1
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Reydellet L, Le Saux A, Blasco V, Nafati C, Harti-Souab K, Armand R, Lannelongue A, Gregoire E, Hardwigsen J, Albanese J, Chopinet S. Impact of Hyperoxia after Graft Reperfusion on Lactate Level and Outcomes in Adults Undergoing Orthotopic Liver Transplantation. J Clin Med 2023; 12:jcm12082940. [PMID: 37109276 PMCID: PMC10145037 DOI: 10.3390/jcm12082940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Hyperoxia is common during liver transplantation (LT), without being supported by any guidelines. Recent studies have shown the potential deleterious effect of hyperoxia in similar models of ischemia-reperfusion. Hyperoxia after graft reperfusion during orthotopic LT could increase lactate levels and worsen patient outcomes. METHODS We conducted a retrospective and monocentric pilot study. All adult patients who underwent LT from 26 July 2013 to 26 December 2017 were considered for inclusion. Patients were classified into two groups according to oxygen levels before graft reperfusion: the hyperoxic group (PaO2 > 200 mmHg) and the nonhyperoxic group (PaO2 < 200 mmHg). The primary endpoint was arterial lactatemia 15 min after graft revascularization. Secondary endpoints included postoperative clinical outcomes and laboratory data. RESULTS A total of 222 liver transplant recipients were included. Arterial lactatemia after graft revascularization was significantly higher in the hyperoxic group (6.03 ± 4 mmol/L) than in the nonhyperoxic group (4.81 ± 2 mmol/L), p < 0.01. The postoperative hepatic cytolysis peak, duration of mechanical ventilation and duration of ileus were significantly increased in the hyperoxic group. CONCLUSIONS In the hyperoxic group, the arterial lactatemia, the hepatic cytolysis peak, the mechanical ventilation and the postoperative ileus were higher than in the nonhyperoxic group, suggesting that hyperoxia worsens short-term outcomes and could lead to increase ischemia-reperfusion injury after liver transplantation. A multicenter prospective study should be performed to confirm these results.
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Affiliation(s)
- Laurent Reydellet
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Audrey Le Saux
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Valery Blasco
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Cyril Nafati
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Karim Harti-Souab
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Romain Armand
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Ariane Lannelongue
- Department of Anaesthesia and Intensive Care, Carémeau Hospital, 30029 Nîmes, France
| | - Emilie Gregoire
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 13005 Marseille, France
- European Center for Medical Imaging Research CERIMED/LIIE, Aix-Marseille Université, 13385 Marseille, France
| | - Jean Hardwigsen
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 13005 Marseille, France
- École de Médecine, Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Jacques Albanese
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
- École de Médecine, Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Sophie Chopinet
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 13005 Marseille, France
- European Center for Medical Imaging Research CERIMED/LIIE, Aix-Marseille Université, 13385 Marseille, France
- École de Médecine, Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385 Marseille, France
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2
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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3
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Januszko-Giergielewicz B, Kobryń A, Donderski R, Trzcinska J, Theda-Pawelska J, Romaszko-Wojtowicz A, Shevchuk A, Słupski M. Hepatorenal Syndrome and Other Post-Liver Transplantation Complications: Case Studies and Literature Review. Transplant Proc 2022; 54:1029-1036. [PMID: 35760626 DOI: 10.1016/j.transproceed.2022.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/05/2022] [Accepted: 03/14/2022] [Indexed: 01/09/2023]
Abstract
Hepatorenal syndrome (HRS) was originally defined as a renal dysfunction caused by a decreased renal perfusion due to hemodynamic disturbances in the arterial circulation and an excessive activity of endogenous vasoactive systems in the course of cirrhosis. Considering the latest research, this syndrome may have a more complex pathomechanism. Equally often as in cirrhosis, HRS develops after orthotopic liver transplantation (OLTx) and worsens the prognosis significantly increasing mortality rates in this patient population. The prevalence of renal complications after OLTx and their negative prognostic impact on the survival of both the graft and the recipient prompted the authors of this work to analyze in detail 2 cases of HRS after OLTx to indicate the multiplicity of factors contributing to the pathophysiology of this syndrome. Attention was paid to risk factors for HRS found in the anamnesis before OLTx, especially a pre-existing renal dysfunction. In both cases early post-OLTx complications associated with the transplantation procedure were described: destabilization of the circulatory system, transfusions of blood products, prolonged stay at an intensive care unit, and necessity of introducing continuous renal replacement therapy. In the later period after the OLTx, infections (bacterial, fungal, viral) and drug nephrotoxicity, including the activity of immunosuppressants (tacrolimus), contributed primarily to the renal function impairment.
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Affiliation(s)
- Beata Januszko-Giergielewicz
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland.
| | - Andrzej Kobryń
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Rafał Donderski
- Department of Nephrology, Internal Diseases and Hypertention, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Joanna Trzcinska
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Joanna Theda-Pawelska
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Anna Romaszko-Wojtowicz
- Department of Pulmonology, Faculty of Public Health, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Poland
| | - Andii Shevchuk
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Maciej Słupski
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
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4
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Milne B. Role of Early Extubation After Orthotopic Liver Transplant. EXP CLIN TRANSPLANT 2021; 20:108-111. [PMID: 34775935 DOI: 10.6002/ect.2021.0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Benjamin Milne
- From the Department of Anaesthesia, King's College Hospital, London, United Kingdom
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5
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Chu NM, Segev DL, McAdams-DeMarco MA. Delirium Among Adults Undergoing Solid Organ Transplantation. CURRENT TRANSPLANTATION REPORTS 2021; 8:118-126. [PMID: 35321347 PMCID: PMC8936706 DOI: 10.1007/s40472-021-00326-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/01/2023]
Abstract
Purpose of Review To summarize the research on post-operative delirium among patients undergoing solid organ transplantation in efforts to improve recognition, evaluation, and management, as well as highlight areas for future research. Recent Findings Delirium is a common complication in patients with organ failure before and after undergoing solid organ transplant (range: 4.7-47%). However, it is frequently unrecognized and underdiagnosed-even among those closely monitored after major surgery-given that its manifestation is often variable and inconsistent. Delirium has multifactorial etiologies comprising of a complex mix of predisposing recipient, donor, and transplant factors, as well as intraoperative and perioperative factors. Evidence suggests that delirium risk increases with presence of a greater number of such risk factors, and can lead to adverse outcomes such as increased hospital length of stay, time in the ICU, time on mechanical ventilators, graft dysfunction, graft loss, and mortality. Though no trials have been conducted among transplant populations specifically, delirium has been shown to be preventable among hospitalized older adults generally. Multicomponent, primary prevention strategies designed to target multiple risk factors of delirium, such as cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration, have been identified as most effective. Whether these approaches translate to improvements in quality of life and long-term health outcomes among patients with organ failure before and after transplantation is yet to be determined. Summary Delirium is an important, common, yet potentially preventable complication among patients with organ failure. Future studies are needed to test the efficacy of multicomponent, primary prevention strategies on long-term health outcomes among these vulnerable populations.
