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Anilir E, Sönmez Topçu F, Şahin E, Oral A, Ayyildiz Civan H, Orhan Poyrazoğlu K, Dirican A, Ünal B. Effects of Peroperative Cold Ischemia Time and Anhepatic Phase in Adult Living Donor Liver Transplant Recipients: Operation Time That is Not Affected by the Anhepatic Phase But is Prolonged by Cold Ischemia Time. Transplant Proc 2024:S0041-1345(24)00322-1. [PMID: 39003204 DOI: 10.1016/j.transproceed.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/25/2024] [Accepted: 02/16/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE It was aimed to examine the overall role of cold ischemia time and anhepatic phase durations in terms of peroperative blood transfusion needs, hospital stay conditions and postoperative charges, and survival in recipients. MATERIAL AND METHODS One hundred forty-eight adult living donor liver transplant recipients (18 years and older) were included in the study. Whether the anhepatic phase and cold ischemia duration have an effect on the rates of surgery time, blood product transfusion, total hospital and intensive care unit stay, postoperative biliary complications, hepatic vein thrombosis, portal vein thrombosis, early postoperative bleeding, sepsis, and primary graft dysfunction. Was analyzed statistically. In addition, the effect of the anhepatic phase and cold ischemia time on graft survival was statistically examined by creating an average of the patient follow-up period. RESULTS It was observed that the operation time increased statistically as the cold ischemia time increased (P = .000). No statistically significant relationship was found between other findings and cold ischemia time and anhepatic phase. CONCLUSION Prolonged surgery time due to increased cold ischemia time may be an important finding in terms of peroperative and postoperative results of the graft.
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Affiliation(s)
- Ender Anilir
- Organ Transplantation Center, Biruni University Hospital, İstanbul, Türkiye.
| | - Feyza Sönmez Topçu
- Radiology Department, İstanbul Aydın University Medical Park Florya Hospital, İstanbul, Türkiye
| | - Emrah Şahin
- Organ Transplantation Center, İstanbul Aydın University Medical Park Florya Hospital, İstanbul, Türkiye
| | - Alihan Oral
- İnternal Medicine Department, Fenerbahce University, Biruni University, İstanbul, Türkiye
| | - Hasret Ayyildiz Civan
- Pediatric Gastroenterology Department, İstanbul Aydın University Medical Park Florya Hospital, İstanbul, Türkiye
| | - Kürşat Orhan Poyrazoğlu
- Gastroenterology Department, İstanbul Aydın University Medical Park Florya Hospital, İstanbul, Türkiye
| | - Abuzer Dirican
- Organ Transplantation Center, İstanbul Aydın University Medical Park Florya Hospital, İstanbul, Türkiye
| | - Bülent Ünal
- Organ Transplantation Center, İstanbul Aydın University Medical Park Florya Hospital, İstanbul, Türkiye
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Harle CC. Guidelines to manage liver transplant recipients: time for consensus? Can J Anaesth 2023; 70:1123-1127. [PMID: 37369814 DOI: 10.1007/s12630-023-02498-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 06/29/2023] Open
Affiliation(s)
- Christopher C Harle
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, ON, Canada.
- University Hospital - London Health Sciences Centre, 339 Windermere Rd., Rm C3-105, London, ON, N6A 5A5, Canada.
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3
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Jose A, Jones CR, Elwing JM. Struggling Between Liver Transplantation and Portopulmonary Hypertension. Heart Fail Clin 2023; 19:55-65. [PMID: 36435573 DOI: 10.1016/j.hfc.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Portopulmonary hypertension (PoPH) is a progressive, ultimately fatal cardiopulmonary disease that occurs exclusively in patients with underlying portal hypertensive liver disease. PoPH outcomes are driven by both the severity of underlying liver disease and the degree of cardiac adaptation to elevated pulmonary pressures. The mainstay of treatment in PoPH is targeted pulmonary vascular therapy. Liver transplantation (LT) can be beneficial in some patients, but is associated with considerable risks in the PoPH population, and outcomes are variable. The optimal management strategy for PoPH, LT, or medical therapy alone, is unclear, and further research is needed to help guide clinical decision-making.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, ML 0564, Medical Sciences Building, 231 Albert Sabin Way, Cincinnati, OH 45267, USA.
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, ML 3553, Medical Sciences Building, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, ML 0564, Medical Sciences Building, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
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Kozlik A, Wiseman K, Upadhyaya VD, Sharma A, Chatterjee S. Preoperative Coronary Intervention Before Orthotopic Liver Transplantation (from a Review of Literature). Am J Cardiol 2022; 185:94-99. [DOI: 10.1016/j.amjcard.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022]
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Kohli M, Garg N, Sindwani G, Tempe D, Pamecha V, Pasupuleti SSR. Effect of positive cumulative fluid balance on postoperative complications after living donor liver transplantation: A retrospective analysis. Indian J Anaesth 2021; 65:383-389. [PMID: 34211196 PMCID: PMC8202804 DOI: 10.4103/ija.ija_1457_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/02/2021] [Accepted: 03/02/2021] [Indexed: 12/14/2022] Open
Abstract
Background and Aims: Fluid administration during liver transplant (LT) surgery is controversial. Although adverse outcomes following positive intraoperative fluid balance have been reported, studies presenting the influence of cumulative postoperative fluid balance (CFB) on complications following LT are sparse. Patients with chronic liver disease tend to receive more fluid during and after surgery due to their unique physiological disease state. The aim of this study was to evaluate the influence of 48-hour CFB on the development of acute kidney injury (AKI) and pulmonary complications on day 4 after live donor LT. Methods: This retrospective study included 230 patients undergoing live donor LT. The effect of CFB on day 2 on AKI and pulmonary complications was analysed. Chi-square test, Fisher's exact test, samples t-test, Mann-Whitney U-test were used. Results: Bivariate analysis showed a lower graft vs recipient weight ratio (GRWR), sepsis (P < 0.001) and a higher 48-hour CFB after surgery significantly increased the development of AKI. For pulmonary complications, higher Model for End- stage Liver Disease-Na(MELD-Na) score, higher peak arterial lactate, higher 48-hour CFB (P = 0.016) and sepsis (P = 0.003) were found to be statistically significant. Upon multivariate analysis, CFB at 48 hours was significantly higher in patients suffering from pulmonary complications, and GRWR and sepsis were significant for AKI. For every one litre increase in CFB on day 2, the odds of pulmonary complications increased by 37%. Conclusion: A more positive CFB on day 2 increased the development of pulmonary complications and lower GRWR and sepsis increased the development of AKI.
