabilize. A repeat CTA 5-7 days from admission (often prior to discharge) is usually appropriate.
  12. The most common indication for repair is aneurysmal degeneration at the dissection site. Extension of the dissection, in the setting of appropriate medical management, is less common although possible, and may also indicate the need for repair.
  13. The primary goal of repair is to cover the entry to the dissection, and potentially stenting to expand the true lumen. When there is involvement of the iliac arteries, stenting is usually needed there. Malperfusion to visceral vessels is often corrected with these maneuvers, but they can be specifically stented or thrombectomy performed if needed.
  14. Open repair of type B dissection has become vanishingly rare due to high morbidity and rare indication.
  15. Stenting of the aorta creates risk for spinal cord ischemia, so keep BP higher. Extremity neuro changes should prompt driving the MAP >90, naloxone, and IV steroids.
  16. Lumber drain placement probably reduces this risk, and can be placed either reactively or proactively. Neurosurgery and/or anesthesiology or interventional radiology may do this.
  17. Shorter ischemic time to organs or extremities, and baseline vasculopathy (which gives time for the body to develop a tolerance to it), portend better recovery after revascularization. Prolonged ischemia to extremities may require amputation or at least fasciotomies to prevent compartment syndrome.
  18. Aspirin and perhaps clopidogrel (with or without a load) will usually be needed post-operatively.
  19. Infection of long-standing grafts are not common but can occur. Contrast imaging and perhaps tagged WBC scans (nuclear scintigraphy) can identify these. Surgical removal may or may not be possible and tends to be morbid.