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Affiliation(s)
- Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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6
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McCreery RJ, Florescu DF, Kalil AC. Sepsis in Immunocompromised Patients Without Human Immunodeficiency Virus. J Infect Dis 2021; 222:S156-S165. [PMID: 32691837 DOI: 10.1093/infdis/jiaa320] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Sepsis remains among the most common complications from infectious diseases worldwide. The morbidity and mortality rates associated with sepsis range from 20% to 50%. The advances in care for patients with an immunocompromised status have been remarkable over the last 2 decades, but sepsis continues to be a major cause of death in this population Immunocompromised patients who are recipients of a solid organ or hematopoietic stem cell transplant are living longer with a better quality of life. However, some of these patients need lifelong treatment with immunosuppressive medications to maintain their transplant status. A consequence of the need for this permanent immunosuppression is the high risk of opportunistic, community, and hospital-acquired infections, all of which can lead to sepsis. In addition, the detection of serious infections may be more challenging owing to patients' lower ability to mount the clinical symptoms that usually accompany sepsis. This article provides an update on the current knowledge of sepsis in immunocompromised patients without human immunodeficiency virus. It reviews the most pertinent causes of sepsis in this population, and addresses the specific diagnostic and therapeutic challenges in neutropenia and solid organ and hematopoietic stem cell transplantation.
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Affiliation(s)
- Randy J McCreery
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Diana F Florescu
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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7
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Olsen LB, Kjeldsen AD, Poulsen MK, Kjeldsen J, Fialla AD. High output cardiac failure in 3 patients with hereditary hemorrhagic telangiectasia and hepatic vascular malformations, evaluation of treatment. Orphanet J Rare Dis 2020; 15:334. [PMID: 33243256 PMCID: PMC7691053 DOI: 10.1186/s13023-020-01583-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This report addresses how patients with hereditary hemorrhagic telangiectasia (HHT) and high output cardiac failure (HOCF) due to hepatic vascular malformations, should be evaluated and could be treated. HHT is a genetic disorder, leading to vascular abnormalities with potentially serious clinical implications. In the liver, arteriovenous malformations occur in more than 70% of patients, but only about 8% present clinical symptoms such as HOCF with pulmonary hypertension and less commonly portal hypertension, biliary ischemia and hepatic encephalopathy. RESULTS Three female patients with HHT type 2 and HOCF caused by severe arteriovenous malformations in the liver are presented in this case series. The patients were seen at the HHT-Centre at Odense University Hospital. Treatment with either orthotopic liver transplantation (one patient) or bevacizumab (two patients) was initiated. All patients experienced marked symptom relief and objective improvement. New York Heart Association-class were improved, ascites, peripheral edema and hence diuretic treatment was markedly reduced or discontinued in all three patients. Bevacizumab also resulted in notable effects on epistaxis and anemia. CONCLUSION Our findings substantiate the importance of identification of symptomatic arteriovenous malformations in the liver in patients with HHT. Bevacizumab may possibly, as suggested in this case series and supported by previous case studies, postpone the time to orthotopic liver transplantation or even make it unnecessary. Bevacizumab represents a promising new treatment option, which should be investigated further in clinical trials.
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Affiliation(s)
- Lilian B Olsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark
| | - Anette D Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Otorhinolaryngology Head and Neck Surgery, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Mikael K Poulsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Jens Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Annette D Fialla
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark. .,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark. .,Institute of Clinical Research, Odense, Denmark.
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8
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Amaral B, Vicente M, Pereira CSM, Araújo T, Ribeiro A, Pereira R, Perdigoto R, Marcelino P. Approach to the liver transplant early postoperative period: an institutional standpoint. Rev Bras Ter Intensiva 2020; 31:561-570. [PMID: 31967233 PMCID: PMC7009000 DOI: 10.5935/0103-507x.20190076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 03/04/2019] [Indexed: 12/16/2022] Open
Abstract
The liver transplant program in our center started in 1992, and post-liver transplant patients are still admitted to the intensive care unit. For the intensive care physician, a learning curve started then, skills were acquired, and a specific practice was established. Throughout this time, several concepts changed, improving the care of these patients. The practical approach varies between liver transplant centers, according to local specificities. Hence, we wanted to present our routine practice to stimulate the debate between dedicated teams, which can allow the introduction of new ideas and potentially improve each local standard of care.
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Affiliation(s)
- Beatriz Amaral
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Madalena Vicente
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | | | - Teresa Araújo
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Ana Ribeiro
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Pereira
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Perdigoto
- Unidade de Transplante Hepático, Hospital Curry Cabral - Lisboa, Portugal
| | - Paulo Marcelino
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
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9
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Xu Q, Zhu M, Li Z, Zhu J, Xiao F, Liu F, Wang Y, Liu C. Enhanced recovery after surgery protocols in patients undergoing liver transplantation: A retrospective comparative cohort study. Int J Surg 2020; 78:108-112. [PMID: 32304897 DOI: 10.1016/j.ijsu.2020.03.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Enhanced Recovery after Surgery (ERAS) is a multimodal pathway to overcome the deleterious effect of perioperative stress, and has been applied to different surgeries including liver resection surgery. Explorative studies have shown the safety of some ERAS measures in liver transplantation patients, although no consensus was reached. This study aimed to evaluate the effect of ERAS protocols compared with conventional care in patients undergoing liver transplantation. METHOD All patients (aged 16-70) undergoing liver transplantation for their first time in our centers between January 2016 and July 2019 were retrospectively reviewed and included into this cohort study. They were divided into ERAS group and conventional group depending on the perioperative protocols. Operative time, anhepatic phase time, intraoperative blood loss, intraoperative hypothermia, Surgical Intensive Care Unit (SICU) stay, postoperative complications, pain score, postoperative hospital stay, and mortality were compared between the two groups. RESULTS A total of 40 and 53 patients were included in the ERAS and conventional groups, respectively. The ERAS group had shorter SICU stay (2 vs. 4 days, p < 0.001) and postoperative hospital stay (14.5 vs. 16 days, p < 0.001) compared with the conventional group. Intraoperative hypothermia rate, postoperative pulmonary complications rate, and postoperative pain score were lower in the ERAS group (p < 0.05). There were no differences in operative time, anhepatic phase time, blood loss, mortality, reintubation, lower extremity venous thrombosis and other complications incidence between the two groups. CONCLUSION ERAS procedures effectively improved the patients' recovery, alleviated the suffering and pulmonary complications, and reduced SICU stay and postoperative hospital stay, without increasing incidence of other complications or reintubation. As a safe and feasible choice, ERAS protocols may also have some socioeconomic advantages, which should be addressed in further prospective cohort or clinical trial studies.
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Affiliation(s)
- Qianqian Xu
- Department of Organ Transplantation, Qilu Hospital of Shandong University, NO. 107 Wenhuaxi Road, Jinan, 250012, China
| | - Min Zhu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Zhu Li
- Department of Organ Transplantation, Liaocheng People's Hospital, NO. 67 Dongchangxi Road, Liaocheng, 252000, China
| | - Jiankang Zhu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Fei Xiao
- Department of Organ Transplantation, Liaocheng People's Hospital, NO. 67 Dongchangxi Road, Liaocheng, 252000, China
| | - Fengyue Liu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Yadong Wang
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China
| | - Chongzhong Liu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital of Shandong University, NO 107 Wenhuaxi Road, Jinan, 250012, China.
