Ryan Wang

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This review highlights noteworthy literature published in 2025 pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We feature 19 studies from 5334 peer-reviewed publications on kidney transplantation, four studies from 2231 publications on pancreas transplantation, and four studies from 2162 publications on intestinal transplantation. The liver transplantation section includes a special focus on 28 studies from 4925 clinical trials published in 2025. The notable research articles were found in the areas including machine perfusion in kidney and liver transplantations, donor and recipient pain management, and impact of recipient sarcopenia on the outcome in liver transplantation.

Background: Intracardiac thrombosis (ICT) during liver transplantation (LT) is a rare but life-threatening complication with limited data regarding its risk factors, management, and outcomes. This study aimed to identify factors associated with ICT development, define predictors of intraoperative outcomes, and propose a novel classification and management algorithm for ICT. Methods: A multicenter, international retrospective case-control study was conducted on liver transplant recipients from seven centers between January 2005 and December 2023. ICT cases were identified through transesophageal echocardiography (TEE) or autopsy and matched 1:1 with controls. Results: Among 11 077 liver transplant recipients screened, 133 patients (1.2%) developed ICT. ICT occurred predominantly after reperfusion (58%). Compared to controls, ICT cases exhibited higher preoperative international normalized ratio ( P = 0.001) and fibrinogen levels ( P = 0.014). Post-reperfusion syndrome ( P < 0.001), disseminated intravascular coagulation ( P < 0.001), and primary graft failure ( P = 0.002) were also more common in the ICT group. Continuous veno-venous hemofiltration during surgery (odds ratio [OR] 8.20, 95% confidence interval [CI]: 2.09–38.1; P = 0.004) was associated with ICT development. ICT was associated with markedly higher rates of cardiac arrest ( P < 0.001) and intraoperative mortality ( P < 0.001), with thrombus location in the left heart chambers representing a significant predictor of mortality (OR 20.7, 95% CI: 6.25–81.3; P < 0.001). ICT grades 2 and 3 were associated with a markedly increased risk of intraoperative cardiac arrest ( P < 0.05). Importantly, delayed use of TEE was strongly associated with intraoperative death (OR 6.27, 95% CI: 1.45–27.1; P = 0.014). The 90-day mortality was 43% in ICT cases compared to 4.5% in controls, while 1-year mortality was 46% versus 10.5%, respectively. Conclusions: ICT during LT is a rare but severe complication associated with intraoperative mortality and poor short-term survival. Coagulation profile and intraoperative management play critical roles in ICT development. The early use of TEE enables timely diagnosis and intervention, improving patient outcomes. We propose a novel ICT classification offering a systematic framework for risk stratification and management to mitigate progression and mortality.

This review highlights noteworthy literature published in 2024 pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We feature 13 studies from over 5555 peer-reviewed publications on kidney transplantation, 4 studies from 1963 publications on pancreas transplantation, and 3 studies from 1879 publications on intestinal transplantation. The liver transplantation section includes a special focus on 22 studies from 4571 clinical trials published in 2024. We identified the new findings with our specialty interest, including cardiovascular risk assessment, machine perfusion, hemodynamic management, mode of anesthesia and regional techniques, donor management, fluid management, intraoperative monitoring, blood salvage, frailty, and rehabilitation and prehabilitation.

Introduction: Postreperfusion syndrome (PRS) is associated with complications following liver transplantation (LT). Mannitol may play a role in attenuating PRS as a free radical scavenger. This study aimed to evaluate the association between intraoperative mannitol administration and the incidence of PRS and postoperative acute kidney injury (AKI) in LT. Methods: A retrospective analysis of adult liver-only transplantation between August 2019 and January 2023 at the Mount Sinai Hospital was performed. Patients in the mannitol group received 25G of the drug intravenously prior to reperfusion. Any recipients with pre-existing renal diagnoses were excluded. Demographic, laboratory, intraoperative, and hospital course data were extracted from an institutional data warehouse. Multivariable logistic regressions were used to evaluate the association between mannitol administration and PRS, AKI, early allograft dysfunction, and postoperative cardiac complications. Negative binomial regression was used to evaluate the association with postoperative length of stay (LOS) and ICU LOS. Results: 495 LT cases were included. A total of 81 patients received mannitol before graft reperfusion, while 414 patients did not. The incidence of PRS in patients who received mannitol was 13% and 17% for those who did not receive mannitol (p = 0.53). Additionally, 79% of patients who received mannitol experienced AKI at 7 days, compared to 73% in those who did not receive mannitol (p = 0.48). In the multivariable regression models, mannitol administration was not associated with decreased incidence of PRS or postoperative AKI. It was, however, associated with increased postoperative cardiac complications (risk-adjusted odds ratio 2.70, 95% confidence interval 1.15–6.14, p = 0.02). Conclusions: Mannitol administration during LT was not an effective therapy for reducing PRS or postoperative AKI.