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Affiliation(s)
- Megha Kohli
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Neha Garg
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Gaurav Sindwani
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Deepak Tempe
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Viniyendra Pamecha
- Department of Liver Transplant and Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, Delhi, India
| | - Samba Siva Rao Pasupuleti
- Department of Statistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, Mizoram, India
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Imam A, Karatas C, Mecit N, Kalayoglu M, Kanmaz T. Cardiac Intervention Before Liver Transplantation. Transplant Proc 2021; 53:1622-1625. [PMID: 33892932 DOI: 10.1016/j.transproceed.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/29/2021] [Accepted: 03/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiovascular complication is one of the leading causes of mortality after liver transplantation (LT). Thus, a thorough cardiac evaluation is a must before proceeding to a liver transplant surgery. Percutaneous coronary intervention (PCI) with stent and to a lesser extent coronary artery bypass grafting (CABG) are both valuable treatment options for patients with coronary artery disease. METHODS A retrospective, single-center study that included patients who underwent cardiac intervention and subsequent LT for end-stage liver disease. All patients who had PCI or CABG were included in the study. RESULTS Twenty-nine adult patients out of 51 had a cardiac intervention before liver transplantation. Twenty-four patients had a diagnostic PCI, 3 patients had therapeutic PCI with stent, and 2 had failed PCI and proceeded to CABG before liver transplant. The mean age of the patients was 60.5 years. There were 24 men. All patients had cirrhosis. The 2 CABG cases were done during the same admission with a 13- and 18-day interval between the CABG and the transplantation. Both cases were live-related liver transplantation. No mortality was reported. CONCLUSION In case of PCI failure, CABG may be a valuable and safe treatment option for cirrhotic patients as a preparation for liver transplantation. Live donor liver transplantation may be a good back-up for those patients in case they develop hepatic decompensation.
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Affiliation(s)
- Ashraf Imam
- Liver Transplantation Department, Koc University Hospital, Istanbul, Turkey.
| | - Cihan Karatas
- Liver Transplantation Department, Koc University Hospital, Istanbul, Turkey
| | - Nesimi Mecit
- Liver Transplantation Department, Koc University Hospital, Istanbul, Turkey
| | - Munci Kalayoglu
- Liver Transplantation Department, Koc University Hospital, Istanbul, Turkey
| | - Turan Kanmaz
- Liver Transplantation Department, Koc University Hospital, Istanbul, Turkey
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Cardiovascular and Metabolic Consequences of Liver Transplantation: A Review. ACTA ACUST UNITED AC 2019; 55:medicina55080489. [PMID: 31443295 PMCID: PMC6722584 DOI: 10.3390/medicina55080489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/03/2019] [Accepted: 08/09/2019] [Indexed: 12/14/2022]
Abstract
Liver transplantation (LT) is considered the curative treatment option for selected patients who suffer from end-stage or acute liver disease or hepatic malignancy (primary). After LT, patients should be carefully monitored for complications that may appear, partially due to immunosuppressive therapy, but not entirely. Cardiovascular diseases are frequently encountered in patients with LT, being responsible for high morbidity and mortality. Patients with underlying cardiovascular and metabolic pathologies are prone to complications after the transplant, but these complications can also appear de novo, mostly associated with immunosuppressants. Metabolic syndrome, defined by obesity, hypertension, dyslipidemia, and hyperglycemia, is diagnosed among LT recipients and is aggravated after LT, influencing the long-term survival. In this review, our purpose was to summarize the current knowledge regarding cardiovascular (CV) diseases and the metabolic syndrome associated with LT and to assess their impact on short and long-term morbidity and mortality.
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Kim S, DeMaria S, Li J, Lin HM, Smith N, Wax D, Hill B, So A, Tabrizian P, Florman S, Feierman D, Zerillo J. Persistent acidosis after reperfusion-A prognostic indicator of increased 30-day and in-hospital postoperative mortality in liver transplant recipients. Clin Transplant 2019; 33:e13473. [PMID: 30597632 DOI: 10.1111/ctr.13473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 11/30/2018] [Accepted: 12/08/2018] [Indexed: 11/30/2022]
Abstract
During liver transplantation, the patient is at risk of developing progressive lactic acidosis. Following reperfusion, correction of acidosis may occur. In some patients, acidosis will worsen, a phenomenon referred to as persistent acidosis after reperfusion (PAAR). We compared postoperative outcomes in patients who manifested PAAR vs those that did not. All adult patients undergoing liver transplantation from 2002 to 2015 were included. PAAR is defined by the presence of a significant negative slope coefficient for base excess values measured after hepatic artery anastomosis through 72 hours postoperatively. Primary outcome was a composite of 30-day and in-hospital mortality. Secondary outcomes included: ICU LOS, total hospital LOS, and re-transplantation rate within 7 days. PAAR occurred in 10% of the transplant recipients. Patients with PAAR had higher MELD, BMI, and eGFR and demonstrated a longer median ICU LOS and hospital median LOS with a trend toward mortality difference. But, after propensity matching, the mortality rate difference became significantly higher in patients with PAAR compared with matched controls while the ICU LOS differences disappeared. The re-transplantation rates were similar also between the PAAR and no PAAR groups. The cohort with PAAR had a significant 30-day and in-hospital increase in mortality after propensity score matching.
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Affiliation(s)
- Sang Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jiawen Li
- Department of Biostatistics and Data Management, Abbott Molecular, Des Plaines, Illinois
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Natalie Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David Wax
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bryan Hill
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ashley So
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Parissa Tabrizian
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dennis Feierman
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Abdulatif M, Lotfy M, Mousa M, Afifi MH, Yassen K. Sugammadex antagonism of rocuronium-induced neuromuscular blockade in patients with liver cirrhosis undergoing liver resection: a randomized controlled study. Minerva Anestesiol 2018; 84:929-937. [DOI: 10.23736/s0375-9393.18.12217-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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10
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Bonavia A, Pachuski J, Bezinover D. Perioperative Anesthetic Management of Patients Having Liver Transplantation for Uncommon Conditions. Semin Cardiothorac Vasc Anesth 2017; 22:197-210. [PMID: 28922972 DOI: 10.1177/1089253217732129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This review focuses on the perioperative anesthetic management of patients having liver transplantation (LT) performed for several uncommon indications or in combination with rare pathology. Conditions discussed in the article include Alagille syndrome, hypertrophic cardiomyopathy, Gilbert's syndrome, porphyria, Wilson's disease, and Budd-Chiari syndrome. In comparison to other indications, LT in these settings is infrequent because of the low incidence of these pathologies. Most of these conditions (with the exception of Gilbert syndrome) are associated with a high probability of significant perioperative complications and increased mortality and morbidity. Experience in management of these unusual conditions is only gained over time. Developing clinical pathways for patients with these conditions should result in outcomes similar to LT performed for more common indications.