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10
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Feltracco P, Barbieri S, Carollo C, Bortolato A, Michieletto E, Bertacco A, Gringeri E, Cillo U. Early circulatory complications in liver transplant patients. Transplant Rev (Orlando) 2019; 33:219-230. [PMID: 31327573 DOI: 10.1016/j.trre.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Feltracco
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy.
| | - Stefania Barbieri
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Cristiana Carollo
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Andrea Bortolato
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Elisa Michieletto
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Alessandra Bertacco
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
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11
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Ali AY, William KY, Emad N, Mogawer MS, Elshazli MM, Youssof M, Zidan M. Effect of Duration of Intensive Care Unit Stay on Outcomes of Adult Living Donor Liver Transplant Recipients. Transplant Proc 2019; 51:2425-2429. [PMID: 31277908 DOI: 10.1016/j.transproceed.2019.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/10/2019] [Accepted: 03/23/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIM Acute kidney injury (AKI) is common in patients undergoing liver transplantation and is associated with reduced patient and graft survival. The aim is to assess the occurrence of AKI following living donor liver transplantation and to evaluate the associated risk factors and outcomes. SUBJECTS AND METHODS Forty-nine Egyptian patients with hepatitis C virus who underwent living donor liver transplantation were divided into Group A (17 patients with AKI defined as increased creatinine > 50% of the initial pretransplant level) and Group B (non-AKI patients). Fluid balance, kidney function, preoperative and intraoperative risk factors, outcomes, and 1-year mortality were assessed. RESULTS The mean age was 48 ± 7.51 and the majority of patients assessed were men (89.8%). The 17 patients with AKI had higher preoperative creatinine and higher Model for End-Stage Liver Disease scores (1.3 ± 0.16, 15.7 ± 5.07, respectively) than the non-AKI patients (1.1 ± .15, 13.7 ± 4.61, respectively), with P values of .04 and < .01, respectively. They also had significantly lower levels of albumin (2.98 ± .50). AKI patients had longer intensive care unit (ICU) stays (10 ± 3 d) compared to non-AKI patients (5 ± 2), with a P value of .03. A logistic multivariable regression test revealed that only a long ICU stay is a predictor of developing acute kidney injury among patients who have undergone living donor liver transplantation (odds ratio 1.23, 95% confidence interval 1.1-2.1, with a P value of .012). CONCLUSION Many pre- and intra-operative factors are associated with AKI development; however, a long ICU stay is an independent potential factor for kidney infection.
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Affiliation(s)
- Ahmed Y Ali
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Kerolis Y William
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nahla Emad
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed S Mogawer
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mostafa M Elshazli
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha Youssof
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud Zidan
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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12
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Sundaram V, Jalan R, Wu T, Volk ML, Asrani SK, Klein AS, Wong RJ. Factors Associated with Survival of Patients With Severe Acute-On-Chronic Liver Failure Before and After Liver Transplantation. Gastroenterology 2019; 156:1381-1391.e3. [PMID: 30576643 DOI: 10.1053/j.gastro.2018.12.007] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/04/2018] [Accepted: 12/07/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Liver transplantation for patients with acute-on-chronic liver failure (ACLF) with 3 or more failing organs (ACLF-3) is controversial. We compared liver waitlist mortality or removal according to model for end-stage liver disease (MELD) score vs ACLF category. We also studied factors associated with reduced odds of survival for 1 year after liver transplantation in patients with ACLF-3. METHODS We analyzed data from the United Network for Organ Sharing (UNOS) from 2005 through 2016. We identified patients who were on the waitlist (100,594) and those who received liver transplants (50,552). Patients with ACLF were identified based on the European Association for the Study of the Liver-chronic liver failure criteria. Outcomes were evaluated with competing risks regression, Kaplan-Meier analysis, and Cox proportional hazards regression. RESULTS Patients with ACLF-3 were more likely to die or be removed from the waitlist, regardless of MELD-sodium (MELD-Na) score, compared with the other ACLF groups; the proportion was greatest for patients with an ACLF-3 score and MELD-Na score below 25 (43.8% at 28 days). Mechanical ventilation at liver transplantation (hazard ratio [HR] 1.49; 95% confidence interval [CI] 1.22-1.84), donor risk index above 1.7 (HR 1.22; 95% CI 1.09-1.35), and liver transplantation within 30 days of listing (HR 0.89; 95% CI 0.81-0.98) were independently associated with survival for 1 year after liver transplantation CONCLUSIONS: In an analysis of data from the UNOS registry, we found high mortality among patients with ACLF-3 on the liver transplant waitlist, even among those with lower MELD-Na scores. So, certain patients with ACLF-3 have poor outcomes regardless of MELD-Na score. Liver transplantation increases odds of survival for these patients, particularly if performed within 30 days of placement on the waitlist. Mechanical ventilation at liver transplantation and use of marginal organs were associated with increased risk of death.
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Affiliation(s)
- Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Tiffany Wu
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael L Volk
- Division of Gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, California
| | | | - Andrew S Klein
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, California
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Early Postoperative Neutrophil Gelatinase-Associated Lipocalin Predicts the Development of Chronic Kidney Disease After Liver Transplantation. Transplantation 2019; 102:809-815. [PMID: 29300232 DOI: 10.1097/tp.0000000000002075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Urinary neutrophil gelatinase-associated lipocalin (uNGAL)-associated acute kidney injury is common after liver transplantation (LT), but whether early acute kidney injury predicts chronic kidney disease (CKD) and mortality remains uncertain. METHODS Adults with LT from 2008 to 2010 in a previously published prospective cohort evaluating serial uNGAL pre- and post-LT were retrospectively assessed to evaluate uNGAL as a predictor of long-term outcomes post-LT. The primary outcomes were post-LT CKD, defined as Modification of Diet in Renal Disease estimated glomerular filtration rate less than 60 mL/min per 1.73 m for 3 continuous months, and death. RESULTS uNGAL at 24 hours postreperfusion was significantly higher among patients who developed CKD. Multivariable modeling for the development of CKD demonstrated that uNGAL at 24-hours postreperfusion, 24 hours post-LT renal function, initial calcineurin inhibitor, and age were independent predictors of the development of CKD at in this cohort with long-term follow-up post-LT. Further, this association was stronger in those with preserved pre-LT renal function, a population where renal outcomes are often difficult to predict. CONCLUSIONS We propose that perioperative uNGAL may identify patients at risk for CKD and allow for targeted early implementation of renal-sparing strategies.