Introduction: Serum albumin’s association with liver transplant outcomes has been investigated with mixed findings. This study aimed to evaluate perioperative albumin level, independently and as part of the albumin–bilirubin (ALBI) grade, as a predictor of post-liver transplant hospital and intensive care unit (ICU) length of stay (LOS). Methods: Adult liver-only transplant recipients at our institution from September 2011 to May 2019 were included in this retrospective study. Repeat transplants were excluded. Demographic, laboratory, and hospital course data were extracted from an institutional data warehouse. Negative binomial regression was used to assess the association of LOS with ALBI grade, age, BMI, ASA score, Elixhauser comorbidity index, MELD-Na, warm ischemia time, units of platelets and cryoprecipitate transfused, and preoperative serum albumin. Results: Six hundred and sixty-three liver transplant recipients met inclusion criteria. The median preoperative serum albumin was 3.1 [2.6–3.6] g/dL. The median postoperative ICU and hospital LOS were 3.8 [2.4–6.8] and 12 [8–20] days, respectively. Preoperative serum albumin predicted hospital but not ICU LOS (ratio .9 [95% confidence interval (CI) .84–.99], P = .03, hospital LOS vs ratio .92 [95% CI 0.84–1.02], P = .10, ICU LOS). For patients with MELD-Na ≤ 20, ALBI grade-3 predicted longer hospital and ICU LOS (ratio 1.40 [95% CI 1.18–1.66], P < .001, hospital LOS vs ratio 1.62 [95% CI 1.32–1.99], P < .001, ICU LOS). These associations were not significant for patients with MELD-Na > 20. Conclusions: Serum albumin predicted post-liver transplant hospital LOS. ALBI grade-3 predicted increased hospital and ICU LOS in low MELD-Na recipients.

BACKGROUND: Spinal anesthesia has become the most common type of anesthetic for cesarean delivery. The major limitation to spinal anesthesia is that the duration of the anesthetic may not be adequate in the event of a prolonged surgery. Some practitioners add epinephrine to hyperbaric bupivacaine to increase the duration, although its effect has not been fully studied. We therefore aimed to evaluate whether adding epinephrine to the spinal medication prolongs the duration of action of the resultant block in women presenting for repeat cesarean delivery. METHODS: Sixty-eight patients were randomized to receive no epinephrine (NE group), epinephrine 100 µg (low-dose [LD] group), or epinephrine 200 µg (high-dose [HD] group) with a standardized spinal mixture (1.5 mL 0.75% hyperbaric bupivacaine with 0.25 mg morphine). Sixty-five patients were included for primary analysis. Our primary outcome was time to intraoperative activation of the epidural catheter or postoperative regression of sensory blockade to T-10 dermatome level as measured by pinprick sensation; motor recovery was a secondary outcome, and graded via a Modified Bromage scale. RESULTS: Block onset time, vital sign changes, and the incidence of hypotension; nausea, and vomiting were similar among groups. Median difference in time to T-10 regression was greatest in the HD group compared to the NE group (median difference [min] [95% confidence interval]: 40 [15–60]; P = .007), followed by the HD group to the LD group (30 [15–45]; P = .007). Comparisons of LD to NE were not significant, but trended to an increase in T-10 regression time (10 [−15 to 30]; P = .76). Median difference in time to knee extension (Bromage 3) was also greatest in the HD group when compared to both the LD and NE group (median difference [min] [95% confidence interval]: 30 [0–60]; P = .034, 60 [0–93]; P = .007). Median difference time to knee extension (min) between the LD and NE group was also significant (37.5 [15–60]; P = .001]. Pain scores during the procedure were higher in the NE group (median [interquartile range] HD: 0 [0–0], LD: 0 [0–0], NE: 0 [0–3]; P = .02) during uterine closure and were otherwise not significantly different from the other groups. CONCLUSIONS: In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block quality may have been enhanced.

Anesthetic management of orthotopic liver transplantation (OLT) is complex. Given the unequal distributions of liver transplant surgeries performed at different centers, anesthesiology providers receive relatively uneven OLT training and exposure. One well-suited modality for OLT training is the “serious game”, an interactive application created for the purpose of imparting knowledge or skills, while leveraging the self-motivating elements of video games. We therefore developed a serious game designed to teach best practices for the anesthetic management of a standard OLT and determined if the game would improve resident performance in a simulated OLT. 44 residents on the liver transplant rotation were randomized to either the Gaming Group (GG) or the Control Group (CG) prior to their introductory simulation. Both groups were given access to the same educational materials and literature during their rotation but the Gaming Group also had access to the OLT Trainer. Performance on the simulations were recorded on a standardized grading rubric. Both groups experienced an increase in score relative to baseline that was statistically significant at every stage. The improvements in scores were greater for the GG participants than the CG participants. Overall score improvement between the GG and CG (Mean (SD)) was statistically significant (GG: 7.95 (3.65), CG: 4.8 (4.48) p=0.02), as were scores for pre-operative assessment (GG: 2.67 (2.09), CG: 1.17 (1.43) p=0.01) and anhepatic phase (GG: 1.62 (1.01), CG: 0.75 (1.28) p=0.02). 81% of residents with game access were “very satisfied” or “satisfied” with the game overall. Conclusion: Adding a serious game to an existing educational curriculum for liver transplant anesthesia resulted in significant learning gains for rotating anesthesia residents. The intervention was straight-forward to implement and cost-effective.

Serious games are computer-based games designed for training purposes. They are poised to expand their role in medical education. This systematic review, conducted in accordance with PRISMA guidelines, aimed to synthesize current serious gaming trends in health care training, especially those pertaining to developmental methodologies and game evaluation. PubMed, EMBASE, and Cochrane databases were queried for relevant documents published through December 2014. Of the 3737 publications identified, 48 of them, covering 42 serious games, were included. From 2007 to 2014, they demonstrate a growth from 2 games and 2 genres to 42 games and 8 genres. Overall, study design was heterogeneous and methodological quality by MERQSI score averaged 10.5/18, which is modest. Seventy-nine percent of serious games were evaluated for training outcomes. As the number of serious games for health care training continues to grow, having schemas that organize how educators approach their development and evaluation is essential for their success.