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Affiliation(s)
- Anthony Bonavia
- 1 Penn State Milton S Hershey Medical Center, Hershey, PA, USA
| | - Justin Pachuski
- 1 Penn State Milton S Hershey Medical Center, Hershey, PA, USA
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11
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Katz D, Zerillo J, Kim S, Hill B, Wang R, Goldberg A, DeMaria S. Serious gaming for orthotopic liver transplant anesthesiology: A randomized control trial. Liver Transpl 2017; 23:430-439. [PMID: 28133947 DOI: 10.1002/lt.24732] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/09/2016] [Accepted: 01/02/2017] [Indexed: 02/07/2023]
Abstract
Anesthetic management of orthotopic liver transplantation (OLT) is complex. Given the unequal distributions of liver transplant surgeries performed at different centers, anesthesiology providers receive relatively uneven OLT training and exposure. One well-suited modality for OLT training is the "serious game," an interactive application created for the purpose of imparting knowledge or skills, while leveraging the self-motivating elements of video games. We therefore developed a serious game designed to teach best practices for the anesthetic management of a standard OLT and determined if the game would improve resident performance in a simulated OLT. Forty-four residents on the liver transplant rotation were randomized to either the gaming group (GG) or the control group (CG) prior to their introductory simulation. Both groups were given access to the same educational materials and literature during their rotation, but the GG also had access to the OLT Trainer. Performance on the simulations were recorded on a standardized grading rubric. Both groups experienced an increase in score relative to baseline that was statistically significant at every stage. The improvements in scores were greater for the GG participants than the CG participants. Overall score improvement between the GG and CG (mean [standard deviation]) was statistically significant (GG, 7.95 [3.65]; CG, 4.8 [4.48]; P = 0.02), as were scores for preoperative assessment (GG, 2.67 [2.09]; CG, 1.17 [1.43]; P = 0.01) and anhepatic phase (GG, 1.62 [1.01]; CG, 0.75 [1.28]; P = 0.02). Of the residents with game access, 81% were "very satisfied" or "satisfied" with the game overall. In conclusion, adding a serious game to an existing educational curriculum for liver transplant anesthesia resulted in significant learning gains for rotating anesthesia residents. The intervention was straightforward to implement and cost-effective. Liver Transplantation 23 430-439 2017 AASLD.
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Affiliation(s)
- Daniel Katz
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeron Zerillo
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sang Kim
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bryan Hill
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan Wang
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew Goldberg
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samuel DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
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Rajakumar A, Gupta S, Malleeswaran S, Varghese J, Kaliamoorthy I, Rela M. Anaesthesia and intensive care for simultaneous liver-kidney transplantation: A single-centre experience with 12 recipients. Indian J Anaesth 2016; 60:476-83. [PMID: 27512163 PMCID: PMC4966351 DOI: 10.4103/0019-5049.186025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and Aims: The perioperative management of patients presenting for simultaneous liver and kidney transplantation (SLKT) is a complex process. We analysed SLKTs performed in our institution to identify preoperative, intraoperative and post-operative challenges encountered in the management. Methods: We retrospectively studied the case records of 12 patients who underwent SLKT between 2009 and 2014 and analysed details of pre-operative evaluation and optimisation, intraoperative anaesthetic management and the implications of use of perioperative continuous renal replacement therapy (CRRT) and the post-operative course of these patients. Results: Of the total 12 cases, 4 were under 16 years of age. The indications for SLKT were primary hyperoxaluria (5), congenital hepatic fibrosis with polycystic kidney disease (2), ethanol-related end-stage liver disease (ESLD) with hepatorenal syndrome type 1 (1). Four patients had ESLD with end-stage renal disease due to other causes. Six recipients received live donor grafts and 6 patients received cadaveric grafts. Seven patients received intraoperative CRRT. Mean duration of surgery was 12.5 h. Cardiac output monitors used were trans-oesophageal echocardiogram (2), pulmonary artery catheter (1) and pulse contour cardiac output monitor (3). There was 1 sepsis-related mortality on 7th post-operative day. Conclusion: A thorough pre-operative evaluation and optimisation, knowledge and anticipation of potential problems, and meticulous intraoperative fluid management guided by appropriate monitoring and use of CRRT when needed can help in achieving successful outcomes.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Shiwalika Gupta
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Selvakumar Malleeswaran
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Joy Varghese
- Department of Hepatology, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Hepatobiliary and Liver Transplant Surgery, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India; Department of Hepatobiliary and Liver Transplant Surgery, Institute of Liver Studies, King's College, London
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Conditioning With Sevoflurane in Liver Transplantation: Results of a Multicenter Randomized Controlled Trial. Transplantation 2015; 99:1606-12. [PMID: 25769076 DOI: 10.1097/tp.0000000000000644] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND During times of organ scarcity and extended use of liver grafts, protective strategies in transplantation are gaining importance. We demonstrated in the past that volatile anesthetics such as sevoflurane attenuate ischemia-reperfusion injury during liver resection. In this randomized study, we examined if volatile anesthetics have an effect on acute graft injury and clinical outcomes after liver transplantation. METHODS Cadaveric liver transplant recipients were enrolled from January 2009 to September 2012 at 3 University Centers (Zurich/Sao Paulo/Ghent). Recipients were randomly assigned to propofol (control group) or sevoflurane anesthesia. Postoperative peak of aspartate transaminase was defined as primary endpoint, secondary endpoints were early allograft dysfunction, in-hospital complications, intensive care unit, and hospital stay. RESULTS Ninety-eight recipients were randomized to propofol (n = 48) or sevoflurane (n = 50). Median peak aspartate transaminase after transplantation was 925 (interquartile range, 512-3274) in the propofol and 1097 (interquartile range, 540-2633) in the sevoflurane group. In the propofol arm, 11 patients (23%) experienced early allograft dysfunction, 7 (14%) in the sevoflurane one (odds ratio, 0.64 (0.20 to 2.02, P = 0.45). There were 4 mortalities (8.3%) in the propofol and 2 (4.0%) in the sevoflurane group. Overall and major complication rates were not different. An effect on clinical outcomes was observed favoring the sevoflurane group (less severe complications), but without significance. CONCLUSIONS This first multicenter trial comparing propofol with sevoflurane anesthesia in liver transplantation shows no difference in biochemical markers of acute organ injury and clinical outcomes between the 2 regimens. Sevoflurane has no significant added beneficial effect on ischemia-reperfusion injury compared to propofol.