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Pita A, Nguyen B, Rios D, Maalouf N, Lo M, Genyk Y, Sher L, Cobb JP. Variability in intensive care unit length of stay after liver transplant: Determinants and potential opportunities for improvement. J Crit Care 2019; 50:296-302. [PMID: 30677626 DOI: 10.1016/j.jcrc.2019.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/27/2018] [Accepted: 01/08/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Recovery after liver transplant (LT) requires extensive resources, including prolonged intensive care unit stays. The objective of this study was to use an assessment tool to determine if LT recipients remain in ICU beyond designated indications. METHODS Records from 100 consecutive LTs performed in a single institution were retrospectively reviewed. An admission, discharge, and triage screening (ADT) tool was utilized to assess the indications for each ICU day. Data collected included demographics; pre-, intra-, and post-operative course; and complications. Days not meeting ADT criteria were considered additional ICU days. RESULTS 100 patients: mean age 55 years (range 24-78 years) and mean MELD score 30 (range 6-47). Three recipients who died within one week were excluded. Forty-eight (49.5%) patients had a total of 75 additional days on initial ICU stay. Univariate analysis revealed no significant differences between patients with and without additional days. 12/97 (12.4%) patients returned to ICU including 5/48 and 7/49 with and without additional days. CONCLUSION Nearly half of the LT recipients remained in ICU an average of 1.6 additional days. Monitoring of organ function appeared to be the most common reason. Opportunities to improve resource utilization could include transfer to an intermediate/progressive care ("step-down") unit.
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Affiliation(s)
- Alejandro Pita
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.
| | - Brian Nguyen
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Daisy Rios
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Nicolas Maalouf
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mary Lo
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Yuri Genyk
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Linda Sher
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - J Perren Cobb
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Transplant Critical Care: Is there a Need for Sub-specialized Units? - A Perspective. ACTA ACUST UNITED AC 2018; 4:83-89. [PMID: 30582000 PMCID: PMC6294987 DOI: 10.2478/jccm-2018-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/15/2018] [Indexed: 01/27/2023]
Abstract
The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.
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Severe infections in critically ill solid organ transplant recipients. Clin Microbiol Infect 2018; 24:1257-1263. [PMID: 29715551 DOI: 10.1016/j.cmi.2018.04.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/13/2018] [Accepted: 04/19/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe infections are among the most common causes of death in immunocompromised patients admitted to the intensive care unit. The epidemiology, diagnosis and treatment of these infections has evolved in the last decade. AIMS We aim to provide a comprehensive review of these severe infections in this population. SOURCES Review of the literature pertaining to severe infections in critically ill solid organ transplant recipients. PubMed and Embase databases were searched for documents published since database inception until November 2017. CONTENT The epidemiology of severe infections has changed in the immunocompromised patients. This population is presenting to the intensive care unit with specific transplantation procedure-related infections, device-associated infections, a multitude of opportunistic viral infections, an increasing number of nosocomial infections and bacterial diseases with a more limited therapeutic armamentarium. Both molecular diagnostics and imaging techniques have had substantial progress in the last decade, which will, we hope, translate into faster and more precise diagnoses, as well as more optimal empirical treatment de-escalation. IMPLICATIONS The key clinical elements to improve the outcome of critically ill solid organ transplant recipients depend on the knowledge of geographic epidemiology, specific surgical procedures, net state of immunosuppression, hospital microbial ecology, aggressive diagnostic strategy and search for source control, rapid initiation of antimicrobials and minimization of iatrogenic immunosuppression.
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Oh SY, Lee JM, Lee H, Jung CW, Yi NJ, Lee KW, Suh KS, Ryu HG. Emergency department visits and unanticipated readmissions after liver transplantation: A retrospective observational study. Sci Rep 2018; 8:4084. [PMID: 29511254 PMCID: PMC5840329 DOI: 10.1038/s41598-018-22404-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 02/22/2018] [Indexed: 01/25/2023] Open
Abstract
Improved survival after LT are likely to result in increased healthcare resource utilization. The pattern and risk factors of emergency department (ED) visits and unanticipated readmissions, associated cost, and predictors of healthcare resource utilization after liver transplantation (LT) patients who received LT between 2011 and 2014 were analyzed. A total of 430 LT recipients were enrolled and the 1 year all-cause mortality was 1.4%. ED visits occurred in 53% (229/430) and unanticipated readmissions occurred at least once in 58.6% (252/430) of the patients. Overall risk factors for ED visits after LT included emergency operation [OR 1.56 (95%CI 1.02-2.37), p = 0.038] and warm ischemic time of >15 minutes [OR 2.36 (95%CI 1.25-4.47), p = 0.015]. Risk factors for readmissions after LT included greater estimated blood loss during LT [OR 1.09 (95%CI 1.02-1.17), p = 0.012], warm ischemic time of >15 minutes [OR 1.98 (95%CI 1.04-3.78), p = 0.038], and hospital length of stay of >2 weeks.
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Affiliation(s)
- Seung-Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hannah Lee
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Chul-Woo Jung
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho Geol Ryu
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, South Korea.
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Luo Y, Ji WB, Duan WD, Shi XJ, Zhao ZM. Delayed introduction of immunosuppressive regimens in critically ill patients after liver transplantation. Hepatobiliary Pancreat Dis Int 2017; 16:487-492. [PMID: 28992880 DOI: 10.1016/s1499-3872(17)60050-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 05/25/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The manipulation of immunosuppression therapy remains challenging in patients who develop infectious diseases or multiple organ dysfunction after liver transplantation. We evaluated the outcomes of delayed introduction of immunosuppression in the patients after liver transplantation under immune monitoring with ImmuKnow assay. METHODS From March 2009 to February 2014, 225 consecutive liver recipients in our institute were included. The delayed administration of immunosuppressive regimens was attempted in 11 liver recipients with multiple severe comorbidities. RESULTS The median duration of non-immunosuppression was 12 days (range 5-58). Due to the infectious complications, the serial ImmuKnow assay showed a significantly low ATP level of 64±35 ng/mL in the early period after transplantation. With the development of comorbidities, the ImmuKnow value significantly increased. However, the acute allograft rejection developed when a continuous distinct elevation of both ATP and glutamyltranspeptidase levels was detected. The average ATP level measured just before the development of acute rejection was 271±115 ng/mL. CONCLUSIONS The delayed introduction of immunosuppressive regimens is safe and effective in management of critically ill patients after liver transplantation. The serial ImmuKnow assay could provide a reliable depiction of the dynamics of functional immunity throughout the clinical course of a given patient.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China.
