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Singh SA, Pampaniya H, Mehtani R, Jadaun SS, Kumar M, Khurana S, Das DJ, Gupta S, Saigal S. Living donor liver transplant in acute on chronic liver failure grade 3: Who not to transplant. Dig Liver Dis 2024; 56:152-158. [PMID: 37550101 DOI: 10.1016/j.dld.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/05/2023] [Accepted: 07/23/2023] [Indexed: 08/09/2023] [Imported: 08/29/2023]
Abstract
BACKGROUND AND AIM Liver transplantation(LT)offers definitive treatment for acute on chronic liver failure(ACLF) patients. This study was done to analyze and compare the outcomes of living donor LT(LDLT) in patients with ACLF versus Chronic liver disease(CLD) and within the grades of ACLF. Factors affecting mortality in patients with ACLF and ACLF grade3 (ACLF3) following LDLT were also derived. METHODS Records of adult LDLT between 1/2/2017 and 30/9/2021 were analyzed. ACLF was classified based on EASL-CLIF definition. Post-transplant outcomes of ACLF were compared with CLD and within ACLF grades. Post LDLT mortality predictors were identified in ACLF and ACLF3 patients. RESULTS Out of 853 patients who had LT in that period; 704 patients with CLD and 103 with ACLF [of which 54 (52.42%) had ACLF3] underwent LDLT. The one month and one-year post LDLT mortality was 8.81% and 9.80% in CLD; 19.42% and 31.06% in ACLF; and 25.92% and 38.89% in ACLF3 respectively. On log regression analysis, use of grafts from older donors and pre-operative respiratory failure in recipients was associated with poor survival in ACLF, while respiratory failure was a predictor of poor survival in ACLF3 following LDLT. CONCLUSION Outcomes following LDLT are poorer in ACLF as compared to after CLD. Higher donor age and preoperative respiratory failure with PF Ratio<200 were associated with poor survival post LDLT in ACLF and ACLF3.
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Affiliation(s)
- Shweta A Singh
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India.
| | - Hetal Pampaniya
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Rohit Mehtani
- Department of Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Shekhar Singh Jadaun
- Department of Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Mukesh Kumar
- Department of Surgical Gastroenterology and LT, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, 11001, India
| | - Saurabh Khurana
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Dibya Jyoti Das
- Department of Surgical Gastroenterology and LT, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, 11001, India
| | - Subhash Gupta
- Department of Surgical Gastroenterology and LT, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, 11001, India
| | - Sanjiv Saigal
- Department of Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
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Bhargava R, Garg P, Singh SA, Madan K, Agarwal AR, Rastogi R, Gupta S. Skeletal muscle indices for healthy Indians. Indian J Gastroenterol 2023; 42:589-590. [PMID: 37160837 DOI: 10.1007/s12664-023-01353-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] [Imported: 08/29/2023]
Affiliation(s)
- Richa Bhargava
- Max Centre for Liver and Biliary Sciences and Centre for Gastroenterology, Hepatology and Endoscopy, New Delhi, 110 017, India
| | - Pallavi Garg
- Max Centre for Liver and Biliary Sciences and Centre for Gastroenterology, Hepatology and Endoscopy, New Delhi, 110 017, India
| | - Shweta A Singh
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India.
| | - Kaushal Madan
- Max Centre for Liver and Biliary Sciences and Centre for Gastroenterology, Hepatology and Endoscopy, New Delhi, 110 017, India
| | | | - Ruchi Rastogi
- Department of Radiology, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Subhash Gupta
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
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Singh SA, Shrivastava P, Agarwal A, Nandakumar K, Nasa VK, Premkumar G, Rajakumar A, Panchwagh A, Vohra V, Ranade S, Kumar L, Saraf N, Shah V, Sudhidharan S. LTSI Consensus Guidelines: Preoperative Pulmonary Evaluation in Adult Liver Transplant Recipients. J Clin Exp Hepatol 2023; 13:523-531. [PMID: 37250889 PMCID: PMC10213854 DOI: 10.1016/j.jceh.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/20/2022] [Indexed: 05/31/2023] [Imported: 08/29/2023] Open
Abstract
The relationship between chronic liver disease and respiratory symptoms and hypoxia is well recognized. Over the last century, three pulmonary complications specific to chronic liver disease (CLD) have been characterized: hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. Apart from that coexisting pulmonary disease like chronic obstructive lung disease and interstitial lung disease also complicate the outcomes after liver transplantation (LT). Assessment for evaluation of underlying pulmonary disorders is essential to improve outcomes in patients with CLD, posted for LT. This consensus guideline of the Liver Transplant Society of India (LTSI) provides a comprehensive review of pulmonary issues in CLD, related and unrelated to underlying liver disease and gives recommendations for pulmonary screening in specific clinical scenarios in adults with chronic liver disease planned for LT. This document also aims to standardize the strategies for preoperative evaluation of these pulmonary issues in this subset of patients. Proposed recommendations were based on selected single case reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Additionally, this review will highlight the lacunae in our current evaluation strategy, challenges faced, and will provide direction to potentially useful futuristic preoperative evaluation strategies.