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De Pietri L, Mocchegiani F, Leuzzi C, Montalti R, Vivarelli M, Agnoletti V. Transoesophageal echocardiography during liver transplantation. World J Hepatol 2015; 7:2432-2448. [PMID: 26483865 PMCID: PMC4606199 DOI: 10.4254/wjh.v7.i23.2432] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/22/2015] [Accepted: 09/09/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver transplant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the procedures as a result of both the disease process and the surgery. Transoesophageal echocardiography (TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. Moreover, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.
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Zaky A, Bendjelid K. Appraising cardiac dysfunction in liver transplantation: an ongoing challenge. Liver Int 2015; 35:12-29. [PMID: 24797833 DOI: 10.1111/liv.12582] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 04/26/2014] [Indexed: 12/26/2022]
Abstract
End-stage liver disease (ESLD) is a multisystemic disease that adversely and mutually aggravates other organs such as the heart. Cardiac dysfunction in ESLD encompasses a spectrum of disease that could be aggravated, precipitated or be occurring hand-in-hand with coexisting aetiological factors precipitating cirrhosis. Additionally and more complexly, liver transplantation, the curative modality of ESLD, is responsible for additional intra- and postoperative short- and long-term cardiac morbidity. The phenotypic distinction of the different forms of cardiac dysfunction in ESLD albeit important prognostically and therapeutically is not allowed by the current societal recommendations, due to conceptual, and methodological limitations in the appraisal of cardiac function and structure in ESLD and in designing studies that are based on this appraisal. This review comprehensively discusses the spectrum of cardiac dysfunction in ESLD, discusses the limitations of the current appraisal of cardiac dysfunction in ESLD, and proposes a hypothetical approach for studying cardiac dysfunction in liver transplant candidates.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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16
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Anaesthetic and Perioperative Management for Liver Transplantation. ABDOMINAL SOLID ORGAN TRANSPLANTATION 2015. [PMCID: PMC7124066 DOI: 10.1007/978-3-319-16997-2_9] [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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Hofer I, Spivack J, Yaport M, Zerillo J, Reich DL, Wax D, DeMaria S. Association between anesthesiologist experience and mortality after orthotopic liver transplantation. Liver Transpl 2015; 21:89-95. [PMID: 25283640 DOI: 10.1002/lt.24014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 09/03/2014] [Accepted: 09/14/2014] [Indexed: 02/07/2023]
Abstract
The anesthesiologist has been recognized as an integral member of the liver transplant team, and previous studies have demonstrated that inter-anesthesiologist variability can be a driver of outcomes for high-risk patients. We hypothesized that anesthesiologist experience, defined as the number of previous liver transplants performed at our institution, the Icahn School of Medicine at Mount Sinai, would be independently associated with outcomes for liver transplant patients. Eight hundred forty-nine liver transplants performed between January 2003 and January 2013 with a total of 22 anesthesiologists were analyzed. Each transplant was assigned an incremental case number that corresponded to the number of transplants that the attending anesthesiologist had already performed at our institution. Several perioperative covariates were controlled for in the context of a generalized linear mixed effects model to detail the influence of threshold levels of the incremental case number on the primary outcome, 30-day mortality, and a secondary outcome, 30-day graft failure. Sensitivity analyses were conducted to confirm the robustness of these findings. An incremental case number ≤ 5 was associated with a significantly greater risk of 30-day mortality (odds ratio = 2.24, 95% confidence interval = 1.11-4.54, P = 0.025), and there was evidence suggestive of a greater risk of 30-day graft failure (odds ratio = 1.93, 95% confidence interval = 0.95-3.93, P = 0.071). Sensitivity analyses ruled out threats to the validity of these findings, including dropout effects and time trends in the overall performance of the transplantation unit. In conclusion, this study shows that an anesthesiologist's level of experience has a significant effect on outcomes for liver transplant recipients, with increased mortality and possibly graft failure during a provider's first 5 cases. These findings may indicate the need for increased training and supervision for anesthesiologists joining the liver transplant team.
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Affiliation(s)
- Ira Hofer
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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Sahmeddini MA, Zahiri S, Khosravi MB, Ghaffaripour S, Eghbal MH, Shokrizadeh S. Effect of mannitol on postreperfusion cardiac output and central venous oxygen saturation during orthotopic liver transplant: a double-blind randomized clinical trial. Prog Transplant 2014; 24:121-5. [PMID: 24919727 DOI: 10.7182/pit2014483] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Attenuating postreperfusion syndrome during orthotopic liver transplant is very important for transplant anesthesiologists because of the syndrome's complications. Oxygen-derived free radicals play an important role in the genesis of postreperfusion syndrome, but the effect of mannitol (a free radical scavenger) on attenuating the syndrome is unclear.OBJECTIVES-To investigate the effectiveness of infusing mannitol during the anhepatic phase in preventing postreperfusion syndrome, as indicated by postreperfusion cardiac output and central venous oxygen saturation. DESIGN In a randomized clinical trial, 53 patients who had undergone orthotopic liver transplant were allocated to 2 groups. During the anhepatic phase, patients in the mannitol group received 1g/kg mannitol, whereas those in the control group received physiological saline. Mean arterial pressure, cardiac output, and central venous oxygen saturation were measured before and after the portal vein was declamped. Serum levels of sodium and potassium were recorded at baseline and after portal vein declamping.Setting-Shiraz Organ Transplant Center, Shiraz, Iran. RESULTS In the mannitol group, no significant change was found in mean arterial pressure, cardiac output, and central venous oxygen saturation before and after declamping of the portal vein (P= .78, P= .59, and P= .83, respectively). However, after declamping in the control group, mean arterial pressure, cardiac output, and central venous oxygen saturation were significantly lower than before declamping (P=.003, P=.001, and P<.001, respectively). No significant change in serum levels of sodium and potassium from baseline to after declamping were found in either group. CONCLUSION Infusion of mannitol 1 g/kg during the anhepatic phase was effective in attenuating postreperfusion syndrome without stress about hyperkalemia or hyponatremia during anesthesia.