| | - Wen-Bin Ji
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Wei-Dong Duan
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Xian-Jie Shi
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhi-Ming Zhao
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
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Liver transplantation in the most severely ill cirrhotic patients: A multicenter study in acute-on-chronic liver failure grade 3. J Hepatol 2017. [PMID: 28645736 DOI: 10.1016/j.jhep.2017.06.009] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Liver transplantation (LT) for the most severely ill patients with cirrhosis, with multiple organ dysfunction (accurately assessed by the acute-on-chronic liver failure [ACLF] classification) remains controversial. We aimed to report the results of LT in patients with ACLF grade 3 and to compare these patients to non-transplanted patients with cirrhosis and multiple organ dysfunction as well as to patients transplanted with lower ACLF grade. METHODS All patients with ACLF-3 transplanted in three liver intensive care units (ICUs) were retrospectively included. Each patient with ACLF-3 was matched to a) non-transplanted patients hospitalized in the ICU with multiple organ dysfunction, or b) control patients transplanted with each of the lower ACLF grades (three groups). RESULTS Seventy-three patients were included. These severely ill patients were transplanted following management to stabilize their condition with a median of nine days after admission (progression of mean organ failure from 4.03 to 3.67, p=0.009). One-year survival of transplanted patients with ACLF-3 was higher than that of non-transplanted controls: 83.9 vs. 7.9%, p<0.0001. This high survival rate was not different from that of matched control patients with no ACLF (90%), ACLF-1 (82.3%) or ACLF-2 (86.2%). However, a higher rate of complications was observed (100 vs. 51.2 vs. 76.5 vs. 74.3%, respectively), with a longer hospital stay. The notion of a "transplantation window" is discussed. CONCLUSIONS LT strongly influences the survival of patients with cirrhosis and ACLF-3 with a 1-year survival similar to that of patients with a lower grade of ACLF. A rapid decision-making process is needed because of the short "transplantation window" suggesting that patients with ACLF-3 should be rapidly referred to a specific liver ICU. Lay summary: Liver transplantation improves survival of patients with very severe cirrhosis. These patients must be carefully monitored and managed in a specialized unit. The decision to transplant a patient must be quick to avoid a high risk of mortality.
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20
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Avoiding ICU Admission by Using a Fast-Track Protocol Is Safe in Selected Adult-to-Adult Live Donor Liver Transplant Recipients. Transplant Direct 2017; 3:e213. [PMID: 29026876 PMCID: PMC5627744 DOI: 10.1097/txd.0000000000000730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/18/2017] [Indexed: 01/27/2023] Open
Abstract
Background We evaluated patient characteristics of live donor liver transplant (LDLT) recipients undergoing a fast-track protocol without intensive care unit (ICU) admission versus LDLT patients receiving posttransplant ICU care. Methods Of the 153 LDLT recipients, 46 patients were included in our fast-track protocol without ICU admission. Both, fast-tracked patients and ICU-admitted patients were compared regarding donor and patient characteristics, perioperative characteristics, and postoperative outcomes and complications. In a subgroup analysis, we compared fast-tracked patients with patients who were admitted in the ICU for less than 24 hours. Results Fast-tracked versus ICU patients had a lower model for end-stage liver disease score (13 ± 4 vs 18 ± 7; P < 0.0001), lower preoperative bilirubin levels (51 ± 50 μmol/L vs 119.4 ± 137.3 μmol/L; P < 0.001), required fewer units of packed red blood cells (1.7 ± 1.78 vs 4.4 ± 4; P < 0.0001), and less fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 5; P < 0.0001) during transplantation. Regarding postoperative outcomes, fast-tracked patients presented fewer bacterial infections within 30 days (6.5% [3] vs 29% [28]; P = 0.002), no episodes of pneumonia (0% vs 11.3% [11]; P = 0.02), and less biliary complications within the first year (6% [3] vs 26% [25]; P = 0.001). Also, fast-tracked patients had a shorter posttransplant hospital stay (10.8 ± 5 vs 21.3 ± 29; P = 0.002). In the subgroup analysis, fast-tracked vs ICU patients admitted for less than 24 hours had lower requirements of packed red blood cells (1.7 ± 1.78 vs 3.9 ± 4; P = 0.001) and fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 4.5; P = 0.0001). Conclusions Fast-track of selected patients after LDLT is safe and feasible. An objective score to perioperatively select LDLT recipients amenable to fast track is yet to be determined.
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Bates E, Martin D. Immediate postoperative management and complications on the intensive care unit. Br J Hosp Med (Lond) 2017; 78:273-277. [PMID: 28489448 DOI: 10.12968/hmed.2017.78.5.273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The postoperative management of patients immediately after liver transplantation requires knowledge of this complex surgery and the physiology that accompanies liver failure. A multidisciplinary approach to the care of these patients is essential in order to reduce postoperative complications and preserve function in the transplanted organ. By their nature, patients undergoing liver transplantation have complicated medical problems before surgery which must be borne in mind when managing them after surgery. Haemorrhage, haemodynamic instability, acute renal failure, hepatic artery thrombosis and primary graft non-function are some of the complications that clinicians must be prepared for in the first days after transplantation. Pre-empting complications and acting rapidly to overt them is likely to have a considerable positive impact in these patients.
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Affiliation(s)
- Eleanor Bates
- Specialty Registrar, Royal Free Perioperative Research Group, The Royal Free NHS Foundation Trust, London
| | - Daniel Martin
- Senior Lecturer in Perioperative and Critical Care Medicine, Royal Free Hospital, London NW3 2QG, and Division of Surgery and Interventional Science, University College London, London
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Florescu DF, Sandkovsky U, Kalil AC. Sepsis and Challenging Infections in the Immunosuppressed Patient in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:415-434. [PMID: 28687212 DOI: 10.1016/j.idc.2017.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In 2017, most intensive care units (ICUs) worldwide are admitting a growing population of immunosuppressed patients. The most common causes of pre-ICU immunosuppression are solid organ transplantation, hematopoietic stem cell transplantation, and infection due to human immunodeficiency virus. In this article, the authors review the most frequent infections that cause critical care illness in each of these 3 immunosuppressed patient populations.
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Affiliation(s)
- Diana F Florescu
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA
| | - Uriel Sandkovsky
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA
| | - Andre C Kalil
- Transplant Infectious Diseases Program, Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA.
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23
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Total IVC Occlusion as an Unusual Cause of Acute Renal Failure After Orthotopic Liver Transplantation. Int Surg 2017. [DOI: 10.9738/intsurg-d-14-00308.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Renal dysfunction before and after orthotopic liver transplantation (OLT) has significant implications for morbidity and mortality of these patients. We describe the management of a 72-year-old male patient with history of alcoholic liver cirrhosis (MELD 38) undergoing OLT. The patient presented with declining renal function prior to OLT (baseline GFR <25 mL/min) due to diuretic therapy for refractory ascites, hypovolemia postgastrointestinal bleed, and possible hepatorenal syndrome. The intraoperative management was complicated by preexisting anemia (hematocrit, 22%), unusual RBC antibody (anti-JKa) and significant surgical blood loss. To achieve surgical hemostasis, temporary clamping of the inferior vena cava (IVC) caudal to the transplanted liver was necessary. Postoperatively, the patient remained anuric despite appropriate fluid resuscitation. Renal replacement therapy was initiated to balance volume and acid-base status. A venogram on postoperative day (POD) 5 indicated a complete IVC occlusion and caval thrombectomy was performed on POD 6. After restoration of venous renal drainage, renal function improved and renal replacement therapy was weaned. Renal function indicators normalized in 8 weeks, and remained unimpaired up to 3 months post-OLT. Unintended complete obstruction of the suprarenal IVC may occur during OLT to control surgical bleeding, and should be considered as a cause for acute renal failure after liver transplant. Despite the preexisting renal dysfunction, renal function quickly improved after restoration of blood flow drainage and normalized in less than 8 weeks post obstruction.