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Affiliation(s)
- Shweta A. Singh
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, New Delhi, 110017, India
| | | | - Anil Agarwal
- Liver Transplant Anaesthesia, Fortis Hospital, Noida, India
| | - K. Nandakumar
- Liver Transplant Anaesthesia, Apollo Main Hospital, Greams Road, Chennai, India
| | - Vaibhav K. Nasa
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, New Delhi, 110017, India
| | | | - Akila Rajakumar
- Dr. Rela Institute and Medical Centre, Chromepet, Chennai, Tamil Nadu, India
| | | | - Vijay Vohra
- Medanta - The Medicity Hospital, Gurugram, India
| | - Sharmila Ranade
- Kokilaben Dhirubhai Ambani Hospital and Medical Research Center, Mumbai, India
| | - Lakshmi Kumar
- Amrita Institute of Medical Sciences & Research Centre, Kochi, India
| | - Neeraj Saraf
- Medanta - The Medicity Hospital, Gurugram, India
| | - V.R. Shah
- Institute of Kidney Disease and Research Centre-ITS, Ahmedabad, Gujarat, India
| | - S. Sudhidharan
- HPB and LT Surgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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4
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Singh SA, Madan K, Prabhudesai AA, Agarwal AR, Rastogi R, Bhargava R, Kriplani P, Pampaniya H, Gupta S, Indrayan A. Normative cutoffs of muscle mass, muscle strength, and frailty for healthy Indian population. Indian J Gastroenterol 2022; 41:591-598. [PMID: 36602720 DOI: 10.1007/s12664-022-01295-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 08/17/2022] [Indexed: 01/06/2023] [Imported: 08/29/2023]
Abstract
BACKGROUND Population-derived cutoffs for low skeletal muscle mass, skeletal muscle strength, and frailty among Indians are lacking. Studies describing sarcopenia and frailty among patients with chronic liver diseases have used cutoffs derived from Caucasian populations giving erroneous results. AIMS We aimed to derive gender-specific cutoffs for low skeletal muscle mass and skeletal muscle strength from healthy Indians. METHODS Healthy Indian population consisted of two groups. Group 1 (Gp I) included 242 healthy liver donors and group 2 (Gp II) 272 healthy health care workers. Skeletal muscle index (SMI) was calculated from computed tomography (CT) abdomen performed prior to donor hepatectomy only in Gp I. Liver frailty index (LFI) was computed using the online calculator, after recording hand grip strength (HGS), chair stand-up test (CSUT), and balance test in both groups. HGS was measured using the Smedley handgrip dynamometer. CSUT was noted as time to complete 5 chair stand-ups with subjects' arms folded across the chest. Gender-specific cutoffs of SMI and HGS were derived as <5th percentile of the distribution values and as >95th percentile for CSUT and LFI values. RESULTS The SMI was measured from Gp I subjects (n=242; 120 males [mean age 31.13] and 122 females [mean age 36.60]). The HGS, CSUT, and LFI were measured in Gp I and Gp II subjects (n=514; 272 males [mean age 34.30] and 242 females [mean age 37.52]). The cutoffs for SMI, HGS, CSUT, and LFI were <27.72 cm2/m2, <25.63 kg, >10 s, and >3.49, respectively for healthy males. The corresponding cutoffs for healthy females were <24.4 cm2/m2, <16.7 kg, > 10 s, and >3.68, respectively. CONCLUSIONS We derived gender-specific cutoffs for SMI, HGS, CSUT, and LFI from healthy adult Indian population, which can be used to detect sarcopenia and frailty among patients with liver diseases, as well as other conditions.