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Affiliation(s)
- Mohammad Ali Sahmeddini
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Siamak Zahiri
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Bagher Khosravi
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sina Ghaffaripour
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Eghbal
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sakine Shokrizadeh
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Hasanin AS, Mahmoud FMA, Yassen KA. Entropy-guided end-tidal desflurane concentration during living donor liver transplantation. Saudi J Anaesth 2013; 7:399-403. [PMID: 24348290 PMCID: PMC3858689 DOI: 10.4103/1658-354x.121048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: The three phases of living donor liver transplantation (LDLT) represent different liver conditions. The aim is to study the required end-tidal desflurane concentration (ET-Des) guided with entropy monitoring for the depth of anesthesia. Methods: After the Ethics and Research Committee approval, 40 patients were included in this prospective study. Anesthesia was maintained with Desflurane-O2-air. State entropy (SE) and Response entropy (RE) were kept between 40 and 60. Results: Age and Model for End-stage Liver Disease (MELD) score were 45±10 years and 15.43±3.92, respectively. ET-Des were significantly lower in the anhepatic phase (2.8±0.4%) than in the pre-anhepatic and neohepatic phases (3.3±0.3%, 3.47±0.3%, respectively, P<0.001). The SE and RE for pre-anhepatic, anhepatic, and neohepatic phases were (45.6±3.7, 47.4±3.2), (44.7±2.1, 46.4±2.04), and (46.1±3.3, 47.9±3.3), respectively, with no significant changes between the phases, P > 0.05. Total operative time was 651±88 minutes, and for each phase it was 276±11, 195±55, and 191±24 minutes, respectively. Significant changes were found in hemoglobin g/dl and hematocrit % between the three phases (10.28±1.5, 30.48±4.3), (9.45±1.34, 28.36±4.1), and (8.88±1.1, 26.63±3.5), P<0.05. The heart rate and mean blood pressures were stable despite the cardiac index demonstrated a significant reduction during the anhepatic phase (2.99±0.22) when compared to the pre-anhepatic and neohepatic phases (3.60±0.29) and (4.72±0.32), respectively, (P<0.05). There was a significant correlation between CI and ET-Des% (r=0.604, P<0.05). Conclusion: Inhalational anesthetic requirements differed from one phase to another during LDLT, with requirements being the least during the anhepatic phase. Monitoring of the anesthesia depth was required, to avoid excess administration, which could compromise the hemodynamics before the critical time of reperfusion.
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Affiliation(s)
- Ashraf S Hasanin
- Department of Anesthesia and ICU, National Liver Institute, Menofia University, Egypt
| | - Fatma M A Mahmoud
- Department of Anesthesia and ICU, National Liver Institute, Menofia University, Egypt
| | - Khaled A Yassen
- Department of Anesthesia and ICU, National Liver Institute, Menofia University, Egypt
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Sahmeddini MA, Amini A, Naderi N. The effect of octreotide on urine output during orthotopic liver transplantation and early postoperative renal function; a randomized, double-blind, placebo-controlled trial. HEPATITIS MONTHLY 2013; 13:e12787. [PMID: 24282425 PMCID: PMC3830523 DOI: 10.5812/hepatmon.12787] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/31/2013] [Accepted: 08/21/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Maintenance of the adequate intraoperative renal perfusion is very important during Orthotopic Liver Transplantation (OLT) to prevent acute renal failure. OBJECTIVES For the first time, this study was designed to survey the effects of octreotide on urine output during anesthesia for OLT and early postoperative renal function. PATIENTS AND METHODS In this randomized double-blind placebo controlled clinical trial, 79 of 89 patients who underwent OLT and fulfilled the study requirement were randomly allocated into two groups. In the octreotide group, the patients received octreotide infusion from the start of the operation. On the other hand, the control group patients received physiologic saline infusion instead of octreotide. The Mean Arterial Pressure (MAP), heart rate, urine output, norepinephrine usage, and dosage during the three stages of OLT, and baseline and postoperative creatinine were recorded and compared between the two groups. RESULTS No significant differences were found between the two groups regarding the demographic characteristics and graft factors (P > 0.05). However, urine output and MAP during the three stages of OLT were significantly higher in the octreotide group compared to the control group (P < 0.05). Moreover, no significant difference was observed between the two groups regarding baseline as well as postoperative creatinine (P > 0.05). CONCLUSIONS The results demonstrated that octreotide infusion during anesthesia for OLT not only augmented the vasoconstriction effect of norepinephrine to increase MAP, but also maintained better renal perfusion and urine output during the operation.
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Affiliation(s)
- Mohammad Ali Sahmeddini
- Shiraz Anesthesiology and Intensive Care Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Mohammad Ali Sahmeddini, Shiraz Anesthesiology and Intensive Care Research Center, Namazi Hospital, Shiraz, IR Iran. Tel: +98-7116474270, Fax: +98-7116474270, E-mail:
| | - Afshin Amini
- Shiraz Anesthesiology and Intensive Care Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Nima Naderi
- Shiraz Anesthesiology and Intensive Care Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
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Robertson AC, Eagle SS. Transesophageal echocardiography during orthotopic liver transplantation: maximizing information without the distraction. J Cardiothorac Vasc Anesth 2013; 28:141-154. [PMID: 23642888 DOI: 10.1053/j.jvca.2012.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Indexed: 12/17/2022]
Affiliation(s)
- Amy C Robertson
- Vanderbilt University School of Medicine, Department of Anesthesiology, Nashville, TN.
| | - Susan S Eagle
- Vanderbilt University School of Medicine, Department of Anesthesiology, Nashville, TN
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Anesthetic management for resection of hepatic paraganglioma metastatic from the donor organ in an orthotopic liver transplant recipient: a case report. Transplant Proc 2013; 45:817-9. [PMID: 23498826 DOI: 10.1016/j.transproceed.2012.10.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 09/20/2012] [Accepted: 10/16/2012] [Indexed: 11/21/2022]
Abstract
This is a case report of the anesthetic management for the hepatic resection of a metastatic paraganglioma in a patient with a history of prior orthotopic liver transplantation. Of interest, the metastatic paraganglioma originated from the donor organ. The patient is an 80-year-old woman with multiple medical problems including a history of cryptogenic cirrhosis who underwent successful orthotopic liver transplantation 9 years prior. She later presented with signs and symptoms of catecholamine excess suggestive of a catecholamine-producing tumor (paraganglioma or pheochromocytoma). Elevated urine catecholamine levels and radiographic evidence of a paraganglioma in the transplanted liver metastatic from the donor organ confirmed the diagnosis. Radiofrequency ablation of the tumor and surgical resection was previously attempted without success. We describe the anesthetic management for the successful resection of the metastatic hepatic paraganglioma, which was complicated by profound intraoperative hypertension and hypotension that necessitated the use of multiple vasoactive infusions, extensive surgical blood loss requiring blood transfusion, and difficult glycemic control in an insulin-dependent diabetic patient. The postoperative course is also described. This unique case presented the anesthesia team with challenges specific to both surgery for hepatic resection as well as for catecholamine-secreting tumors. We are not aware of any reports of paragangliomas of either donor or recipient origin involving a transplanted liver, making this the first such report to the best of our knowledge.