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Stratigopoulou P, Paul A, Hoyer DP, Kykalos S, Saner FH, Sotiropoulos GC. High MELD score and extended operating time predict prolonged initial ICU stay after liver transplantation and influence the outcome. PLoS One 2017; 12:e0174173. [PMID: 28319169 PMCID: PMC5358862 DOI: 10.1371/journal.pone.0174173] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 03/03/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of the present study is to determine the incidence of a prolonged (>3 days) initial ICU-stay after liver transplantation (LT) and to identify risk factors for it. PATIENTS AND METHODS We retrospectively analyzed data of adult recipients who underwent deceased donor first-LT at the University Hospital Essen between 11/2003 and 07/2012 and showed a primary graft function. RESULTS Of the 374 recipients, 225 (60.16%) had prolonged ICU-stay. On univariate analysis, donor INR, high doses of vasopressors, "rescue-offer" grafts, being hospitalized at transplant, high urgency cases, labMELD, alcoholic cirrhosis, being on renal dialysis and length of surgery were associated with prolonged ICU-stay. After multivariate analysis, only the labMELD and the operation's length were independently correlated with prolonged ICU-stay. Cut-off values for these variables were 19 and 293.5 min, respectively. Hospital stay was longer for patients with a prolonged initial ICU-stay (p<0.001). Survival rates differed significantly between the two groups at 3 months, 1-year and 5-years after LT (p<0.001). CONCLUSIONS LabMELD and duration of LT were identified as independent predictors for prolonged ICU-stay after LT. Identification of recipients in need of longer ICU-stay could contribute to a more evidenced-based and cost-effective use of ICU facilities in transplant centers.
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Affiliation(s)
- Panagiota Stratigopoulou
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Dieter P. Hoyer
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Stylianos Kykalos
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
- * E-mail:
| | - Fuat H. Saner
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
| | - Georgios C. Sotiropoulos
- Department of General, Visceral and Transplantation Surgery University Hospital Essen, Essen, Germany
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25
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Razonable RR. Liver Transplantation. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Postoperative Care of the Liver Transplant Recipient. ANESTHESIA AND PERIOPERATIVE CARE FOR ORGAN TRANSPLANTATION 2017. [PMCID: PMC7120127 DOI: 10.1007/978-1-4939-6377-5_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rostved AA, Lundgren JD, Hillingsø J, Peters L, Mocroft A, Rasmussen A. MELD score measured day 10 after orthotopic liver transplantation predicts death and re-transplantation within the first year. Scand J Gastroenterol 2016; 51:1360-6. [PMID: 27319374 DOI: 10.1080/00365521.2016.1196497] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The impact of early allograft dysfunction on the outcome after liver transplantation is yet to be established. We explored the independent predictive value of the Model for End-Stage Liver Disease (MELD) score measured in the post-transplant period on the risk of mortality or re-transplantation. MATERIAL AND METHODS Retrospective cohort study on adults undergoing orthotopic deceased donor liver transplantation from 2004 to 2014. The MELD score was determined prior to transplantation and daily until 21 days after. The risk of mortality or re-transplantation within the first year was assessed according to quartiles of MELD using unadjusted and adjusted stepwise Cox regression analysis. RESULTS We included 374 consecutive liver transplant recipients of whom 60 patients died or were re-transplanted. The pre-transplant MELD score was comparable between patients with good and poor outcome, but from day 1 the MELD score significantly diversified and was higher in the poor outcome group (MELD score quartile 4 versus quartile 1-3 at day 10: HR 5.1, 95% CI: 2.8-9.0). This association remained after adjustment for non-identical blood type, autoimmune liver disease and hepatocellular carcinoma (adjusted HR 5.3, 95% CI: 2.9-9.5 for MELD scores at day 10). The post-transplant MELD score was not associated with pre-transplant MELD score or the Eurotransplant donor risk index. CONCLUSION Early determination of the MELD score as an indicator of early allograft dysfunction after liver transplantation was a strong independent predictor of mortality or re-transplantation and was not influenced by the quality of the donor, or preoperative recipient risk factors.
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Affiliation(s)
- Andreas A Rostved
- a Department of Surgery and Liver Transplantation , Rigshospitalet , Copenhagen , Denmark
| | - Jens D Lundgren
- b Department of Infectious Diseases, Section 2100 , Rigshospitalet, CHIP , Copenhagen , Denmark
| | - Jens Hillingsø
- a Department of Surgery and Liver Transplantation , Rigshospitalet , Copenhagen , Denmark
| | - Lars Peters
- b Department of Infectious Diseases, Section 2100 , Rigshospitalet, CHIP , Copenhagen , Denmark
| | - Amanda Mocroft
- c Department of Infection and Population Health , University College London , London , UK
| | - Allan Rasmussen
- a Department of Surgery and Liver Transplantation , Rigshospitalet , Copenhagen , Denmark
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Resino E, San-Juan R, Aguado JM. Selective intestinal decontamination for the prevention of early bacterial infections after liver transplantation. World J Gastroenterol 2016; 22:5950-5957. [PMID: 27468189 PMCID: PMC4948279 DOI: 10.3748/wjg.v22.i26.5950] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 05/06/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection in the first month after liver transplantation is a frequent complication that poses a serious risk for liver transplant recipients as contributes substantially to increased length of hospitalization and hospital costs being a leading cause of death in this period. Most of these infections are caused by gram-negative bacilli, although gram-positive infections, especially Enterococcus sp. constitute an emerging infectious problem. This high rate of early postoperative infections after liver transplant has generated interest in exploring various prophylactic approaches to surmount this problem. One of these approaches is selective intestinal decontamination (SID). SID is a prophylactic strategy that consists of the administration of antimicrobials with limited anaerobicidal activity in order to reduce the burden of aerobic gram-negative bacteria and/or yeast in the intestinal tract and so prevent infections caused by these organisms. The majority of studies carried out to date have found SID to be effective in the reduction of gram-negative infection, but the effect on overall infection is limited due to a higher number of infection episodes by pathogenic enterococci and coagulase-negative staphylococci. However, difficulties in general extrapolation of the favorable results obtained in specific studies together with the potential risk of selection of multirresistant microorganisms has conditioned controversy about the routinely application of these strategies in liver transplant recipients.
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Postoperative Care of a Liver Transplant Recipient Using a Classification System: Type A (Stable) Versus Type B (Unstable). Crit Care Nurs Q 2016; 39:252-66. [PMID: 27254641 DOI: 10.1097/cnq.0000000000000119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Liver transplantation has become an effective and valuable option for patients with end-stage liver disease and hepatocellular carcinoma. Liver failure, an acute or chronic condition, results in impaired bile production and excretion, clotting factor production, protein synthesis, and regulation of metabolism and glucose. Some acute conditions of liver disease have the potential to recover if the liver heals on its own. However, chronic conditions, such as cirrhosis, often lead to irreversible disease and require liver transplantation. In this publication, we review the pathophysiology of liver failure, examine common conditions that ultimately lead to liver transplantation, and discuss the postoperative management of patients who are either hemodynamically stable (type A) or unstable (type B).