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Affiliation(s)
- Shweta A Singh
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India.
| | - Kaushal Madan
- Center for Gastroenterology, Hepatology and Endoscopy, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Aaditya Anil Prabhudesai
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | | | - Ruchi Rastogi
- Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Richa Bhargava
- Center for Gastroenterology, Hepatology and Endoscopy, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Pinky Kriplani
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Hetal Pampaniya
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Subhash Gupta
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Abhaya Indrayan
- Department of Clinical Research, Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
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Jadaun SS, Mehtani R, Hasnain A, Bhatia S, Moond V, Kumar M, Kuhad V, Singh S, Agarwal S, Gupta S, Saigal S. Good outcomes of living donor liver transplant in primary sclerosing cholangitis: an experience from North India. Hepatol Int 2022; 17:499-506. [PMID: 36376772 PMCID: PMC9662766 DOI: 10.1007/s12072-022-10442-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022] [Imported: 08/29/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. In the absence of effective medical therapy, liver transplant is the definitive treatment for advanced stage. However, recurrence of PSC after liver transplant is of concern which can lead to graft failure and may require retransplant. There are limited data on outcomes of living donor liver transplant (LDLT) in PSC. Also, in LDLT as donors are genetically related there can be an increased risk of recurrence. We conducted this retrospective study to analyze the outcomes of LDLT in PSC at a tertiary liver transplant center in north India. METHODS We conducted a retrospective analysis of 3213 transplant recipients who underwent LDLT from January 2006 to May 2021. Of these 26 (0.80%) patients had PSC as indication for liver transplantation (PSC = 24, PSC-AIH overlap = 2). Data analysis was done to look for baseline demographics, clinical details, transplant outcomes, PSC recurrence, and survival. RESULTS Mean age of study group was 42 (± 13.8) years and 19 patients (73.1%) were males. All patients had decompensated cirrhosis at the time of transplant. Mean CTP score and MELD score were 9.5 (± 1.8) and 18.9 (± 7.1), respectively. Sixteen patients received modified right lobe graft, seven extended right lobe graft and five patients received left lateral graft. Median graft weight and mean graft to recipient weight ratio (GRWR) were 633.5 (IQR 473.5-633.5) grams and 1.23 (± 0.42), respectively. Most common biliary anastomosis was hepaticojejunostomy, done in 19 (73.1%) while duct to duct anastomosis was performed in 7 (26.9%) patients. Median follow-up was 96 (36-123) months. One patient had ulcerative colitis and none had cholangiocarcinoma. Two (7.7%) patients had bile leak during early post-transplant period. Three (11.1%) patients developed graft rejection and were managed successfully with steroid pulses. Three patients died during early post-transplant period while seven deaths occurred during long-term follow-up including one death due to COVID-19. Five (21.73%) patients had recurrence of PSC of which two patients had graft loss including one after retransplantation. The one year graft and patient survival rate was 88.5%. CONCLUSION LDLT can be performed in PSC with good long-term outcomes with a risk of PSC recurrence in about one-fifth patients.
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Affiliation(s)
- Shekhar Singh Jadaun
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
| | - Rohit Mehtani
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
| | - Ana Hasnain
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
| | - Sushant Bhatia
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vikash Moond
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Mukesh Kumar
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vikash Kuhad
- Student’s Scientific Circle of Surgery, Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Ul. Smoluchowskiego 17, 80-214 Gdańsk, Poland
| | - Shweta Singh
- Anesthesia and Critical Care, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Gastroenterology and Hepatology, Centre for Liver and Biliary Sciences, Hepatology and Liver Transplant Medicine Saket, Max Super Speciality Hospital, New Delhi, 110017 India
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Singh SA, Pampaniya H, Kumar V, Kumar M, Jadaun SS, Yadav V, Saigal S, Gupta S. Living donor liver transplant outcomes during the COVID-19 pandemic: does a decrease in case volume impact the overall outcomes? Korean J Transplant 2022; 36:127-135. [PMID: 35919202 PMCID: PMC9296980 DOI: 10.4285/kjt.22.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/07/2022] [Accepted: 05/14/2022] [Indexed: 11/25/2022] [Imported: 08/29/2023] Open