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Abstract
Orthotopic liver transplantation is the only definitive treatment for end-stage liver disease. More than 6000 procedures are performed in the United States annually with excellent survival rates. The shortage of donor organs leads to continued interest in techniques to enlarge the potential donor pool. Patients presenting for liver transplant suffer from important cardiovascular, respiratory, renal, neurological, and gastroenterological comorbidity. In the Western world, liver failure is increasingly caused by steatohepatitis, and transplant candidates are thus becoming older and more comorbid. The role of the transplant anesthesiologist is highly important in the preoperative assessment, intraoperative management, and postoperative care of these complex and sick patients. Appropriate investigation and management of comorbidities such as coronary artery disease and portopulmonary hypertension is controversial and differs between programs. The transplant procedure is a major surgery, and although massive transfusion is no longer commonplace, there is potential for significant hemodynamic instability, coagulopathy, and metabolic disturbance. Liver transplant surgery can be divided into the preanhepatic phase, the anhepatic phase, and the reperfusion phase, with important anesthetic considerations at each point. An understanding of the surgical techniques used for vascular exclusion of the liver and the role of venovenous bypass is crucial for the anesthesiologist. Recent trends in perioperative care include the use of antifibrinolytic drugs and point-of-care coagulation tests, intraoperative renal replacement therapy, and “fast-track” extubation and postoperative care. Care of patients with fulminant hepatic failure or those receiving split-liver grafts requires special consideration.
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Affiliation(s)
| | - Achal Dhir
- London Health Sciences Centre, London, ON, Canada
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25
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Choi YJ, Cho EJ, Yoon SZ, Lee HW, Lim HJ. Bispectral index decreased to zero for a patient undergoing orthotopic liver transplantation. Korean J Anesthesiol 2013; 65:S8-9. [PMID: 24478884 PMCID: PMC3903872 DOI: 10.4097/kjae.2013.65.6s.s8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, Seoul Paik Hospital, College of Medicine, Inje University, Korea
| | - Eun Jung Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Seung Zhoo Yoon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Hye Won Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Hae Ja Lim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea
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26
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Sahmeddini MA, Eghbal MH, Khosravi MB, Ghaffaripour S, Janatmakan F, Shokrizade S. Electro-acupuncture Stimulation at Acupoints Reduced the Severity of Hypotension During Anesthesia in Patients Undergoing Liver Transplantation. J Acupunct Meridian Stud 2012; 5:11-4. [DOI: 10.1016/j.jams.2011.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Revised: 08/21/2011] [Accepted: 08/29/2011] [Indexed: 01/17/2023] Open
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Devi A S, Kapoor D, Gopal PBN, Subrahmanyam M, Ravichandra RS. Effect of antifibrinolytic drugs on transfusion requirement and blood loss during orthotopic liver transplantation: Results from a single center. Asian J Transfus Sci 2011; 2:61-5. [PMID: 20041079 PMCID: PMC2798768 DOI: 10.4103/0973-6247.42693] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND During orthotopic liver transplantation (OLT), activation of the fibrinolytic system can contribute significantly to perioperative bleeding. Prophylactic administration of antifibrinolytic agents has been shown to reduce blood loss and the need for allogenic transfusion. OBJECTIVE To study the effect of antifibrinolytics on requirement of blood components, blood loss and operative time during OLT in patients with end stage liver disease, reporting to a single centre. MATERIALS AND METHODS Consecutive patients who underwent OLT at this centre during the period February 2003-October 2007 were the subjects of this study. Based on the individual anesthesiologist's preference, patients were assigned to receive either two million units of aprotinin (AP) as a bolus followed by 5,00,000 units/hour or 10 mg/kg tranexamic acid (TA) as a bolus followed by 10 mg/kg every six to eight hours, administered from the induction till the end of the surgery. Transfusion policy was standardized in all patients. Intraoperative red cell salvage was done wherever possible. The effect of these two antifibrinolytic drugs on transfusion requirement was evaluated as a whole and in a sub group of patients from each treatment group and compared with a concurrent control group that did not receive antifibrinolytic drugs. RESULTS Fifty patients (40 M / 10 F, 44 adults, 6 pediatric patients) underwent OLT in the study period. Fourteen patients were given AP, 25 patients were given TA and 11 patients did not receive any of the agents(control group). The median volume of total blood components transfused in antifibrinolytic group (n = 39) was 4540 ml(0-19,200ml), blood loss 5 l(0.7-35l) and operative time 9h (4.5-17h) and that of control group(n = 11) was 5700 ml(0-15,500ml), 10 l(0.6-25 l) and 9h (6.4-15.8h) respectively. The median volume of blood transfusions, blood loss and operative time was lesser in AP group(n = 14) than that of TA group(n = 25). CONCLUSION There is definite decrease in transfusion requirement, blood loss and operative time in the patients who received antifibrinolytic drugs than that of patients who did not receive. Because of the small sample size, comparisons carried between different groups did not show statistical significance. Prophylactic use of antifibrinolytics during OLT, possibly helps in blood conservation.