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Factors Affecting Breathing Capacity and Early Tracheal Extubation After Liver Transplantation. Transplant Proc 2016; 48:1692-6. [DOI: 10.1016/j.transproceed.2016.01.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/21/2016] [Indexed: 12/13/2022]
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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med 2016; 44:390-438. [PMID: 26771786 DOI: 10.1097/ccm.0000000000001525] [Citation(s) in RCA: 384] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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32
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40:159-211. [PMID: 26773077 DOI: 10.1177/0148607115621863] [Citation(s) in RCA: 1704] [Impact Index Per Article: 213.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Beth E Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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36
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr 2016. [DOI: 10.1177/0148607115621863 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
| | - Beth E. Taylor
- Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri
| | - Robert G. Martindale
- Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon
| | - Malissa M. Warren
- Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon
| | - Debbie R. Johnson
- Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Carol Braunschweig
- Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Mary S. McCarthy
- Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington
| | - Evangelia Davanos
- Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York
| | - Todd W. Rice
- Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gail A. Cresci
- Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio
| | - Jane M. Gervasio
- Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Gordon S. Sacks
- Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Pamela R. Roberts
- Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Charlene Compher
- Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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Alterations of Endothelial Glycocalyx During Orthotopic Liver Transplantation in Patients With End-Stage Liver Disease. Transplantation 2016; 99:2118-23. [PMID: 25757215 DOI: 10.1097/tp.0000000000000680] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Endothelial glycocalyx participates in the maintenance of vascular integrity, and its perturbations cause capillary leakage, loss of vascular responsiveness, and enhanced adhesion of leukocytes and platelets. We hypothesized that marked shedding of the glycocalyx core protein, syndecan-1, occurs in end-stage liver disease (ESLD) and that it increases during orthotopic liver transplantation (OLT). We further evaluated the effects of general anesthesia on glycocalyx shedding and its association with acute kidney injury (AKI) after OLT. PATIENTS AND METHODS Thirty consecutive liver transplant recipients were enrolled in this prospective study. Ten healthy volunteers served as a control. Acute kidney injury was defined by Acute Kidney Injury Network criteria. RESULTS Plasma syndecan-1 was significantly higher in ESLD patients than in healthy volunteers (74.3 ± 59.9 vs 10.7 ± 9.4 ng/mL), and it further increased significantly after reperfusion (74.3 ± 59.9 vs 312.6 ± 114.8 ng/mL). The type of general anesthesia had no significant effect on syndecan-1. Syndecan-1 was significantly higher during the entire study in patients with posttransplant AKI stage 2 or 3 compared to patients with AKI stage 0 or 1. The area under the curve of the receiver operating characteristics curve of syndecane-1 to predict AKI stage 2 or 3 within 48 hours after reperfusion was 0.76 (95% confidence interval, 0.57-0.89, P = 0.005). CONCLUSIONS Patients with ESLD suffer from glycocalyx alterations, and ischemia-reperfusion injury during OLT further exacerbates its damage. Despite a higher incidence of AKI in patients with elevated syndecan-1, it is not helpful to predict de novo AKI. Volatile anesthetics did not attenuate glycocalyx shedding in human OLT.
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Trifan A, Stoica O, Stanciu C, Cojocariu C, Singeap AM, Girleanu I, Miftode E. Clostridium difficile infection in patients with liver disease: a review. Eur J Clin Microbiol Infect Dis 2015; 34:2313-24. [PMID: 26440041 DOI: 10.1007/s10096-015-2501-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 09/28/2015] [Indexed: 02/05/2023]
Abstract
Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.
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Affiliation(s)
- A Trifan
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - O Stoica
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
| | - C Stanciu
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania.
| | - C Cojocariu
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - A-M Singeap
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
- Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency University Hospital, Independentei Street no. 1, 700111, Iasi, Romania
| | - I Girleanu
- "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
| | - E Miftode
- Hospital of Infectious Diseases, "Gr. T. Popa" University of Medicine and Pharmacy, 700111, Iasi, Romania
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Saez I, Sáez J, Talayero M, González N, Catalán M, Sánchez Izquierdo JÁ, Montejo JC. Central venous-to-arterial carbon dioxide difference in the early postoperative care following liver transplantation. Intensive Care Med Exp 2015. [PMCID: PMC4797917 DOI: 10.1186/2197-425x-3-s1-a821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Fernandez TMA, Gardiner PJ. Critical Care of the Liver Transplant Recipient. CURRENT ANESTHESIOLOGY REPORTS 2015; 5:419-428. [PMID: 32288651 PMCID: PMC7101679 DOI: 10.1007/s40140-015-0133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patient survival following orthotopic liver transplantation has greatly increased following improvements in surgical technique, anesthetic care, and immunosuppression. The critical care of the liver transplant recipient has paralleled these improvements, largely thanks to input from multidisciplinary teams and institution-specific protocols guiding management and care. This article provides an overview of the approach to critical care of the postoperative adult liver transplant recipient outlining common issues faced by the intensivist. Approaches to extubation and hemodynamic assessment are described. The provision of appropriate immunosuppression, infection prophylaxis, and nutrition is addressed. To aid prompt diagnosis and treatment, intensivists must be aware of postoperative complications of bleeding, primary nonfunction, delayed graft function, vascular thromboses, biliary complications, rejection, and organ dysfunction.
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Affiliation(s)
- Thomas M. A. Fernandez
- Department of Anesthesia and Perioperative Care, Auckland City Hospital, 2 Park Road, Grafton, Auckland, 1023 New Zealand
| | - Paul J. Gardiner
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
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Kim JM, Jung KH, Lee ST, Chu K, Roh JK. Central nervous system complications after liver transplantation. J Clin Neurosci 2015; 22:1355-9. [DOI: 10.1016/j.jocn.2015.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 03/01/2015] [Indexed: 12/25/2022]
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Abstract
There are over 65,000 people in the United States who have received a liver transplant. In primary care practice, nurse practitioners must be aware of the special considerations necessary for this population.
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Affiliation(s)
- Amanda Chaney
- Amanda Chaney is a nurse practitioner at Mayo Clinic, Department of Transplant, Jacksonville, Fla
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Klinzing S, Brandi G, Stehberger PA, Raptis DA, Béchir M. The combination of MELD score and ICG liver testing predicts length of stay in the ICU and hospital mortality in liver transplant recipients. BMC Anesthesiol 2014; 14:103. [PMID: 25844060 PMCID: PMC4384315 DOI: 10.1186/1471-2253-14-103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/27/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early prediction of outcome would be useful for an optimal intensive care management of liver transplant recipients. Indocyanine green clearance can be measured non-invasively by pulse spectrophometry and is closely related to liver function. METHODS This study was undertaken to assess the predictive value of a combination of the model of end stage liver disease (MELD) score and early indocyanine plasma disappearance rates (ICG-PDR) for length of stay in the intensive care unit (ICU), length of stay in the hospital and hospital mortality in liver transplant recipients. RESULTS Fifty consecutive liver transplant recipients were included in this post Hoc single-center study. ICG-PDR was determined within 6 hours after ICU admission. Endpoints were length of stay in the ICU, length of hospital stay and hospital mortality. The combination of a high MELD score (MELD >25) and a low ICG-PDR clearance (ICG-PDR < 20%/minute) predicts a significant longer stay in the ICU (p = 0.004), a significant longer stay in the hospital (p < 0.001) and a hospital mortality of 40% vs. 0% (p = 0.003). CONCLUSION The combination of MELD scores and a singular ICG-PDR measurement in the early postoperative phase is an accurate predictor for outcome in liver transplant recipients. This easy-to-assess tool might be valuable for an optimal intensive care management of those patients.