Abstract
Background High-volume centers (HVCs) are classically associated with better outcomes. During the coronavirus disease 2019 (COVID-19) pandemic, there has been a decrease in the regular liver transplantation (LT) activity at our center. This study analyzed the effect of the decline in LT on posttransplant patient outcomes at our HVC. Methods We compared the surgical outcomes of patients who underwent LT during the COVID-19 pandemic lockdown (April 1, 2020 to September 30, 2020) with outcomes in the pre-pandemic calendar year (April 1, 2019 to March 31, 2020). Results During the 6 months of pandemic lockdown, 60 patients underwent LT (43 adults and 17 children) while 228 patients underwent LT (178 adults and 50 children) during the pre-pandemic calendar year. Patients in the pandemic group had significantly higher model for end-stage liver disease (MELD) scores (24.39±9.55 vs. 21.14±9.17, P=0.034), Child-Turcotte-Pugh scores (11.46±2.32 vs. 10.25±2.24, P=0.03), and incidence of acute-on-chronic liver failure (30.2% vs. 10.2%, P=0.002). Despite performing LT in sicker patients with COVID-19-related challenges, the 30-day (14% vs. 18.5%, P=0.479), 3-month (16.3% vs. 20.2%, P=0.557), and 6-month mortality rates (23.3% vs. 28.7%, P=0.477) were lower, but not statistically significant when compared to the pre-pandemic cohort. Conclusions During the COVID-19 pandemic lockdown the number of LT procedures performed at our HVC declined by half because prevailing conditions allowed LT in very sick patients only. Despite these changes, outcomes were not inferior during the pandemic period compared to the pre-pandemic calendar year. Greater individualization of patient care contributed to non-inferior outcomes in these sick recipients.
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Affiliation(s)
- Shweta A. Singh
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Hetal Pampaniya
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vikram Kumar
- Department of Paediatric Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Mukesh Kumar
- Department of Hepatobiliary, Pancreatic Surgery and Liver Transplant, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shekhar Singh Jadaun
- Department of Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vivek Yadav
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Paediatric Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Department of Hepatobiliary, Pancreatic Surgery and Liver Transplant, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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Jadaun SS, Singh SA, Madan K, Gupta S. "SARS-CoV-2 Infection in Liver Transplant Recipients - Immunosuppression is the Silver Lining?". J Clin Exp Hepatol 2022; 12:384-389. [PMID: 34305351 PMCID: PMC8294560 DOI: 10.1016/j.jceh.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/12/2021] [Indexed: 12/12/2022] [Imported: 08/29/2023] Open
Abstract
BACKGROUND COVID-19 is associated with higher mortality among patients who have comorbidities. However, evidences related to COVID-19 among post liver transplant recipients are scarce and evolving. METHODS Adult Indian patients who had undergone liver transplantation at our centre since 2006 and were under regular follow-up, were contacted either telephonically or on email. Data were recorded related to symptoms and diagnosis of COVID-19, need for hospitalization, and need for ICU stay and mortality. RESULTS Eighty one (3.71%) of the 2182 adult Liver transplant (LT) recipients on regular follow-up reported SARS-CoV-2 infection between 1st April 2020 and 31st May 2021. Mean age was 51.3(±9.8) years, and 74(91.4%) were males. Thirty five (43.2%) patients had one or more comorbidities. Twenty one (25.9%) patients were transplanted less than 1 year ago. Forty four (54.3% ) patients had mild disease only while 23(28.4%) patients had severe COVID-19 disease. Of the 81 patients 14 patients died and overall mortality was 17.3. CONCLUSION Uncomplicated liver transplant recipients without comorbidities who acquire SARS-CoV-2 do not have poor outcome.
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Key Words
- ARDS, Acute respiratory distress syndrome
- CAD, Coronary artery disease
- CKD, Chronic kidney disease
- CNIs, Calcineurin inhibitors
- COVID-19
- COVID-19, corona virus disease 2019
- LDLT, live donor liver transplants
- LT, Liver transplant
- NAAT, nucleic acid amplification test
- NAFLD, Nonalcoholic fatty liver disease
- NASH, Nonalcoholic steatohepatitis
- OPD, Outpatients department
- SARS-CoV-2, severe acute respiratory syndrome corona virus-2
- liver transplant
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Affiliation(s)
- Shekhar S. Jadaun
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Shweta A. Singh
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India,Address for correspondence. Dr.Shweta A Singh, MD Anesthesiology, Director & Head Anesthesiology & Critical care, Center for Liver & Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India. Tel.: +919810625177.