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Martín Cancho MF, Celdrán Bonafonte D, Calles Vázquez C, Lima Rodríguez R, García-Montoto F, Carrasco Jiménez MS, Sánchez Margallo FM. [Proposed experimental model to provide training in the management of anesthesia in liver transplantation]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:345-352. [PMID: 21797084 DOI: 10.1016/s0034-9356(11)70083-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To propose and evaluate the use of a porcine model for training in how to manage and improve the quality of anesthesia during liver transplantation. MATERIAL AND METHODS Five trained anesthesiologists who had no previous experience in managing anesthesia during liver transplantation and who did not work in hospitals where the procedure was performed volunteered for the training course and evaluated it. Each trainee anesthetized 5 animals. Surgery was performed under total balanced anesthesia with monitoring of hemodynamics, ventilation, biochemistry, arterial blood gases, and coagulation. Previously set criteria were used to evaluate the trainees' skill in maintaining patient stability. Their work was assessed 7 times: at baseline, 15 minutes into the preanhepatic phase, at the end of the preanhepatic stage, 15 minutes into the anhepatic phase, at the end of the anhepatic phase, 15 minutes into the postanhepatic phase, and at the end of the postanhepatic phase. After completing the course, the trainees filled in a questionnaire to evaluate its usefulness. Analysis of variance was applied to score changes in anesthetic quality criteria. RESULTS After implantation, changes in metabolic (acidosis) and cardiac (hypotension and bradycardia) status were the most critical abnormalities the trainees faced. Their skill in coping with hemodynamic and metabolic changes improved significantly (P<.05). All participants expressed a preference for receiving training in a porcine model before providing anesthesia in this surgical setting. CONCLUSIONS Under this training model, the anesthesiologists understood and were able to manage the hemodynamic and physiologic changes that develop during a liver transplant procedure. We believe that training using a porcine model allows an anesthesiologist to acquire experience and skill in this setting.
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Kim DY, Huh IY, Cho YW, Park ES, Park SE, Nah YW, Park CR. Experience without using venoveno bypass in adult orthotopic liver transplantation. Korean J Anesthesiol 2011; 60:19-24. [PMID: 21359076 PMCID: PMC3040426 DOI: 10.4097/kjae.2011.60.1.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 07/22/2010] [Accepted: 08/23/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Venoveno bypass (VVB) has been used to achieve hemodynamic stability and decrease the incidence of renal dysfunction. However, VVB has many complications. The purpose of this study is to verify the safety of total clamping of the suprahepatic inferior vena cava (IVC) without VVB during orthotropic liver transplantation (OLT) in terms of anesthetic management. METHODS Twenty-five patients without preoperative renal dysfunction who underwent primary OLT were enrolled in this study. Hemodynamic data and blood gas measurements were collected 1 hour after incision, 30 minutes after IVC total clamping and 30 minutes after reperfusion. Postoperative laboratory data, including blood urea nitrogen (BUN), creatinine (Cr) and glomerular filtration rate (GFR), were assessed at postoperative day (POD) 0-7, 30, 90, 180 and 1 year. RESULTS Mean blood pressure was well maintained during IVC total clamping with infusion of inotropics. There was no case of severe acidosis (pH < 7.2) during the anhepatic period. The immediate postoperative Cr and GFR were not significantly different from those of the preoperative values. BUN increased from POD 1 and decreased after POD 6, while Cr increased at POD 90 only. CONCLUSIONS In patients without preoperative renal dysfunction, when IVC was totally clamped, VVB does not need to be routinely performed to maintain hemodynamics during the anhepatic phase and renal function after OLT.
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Affiliation(s)
- Dae-Young Kim
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - In Young Huh
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Young Woo Cho
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Eun Sun Park
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Soon Eun Park
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Yang Won Nah
- Department of General Surgery, Ulsan University Hospital, Ulsan, Korea
| | - Chang Ryul Park
- Department of Thoracic and Cardiovascular Surgery, Ulsan University Hospital, Ulsan, Korea
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Castañeda-Martínez P, Alcaide-Ortega R, Fuentes-García V, Hernández-Plata J, Nieto-Zermeño J, Reyes-López A, Varela-Fascinetto G. Anesthetic Risk Factors Associated With Early Mortality in Pediatric Liver Transplantation. Transplant Proc 2010; 42:2383-6. [DOI: 10.1016/j.transproceed.2010.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nemes B, Gelley F, Zádori G, Görög D, Fehérvári I, Jakab K, Fazakas J, Mándli T, Gerlei Z, Sárváry E, Doros A, Kóbori L. The role of marginal donors in liver transplantation. The Hungarian experience. Orv Hetil 2009; 150:2228-36. [DOI: 10.1556/oh.2009.28743] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A májátültetések számát korlátozza a beültetésre alkalmas donorszervek mennyisége. A szervhiány megoldására az egyik lehetőség az úgynevezett marginális donorok (extended donor criteria) elfogadása a májátültetési programban.
Célkitűzés:
A magyar májátültetési program szervdonációs jellemzőinek vizsgálata, különös tekintettel a marginális donorokra.
Módszer:
Donor- és recipiensadatok retrospektív feldolgozása 2003. január és 2008. december között. A marginálisdonor-kritériumrendszert nemzetközi ajánlások alapján állítottuk fel.
Eredmények:
A vizsgált periódus alatt összesen 1078 donort jelentettek a klinikán. Nyolcszázharmincöt esetben (77,4%) alkalmatlannak ítélték a donormájat a transzplantációra, 243 esetben (22,6%) volt beültetésre alkalmas a donormáj. A beültetett májgraftok közül 40 (16%) származott marginális, 203 (84%) nem marginális donorból. Marginális májgraftok beültetése esetén nem volt különbség a beteg- és grafttúlélésben, a posztoperatív graftfunkciót jelző paraméterekben és az általános szövődmények gyakoriságában. A korai hepatitis C-rekurrencia gyakoribb volt marginális graft beültetése esetén.
Következtetések:
A májátültetésre váró betegek száma hazánkban is folyamatosan növekszik. Marginális májgraftok alkalmazása esetén a betegek morbiditása és mortalitása nem különbözik számottevően a standard donorokból származó májgraftok beültetése után tapasztalt eredményektől. Hepatitis C-vírus esetén nem javasolt marginális májgraft beültetése. A donorok felső életkori határának kiterjesztése megfontolandó.