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Affiliation(s)
- Stephanie Klinzing
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Giovanna Brandi
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Paul A Stehberger
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Visceral- and Transplantation Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Bulatao IG, Heckman MG, Rawal B, Aniskevich S, Shine TS, Keaveny AP, Perry DK, Canabal J, Willingham DL, Taner CB. Avoiding stay in the intensive care unit after liver transplantation: a score to assign location of care. Am J Transplant 2014; 14:2088-96. [PMID: 25088768 DOI: 10.1111/ajt.12796] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/03/2014] [Accepted: 04/23/2014] [Indexed: 01/25/2023]
Abstract
Select liver transplantation (LT) recipients in our program are transferred from operating room to postanesthesia care unit for recovery and extubation with transfer to the ward, completely eliminating an intensive care unit (ICU) stay. Developing a reliable method to determine patients suitable for fast-tracking would be of practical benefit to centers considering this practice. The aim of this study was to create a fast-tracking probability score that could be used to predict successful assignment of care location after LT. Recipient, donor and operative characteristics were assessed for independent association with successful fast-tracking to create a probability score. Of the 1296 LT recipients who met inclusion criteria, 704 (54.3%) were successfully fast-tracked and 592 (45.7%) were directly admitted to the ICU after LT. Based on nine readily available variables at the time of LT, we created a scoring system that classified patients according to the likelihood of being successfully fast-tracked to the surgical ward, with an area under the curve (AUC) of 0.790 (95% CI: 0.765-0.816). This score was validated in an independent group of 372 LT with similar AUC. We describe a score that can be used to predict successful fast-tracking immediately after LT using readily available clinical variables.
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Affiliation(s)
- I G Bulatao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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Lee S, Sa GJ, Kim SY, Park CS. Intraoperative predictors of early tracheal extubation after living-donor liver transplantation. Korean J Anesthesiol 2014; 67:103-9. [PMID: 25237446 PMCID: PMC4166381 DOI: 10.4097/kjae.2014.67.2.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/19/2014] [Accepted: 02/07/2014] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Prolonged mechanical ventilation after liver transplantation has been associated with deleterious clinical outcomes, so early tracheal extubation posttransplant is now increasing. However, there is no universal clinical criterion for predicting early extubation in living-donor liver transplantation (LDLT). We investigated specific predictors of early extubation after LDLT. METHODS Perioperative data of adult patients undergoing LDLT were reviewed. "Early" extubation was defined as tracheal extubation in the operating room or intensive care unit (ICU) within 1 h posttransplant, and we divided patients into early extubation (EX) and non-EX groups. Potentially significant (P < 0.10) perioperative variables from univariate analyses were entered into multivariate logistic regression analyses. Individual cut-offs of the predictors were calculated by area under the receiver operating characteristic curve (AUC) analysis. RESULTS Of 107 patients, 66 (61.7%) were extubated early after LDLT. Patients in the EX group showed shorter stays in the hospital and ICU and lower incidences of reoperation, infection, and vascular thrombosis. Preoperatively, model for end-stage liver disease score, lung disease, hepatic encephalopathy, ascites, and intraoperatively, surgical time, transfusion of packed red blood cell (PRBC), urine output, vasopressors, and last measured serum lactate were associated with early extubation (P < 0.05). After multivariate analysis, only PRBC transfusion of ≤ 7.0 units and last serum lactate of ≤ 8.2 mmol/L were selected as predictors of early extubation after LDLT (AUC 0.865). CONCLUSIONS Intraoperative serum lactate and blood transfusion were predictors of posttransplant early extubation. Aggressive efforts to ameliorate intraoperative circulatory issues would facilitate successful early extubation after LDLT.
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Affiliation(s)
- Serin Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Gye Jeol Sa
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Stephanie Youna Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Graziadei I. [Intensive care treatment before and after liver transplantation]. Med Klin Intensivmed Notfmed 2014; 109:411-7. [PMID: 25142222 DOI: 10.1007/s00063-014-0364-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 06/21/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Liver transplantation (LT) has become an established therapeutic option for patients with acute and chronic liver failure. Overall survival has dramatically increased over the last decades, mainly due to improved surgical techniques, the introduction of new immunosuppressive and anti-infective drugs but also due to continuous progress in the pre- and post-operative intensive care management of these patients. AIM This article aims to give a short overview of the main aspects regarding pre- and post-LT critical care issues. RESULTS Intensive care treatment plays a major role in the management of patients with acute and acute-on-chronic liver failure in order to enable a life-saving LT for these patients. Severe infections/sepsis mostly accompanied by multi-organ failure represent the major challenges for intensive care specialists. The immediate postoperative care takes place in the intensive care unit (ICU) in almost all patients. The expected ICU stay has been significantly shortened over the years to an average of about 1-2 days. Infections as well as acute kidney injury are the main complications in the first post-operative weeks being responsible for prolonged ICU stays. Immunologic and surgical complications are additional important issues in the post-LT intensive care setting. CONCLUSION The intensive care management pre and post LT is an important, multidisciplinary challenge in the successful treatment of patients with acute and chronic liver failure.
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Affiliation(s)
- I Graziadei
- Abteilung für Innere Medizin, Landeskrankenhaus Hall i.T., Milserstr. 10, 6060, Hall, Österreich,
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Peak Serum AST Is a Better Predictor of Acute Liver Graft Injury after Liver Transplantation When Adjusted for Donor/Recipient BSA Size Mismatch (ASTi). J Transplant 2014; 2014:351984. [PMID: 25009741 PMCID: PMC4070360 DOI: 10.1155/2014/351984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/22/2014] [Indexed: 12/11/2022] Open
Abstract
Background. Despite the marked advances in the perioperative management of the liver transplant recipient, an assessment of clinically significant graft injury following preservation and reperfusion remains difficult. In this study, we hypothesized that size-adjusted AST could better approximate real AST values and consequently provide a better reflection of the extent of graft damage, with better sensitivity and specificity than current criteria. Methods. We reviewed data on 930 orthotopic liver transplant recipients. Size-adjusted AST (ASTi) was calculated by dividing peak AST by our previously reported index for donor-recipient size mismatch, the BSAi. The predictive value of ASTi of primary nonfunction (PNF) and graft survival was assessed by receiver operating characteristic curve, logistic regression, Kaplan-Meier survival, and Cox proportional hazard model. Results. Size-adjusted peak AST (ASTi) was significantly associated with subsequent occurrence of PNF and graft failure. In our study cohort, the prediction of PNF by the combination of ASTi and PT-INR had a higher sensitivity and specificity compared to current UNOS criteria. Conclusions. We conclude that size-adjusted AST (ASTi) is a simple, reproducible, and sensitive marker of clinically significant graft damage.
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