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Subhash Gupta
- Center for Liver & Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
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Singh SA. Relevance of Population-Based Cutoffs to Define Sarcopenia in Clinical Studies. J Clin Exp Hepatol 2021; 11:276-277. [PMID: 33746455 PMCID: PMC7953010 DOI: 10.1016/j.jceh.2020.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/27/2020] [Indexed: 12/12/2022] [Imported: 08/29/2023] Open
Affiliation(s)
- Shweta A. Singh
- Address for correspondence: Shweta A. Singh, Anesthesiology Director & Head Anesthesiology & Critical care, Center for Liver & Biliary Sciences: Max Super Speciality Hospital, Saket, New Delhi, 110017, India.
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Singh SA. Comment on "A rare case of Wilson disease associated with intracerebral hemorrhage". Korean J Anesthesiol 2020; 74:278-279. [PMID: 33070579 PMCID: PMC8175883 DOI: 10.4097/kja.20472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 10/13/2020] [Indexed: 11/30/2022] [Imported: 08/29/2023] Open
Affiliation(s)
- Shweta A Singh
- Department of Anesthesiology, Center for Liver & Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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Singh SA, Krishnan G, Ashraf H, Subramanian R, Pandey V, Nasa VK, Goyal S, Gupta S. Correlation between thromboelastography and rotational thromboelastometry values in adult liver transplant recipients. Indian J Anaesth 2020; 64:286-291. [PMID: 32489202 PMCID: PMC7259407 DOI: 10.4103/ija.ija_762_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/19/2020] [Accepted: 02/17/2020] [Indexed: 11/18/2022] [Imported: 08/29/2023] Open
Abstract
Background and Aims: Viscoelastic haemostatic assays (VHA) namely Thromboelastogram (TEG) and Rotational thromboelastometry (ROTEM) are used for global assessment of coagulopathy and guiding transfusion during living donor liver transplant (LDLT).We conducted a study to compare the interchangeability of the values obtained from these devices in patients with End stage liver disease (ESLD) undergoing LDLT. Methods: In 76 patients undergoing LDLT, ROTEM and TEG were performed and assessed for interchangeability using Spearman Correlation. The direction and strength of correlation between equivalent parameters was calculated using Inter Class Correlation (ICC) and Bland Altman analysis. Results: The correlation ρ between CT (clotting time) of ROTEM and R of TEG was 0.16 (P = 0.19).The ICC was 0.15, with 95% confidence interval (CI) of -0.38-0.48 (P = 0.25).The ρ of CFT (ROTEM) with K (TEG) was 0.425 (P=<0.001). The ICC was0.49 with 95% CI of 0.17-0.69, P = 0.003.Alpha of ROTEM correlated with Angle of TEG with ρ of 0.475 (P=<0.001). The ICC was 0.61, with 95% CI of 0.36-0.76, P=<0.001.Maximum Clot firmness (MCF) correlated with maximum amplitude (MA) with ρ=0.76 (P=<0.001).The ICC was 0.86, with 95% CI of 0.77-0.92, P=<0.001. Lysis index (L30) of ROTEM correlated clot lysis (CL30) of TEG with ρ of 0.16 (P = 0.18).However, the ICC was 0.45, with 95% CI of 0.11-0.66, P = 0.08. The correlation between CT of ROTEM and R of TEG as well as L30 of ROTEM and CL30 of TEG was not significant.The strongest correlation was found between MCF and MA (P < 0.001). However the MCF/MA showed an agreement of only 86% (ICC = 0.86). Conclusion: Values from ROTEM and TEG were not found to be interchangeable.