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Affiliation(s)
- Balázs Nemes
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Fanni Gelley
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Gergely Zádori
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Dénes Görög
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Imre Fehérvári
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Katalin Jakab
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - János Fazakas
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Tamás Mándli
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Zsuzsa Gerlei
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Enikő Sárváry
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Attila Doros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - László Kóbori
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
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Filho JAR, Nani RS, Carmona MJC, Ballesteros MV, D'Albuquerque LAC. Anestesia para trasplante hepático en hepatitis fulminante. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2009. [DOI: 10.1016/s0120-3347(09)74010-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Hoffmann K, Weigand MA, Hillebrand N, Büchler MW, Schmidt J, Schemmer P. Is veno-venous bypass still needed during liver transplantation? A review of the literature. Clin Transplant 2009; 23:1-8. [DOI: 10.1111/j.1399-0012.2008.00897.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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35
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Dzik WH, Laposata M, Hertl M, Sandberg WS, Chatterji M, Misdraji J. Case records of the Massachusetts General Hospital. Case 38-2008. A 58-year-old man with hemophilia, hepatocellular carcinoma, and intractable bleeding. N Engl J Med 2008; 359:2587-97. [PMID: 19073979 DOI: 10.1056/nejmcpc0807506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Walter H Dzik
- Blood Transfusion Service, Massachusetts General Hospital, and the Department of Pathology, Harvard Medical School, USA
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Dharancy S, Lemyze M, Boleslawski E, Neviere R, Declerck N, Canva V, Wallaert B, Mathurin P, Pruvot FR. Impact of impaired aerobic capacity on liver transplant candidates. Transplantation 2008; 86:1077-83. [PMID: 18946345 DOI: 10.1097/tp.0b013e318187758b] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Oxygen consumption at peak exercise (peak VO2) is the most accurate index of aerobic capacity (AC), which reflects the physical condition of an individual and is currently considered the gold standard for cardiorespiratory fitness. Evaluation of peak VO2 to identify high-risk candidates for liver transplantation (LT) may represent an interesting approach. The aims of this study were (a) to describe AC and identify factors independently associated with peak VO2; (b) to analyze the prognostic value of peak VO2 in patients referred for preliminary evaluation of LT; and (c) to provide preliminary data on the influence of peak VO2 on length of hospitalization and the need for oxygen support after LT. RESULTS Peak VO2 was determined in patients referred for preliminary evaluation for LT. One hundred thirty-five candidates were included. More than half had severe alterations in peak VO2. Age, gender, model-for-end-stage liver disease (MELD) score, tobacco use, and hemoglobin were independently associated with peak VO2. Candidates with severe alterations in peak VO2 had a lower 1-year survival than others. Model-for-end-stage liver disease score and peak VO2 were independently associated with survival. In patients with a MELD above 17, those with severe alterations of peak VO2 AC had lower 1-year survival than the others. Among patients who underwent LT, those with severe impairment of peak VO2 showed a trend toward a higher mean length of hospitalization after LT and had significantly longer need for oxygen support. CONCLUSIONS Peak VO2 is severely impaired in candidates for LT and affects survival and post-LT course. Perioperative respiratory rehabilitation programs validated in lung and heart transplantation must be tested.
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Affiliation(s)
- Sébastien Dharancy
- Service des Maladies de l'Appareil digestif et de la Nutrition, Hôpital Claude Huriez, France.
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37
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Anesthetic Considerations of Case for Liver Transplantation as Practiced at Apollo Hospital. APOLLO MEDICINE 2008. [DOI: 10.1016/s0976-0016(11)60143-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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38
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Seo KC, Kim JE, Song SY, Rho WS, Choi DL, Chung JY. Perforation of the superior vena cava during liver transplantation - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.4.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Kwi Chu Seo
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu, Daegu, Korea
| | - Jung Eun Kim
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu, Daegu, Korea
| | - Seok Young Song
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu, Daegu, Korea
| | - Woon Seok Rho
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu, Daegu, Korea
| | - Dong Lak Choi
- Department of Surgery, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Jin Yong Chung
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu, Daegu, Korea
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Schemmer P, Nickkholgh A, Hinz U, Gerling T, Mehrabi A, Sauer P, Encke J, Friess H, Weitz J, Büchler MW, Schmidt J. Extended Donor Criteria Have No Negative Impact on Early Outcome After Liver Transplantation: A Single-Center Multivariate Analysis. Transplant Proc 2007; 39:529-34. [PMID: 17362774 DOI: 10.1016/j.transproceed.2006.12.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The organ shortage has driven many transplant centers to accept extended donor criteria and to modify graft allocation policies. This study was designed to analyze the impact of applying extended donor criteria (EDC) in orthotopic liver transplantation (OLT). Between December 2001 and December 2004, we performed 165 primary cadaveric whole OLTs. Up to three EDC, that is, ventilation >7 days; aminotransferases (ALT or AST) >3 x normal; bilirubin >3 mg/dL; anti-HBc or HBs Ag positivity; donor age >65 years; liver steatosis >40%; donor body mass index >30; cold ischemia time >14 hours; peak serum Na(+) >165 mmol/L; history of extrahepatic malignancy; or previous drug abuse were present in 55% of all grafts. Both univariate and multivariate analysis revealed that EDC status had no effect on graft or patient survival, the necessity for retransplantation, the length of intensive care/intermediate care unit stay, mechanical ventilation, complications, or posttransplant laboratory findings. Recipient age of >/=55 years was the only independent prognostic factor for survival, regardless of EDC. These findings suggested that the use of grafts from EDC donors are safe and expand the donor pool.
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Affiliation(s)
- P Schemmer
- Department of General Surgery, Ruprecht-Karls-University, Heidelberg, Germany
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Affiliation(s)
- William T Merritt
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine Center for Information Services, Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Xia VW, Du B, Tran A, Liu L, Hu KQ, Hiatt JR, Busuttil RW, Steadman RH. Intraoperative Hypokalemia in Pediatric Liver Transplantation: Incidence and Risk Factors. Anesth Analg 2006; 103:587-93. [PMID: 16931666 DOI: 10.1213/01.ane.0000229650.23931.0c] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this retrospective study of 268 children undergoing liver transplantation, we investigated the incidence of intraoperative potassium (K+) disturbances and the risk factors for hypokalemia in the preperfusion and postreperfusion periods. Overall, hypokalemia was the predominant disturbance, occurring in 72.0% of pediatric patients during liver transplantation. Hypokalemia was more common during the postreperfusion period than the prereperfusion period. Hyperkalemia, though a commonly cited complication, was infrequent during pediatric liver transplantation. Using multivariate logistic regression analysis, baseline serum K+ < or =3.5 mmol/L, base excess >5 mmol/L, and creatinine < or =0.5 mg/dL were found to be predictors for hypokalemia in the prereperfusion period; and body weight < or =15 kg, K+ < or =3.5 mmol/L, fresh-frozen plasma transfusion >90 mL/kg, and absence of ascites at surgery were independent predictors for hypokalemia in the postreperfusion period. These findings support the use of K+ replacement to maintain normokalemia and avoid the potential complications related to hypokalemia in pediatric liver transplantation, especially in children with the risk factors for hypokalemia.
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Affiliation(s)
- Victor W Xia
- Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, California 90095-1778, USA.
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Affiliation(s)
- Rajeev Kumar Garg
- Department of Anesthesia, University of Cincinnati Medical Center, OH 45267-0531, USA
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