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Affiliation(s)
- Shweta A Singh
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Gopi Krishnan
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Hashir Ashraf
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Rajkumar Subramanian
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Vijaykant Pandey
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Vaibhav K Nasa
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Sumit Goyal
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
| | - Subhash Gupta
- Center for Liver and Biliary Sciences Anaesthesia and Critical Care, Max Super Speciality Hospital, New Delhi, India
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Singh SA, Ashraf H, Subramanian R, Krishnan GA, Pandey V, Gupta S. Living donor liver transplantation in a patient with severe portopulmonary hypertension. Indian J Anaesth 2020; 64:153-155. [PMID: 32139937 PMCID: PMC7017663 DOI: 10.4103/ija.ija_512_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/29/2019] [Accepted: 12/03/2019] [Indexed: 01/24/2023] [Imported: 08/29/2023] Open
Affiliation(s)
- Shweta A Singh
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Hashir Ashraf
- Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Rajkumar Subramanian
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Gopi A Krishnan
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Vijaykant Pandey
- Department of Anesthesiology and Critical Care, CLBS, Max Saket Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant Surgery, CLBS, Max Saket Hospital, Saket, New Delhi, India
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Hashir A, Singh SA, Krishnan G, Subramanian R, Gupta S. Correlation of early ROTEM parameters with conventional coagulation tests in patients with chronic liver disease undergoing liver transplant. Indian J Anaesth 2019; 63:21-25. [PMID: 30745608 PMCID: PMC6341893 DOI: 10.4103/ija.ija_334_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] [Imported: 08/29/2023] Open
Abstract
Background and Aims: Viscoelastic tests such as rotational thromboelastometry (ROTEM) provide a quick and holistic assessment of coagulation status to guide transfusion during liver transplant (LT). Conventional coagulation tests (CCTs) measure single parameters in isolation, and also the results are delayed hampering management of patients during surgery. We evaluated the correlation of early ROTEM-derived parameters with CCTs and also assessed the ability of ROTEM-derived parameters to predict thrombocytopaenia and hypofibrinogenaemia during LT in patients with end-stage liver disease (ESLD). Methods: This retrospective study was carried out in 100 patients with decompensated ESLD undergoing LT. Correlation between CCTs and ROTEM parameters was analyzed. Receiver operating characteristic curves with area under the curve were used to determine the cut-off values of A5 andA10 on EXTEM and FIBTEM. Results: The values of A5EXTEM and A10EXTEM highly correlated with fibrinogen levels and platelet count, whereas A5FIBTEM and A10FIBTEM correlated well with fibrinogen levels. A5EXTEM<21 mm and A10EXTEM<28 mm correlated with a platelet count <75,000 mm−3, whereas A5EXTEM<18 mm and A10EXTEM<25 mm correlated with a platelet count <50,000 mm−3. Fibrinogen levels <100 mg/dL better correlated with A5FIBTEM<5 mm, A10FIBTEM<6 mm, A5EXTEM<21 mm and A10EXTEM<30 mm. Conclusion: Early ROTEM parameters A5 and A10 of both EXTEM and FIBTEM had an excellent correlation with thrombocytopaenia and hypofibrinogenaemia and may potentially guide early transfusion of relevant blood products during LT.
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Affiliation(s)
- A Hashir
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Shweta A Singh
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Gopi Krishnan
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Rajkumar Subramanian
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
| | - Subhash Gupta
- Center for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India
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Subramanian R, Singh SA, Gupta S, Majhi SK, Malhotra R. Perioperative anesthetic management of a combined right atrial thrombectomy with living donor liver transplantation. J Anaesthesiol Clin Pharmacol 2019; 35:396-399. [PMID: 31543592 PMCID: PMC6748015 DOI: 10.4103/joacp.joacp_180_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] [Imported: 08/29/2023] Open
Abstract
Hepatocellular carcinoma (HCC) with vascular invasion is usually considered inoperable. We describe a case of HCC with vascular invasion and right atrial thrombus that was successfully down staged. Patient underwent combined right atrial thrombectomy and living donor liver transplantation (LDLT) in the same setting. Perioperative anesthesia management and perioperative concerns of two major combined procedures are discussed.
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Affiliation(s)
- Rajkumar Subramanian
- Department of Anesthesiology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shweta A Singh
- Department of Anesthesiology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Department of Surgery, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjoy Kumar Majhi
- Department of Cardiac Anaesthesia, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Rajneesh Malhotra
- Department of Cardiothoracic and Vascular Surgery (CTVS), Max Super Speciality Hospital, Saket, New Delhi, India
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Singh SA, Prakash K, Sharma S, Dhakate G, Bhatia V. Comparison of propofol alone and in combination with ketamine or fentanyl for sedation in endoscopic ultrasonography. Korean J Anesthesiol 2017; 71:43-47. [PMID: 29441174 PMCID: PMC5809707 DOI: 10.4097/kjae.2018.71.1.43] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/03/2017] [Accepted: 04/16/2017] [Indexed: 12/13/2022] [Imported: 08/29/2023] Open
Abstract
Background We evaluated whether the addition of a small dose of ketamine or fentanyl would lead to a reduction in the total dose of propofol consumed without compromising the safety and recovery of patients having endoscopic ultrasonography (EUS). Methods A total of 210 adult patients undergoing elective EUS under sedation were included in the study. Patients were randomized into three groups. Patients were premedicated intravenously with normal saline in group 1, 50 µg fentanyl in group 2, and 0.5 mg/kg ketamine in group 3. All patients received intravenous propofol for sedation. Propofol consumption in mg/kg/h was noted. The incidence of hypotension, bradycardia, desaturation, and coughing was noted. The time to achieve a Post Anesthesia Discharge Score (PADS) of 10 was also noted. Results There were 68 patients in group 1, 70 in group 2, and 72 in group 3. The amount of propofol consumed was significantly higher in group 1 (9.25 [7.3–13.2]) than in group 2 (8.8 [6.8–12.2]) and group 3 (7.6 [5.7–9.8]). Patient hemodynamics and oxygenation were well maintained and comparable in all groups. The time to achieve a PADS of 10 was significantly higher in group 3 compared to the other two groups. Conclusions The use of 50 µg fentanyl or 0.5 mg/kg ketamine in a single dose during EUS reduces the dose of propofol required for sedation. However, unlike the addition of fentanyl, the addition of ketamine increased the time to recovery. Thus, 50 µg fentanyl is a good additive to propofol infusion for sedation during EUS to reduce the requirement for propofol without affecting the time to recovery.
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Affiliation(s)
- Shweta A Singh
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Kelika Prakash
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Sandeep Sharma
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Gaurav Dhakate
- Department of Anaesthesiology and Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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Singh SA, Singh A, Pamecha V, Pandey CK, Sarin SK. Living Donor Liver Transplantation for Acute Liver Failure With Fixed Pupils: Are We Fixed? J Clin Exp Hepatol 2017; 7:155-157. [PMID: 28663681 PMCID: PMC5478968 DOI: 10.1016/j.jceh.2016.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 09/28/2016] [Indexed: 12/12/2022] [Imported: 08/29/2023] Open
Abstract
Living donor liver transplantation (LDLT) is fraught with the social and ethical dilemma of excising a part of the liver from a healthy first-degree relative. When LDLT is to be done for an acute liver failure (ALF), identification of a suitable donor is a race against time. Herein, we describe a unique challenge faced by the transplant team of whether to proceed with donor hepatectomy from a son, when the recipient (HBV-related ALF) developed non-reactive fully dilated pupils on the table, prior to beginning the surgery. The patient ultimately underwent a LDLT despite fixed dilated pupils by virtue of further workup, which suggested that cerebral blood flow was maintained despite clinical evidence of brainstem herniation.
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Affiliation(s)
- Shweta A. Singh
- Additional Professor – Anaesthesiology & Critical Care Institute of Liver and Biliary Science, New Delhi 110070, India,Address for correspondence: Shweta A. Singh, Anaesthesiology &Crititcal Care, Institute of Liver and Biliary Sciences, D1, Vasant Kunj, New Delhi 110070, India. Tel.: +91 9810625177.Shweta A. Singh, Anaesthesiology &Crititcal Care, Institute of Liver and Biliary SciencesD1, Vasant KunjNew Delhi110070India
| | - Anshuman Singh
- Assistant Professor – Anaesthesiology & Critical Care Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Viniyendra Pamecha
- Additional Professor – HPB Surgery & Head Liver Transplantation Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Chandra Kant Pandey
- Professor – Anaesthesiology & Critical Care Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Shiv Kumar Sarin
- Senior Professor & Head of Department, Hepatology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
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Singh S, Singh A, Dhankhar M. Malpositioning of pulmonary artery catheter into the inferior vena cava in a liver transplant recipient. J Anaesthesiol Clin Pharmacol 2016; 32:407-8. [PMID: 27625506 PMCID: PMC5009864 DOI: 10.4103/0970-9185.173373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] [Imported: 08/29/2023] Open
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Singh SA, Pandey VK, Prakash K, Choudhary V. A failure of pre-anaesthetic check-up leading to unsuspected difficult intubation. Indian J Anaesth 2016; 60:863-864. [PMID: 27942065 PMCID: PMC5125195 DOI: 10.4103/0019-5049.193697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] [Imported: 08/29/2023] Open
Affiliation(s)
- Shweta A Singh
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vijay Kant Pandey
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kelika Prakash
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vinod Choudhary
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
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Singh SA, Sharma S, Singh A, Singh AK, Sharma U, Bhadoria AS. The safety of ultrasound guided central venous cannulation in patients with liver disease. Saudi J Anaesth 2015; 9:155-60. [PMID: 25829903 PMCID: PMC4374220 DOI: 10.4103/1658-354x.152842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] [Imported: 08/29/2023] Open
Abstract
Background: Central venous cannulation (CVC) is frequently required during the management of patients with liver disease with deranged conventional coagulation parameters (CCP). Since CVC is known to be associated with vascular complications, it is standard practice to transfuse Fresh-Frozen Plasma or platelets to correct CCP. These CCP may not reflect true coagulopathy in liver disease. Additionally CVC when performed under ultrasound guidance (USG-CVC) in itself reduces the incidence of complications. Aim: To assess the safety of USG-CVC and to evaluate the incidence of complications among liver disease patients with coagulopathy. Setting and Design: An audit of all USG-CVCs was performed among adult patients with liver disease in a tertiary care center. Materials and Methods: Data was collected for all the adult patients (18-60 years) of either gender suffering from liver disease who had required USG-CVC. Univariate and multivariate regression analysis was done to identify possible risk factors for complications. Results: The mean age of the patients was 42.1 ± 11.6 years. Mean international normalized ratio was 2.17 ± 1.16 whereas median platelet count was 149.5 (range, 12-683) × 109/L. No major vascular or non-vascular complications were recorded in our patients. Overall incidence of minor vascular complications was 18.6%, of which 13% had significant ooze, 10.3% had hematoma formation and 4.7% had both hematoma and ooze. Arterial puncture and multiple attempts were independent risk factors for superficial hematoma formation whereas low platelet count and presence of ascites were independent risk factors for significant oozing. Conclusion: Ultrasound guidance -CVC in liver disease patients with deranged coagulation is a safe and highly successful modality.
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Affiliation(s)
- Shweta A Singh
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Sandeep Sharma
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Anshuman Singh
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Anil K Singh
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Utpal Sharma
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Ajeet Singh Bhadoria
- Department of Clinical Research, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
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Abstract
Liver transplant (LT) is a major surgical undertaking involving major fluid shifts, hemodynamic instability and metabolic derangements in a patient with preexisting liver failure and multisystemic derangements. Monitoring and organ support initiated in the preoperative phase is continued intraoperatively and into the postoperative phase to ensure an optimal outcome. As cardiovascular events are the leading cause of non-graft related death among LT recipients, major emphasis is placed on cardiovascular monitoring. The other essential monitoring are the continuous assessment of coagulapathy, extent of metabolic derangements, dyselectrolytemis and intracranial pressure monitoring in patients with fulminant hepatic failure. The type and extent of monitoring differs with need according to preexisting child status of the patient and the extent of systemic derangements. It also varies among transplant centers and is mainly determined by individual or institutional practices.
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Key Words
- ACT, activated clotting time
- ALF
- ALF, acute liver failure
- APTT, activated partial thromboplastin time
- ARDS, acute respiratory distress syndrome
- CCO, continuous CO
- CCTs, conventional coagulation tests
- CI, cardiac index
- CL, clot lysis
- CO, cardiac output
- CR, clot rate
- CVP, central venous pressure
- ESLD, end stage liver disease
- EVLWI, extra vascular lung water index
- ICG, indocyanine green
- ICH, intracranial hypertension
- ICP, intracranial pressure
- LT, liver transplant
- MA, maximum amplitude
- ONSD, optic nerve sheath diameter
- PAC, pulmonary artery catheter
- PAOP, pulmonary arterial occlusion pressure
- PF, platelet function
- PI, pulsatility index
- PT, prothrombin time
- ROTEM, rotation thrombelastometry
- RVEDV, right ventricular end-diastolic volume
- SV, stroke volume
- SVR, systemic vascular resistance
- TCD, transcranial Doppler
- TDCO, thermodilution principle
- TEE, transesophageal echocardiography
- TEG, thrombelastography
- cirrhosis
- coagulopathy
- intracranial pressure monitoring
- liver transplant
- mPAP, mean pulmonary artery pressure
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Affiliation(s)
- Shweta Singh
- Address for correspondence: Shweta Singh, Associate Professor, Dept. of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India. Tel.: +91 9810625177.
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