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Rodriguez IE, Asher ZP, Klingenberg K, Wright FL, Nydam TL, Adams MA, Bababekov YJ, Peltz E, Smith JW, Saben JL, Kennealey P, Pomposelli JJ, Pomfret EA, Moore HB. Phase I clinical trial of the feasibility and safety of direct peritoneal resuscitation in liver transplantation. Am J Surg 2024:115815. [PMID: 39003094 DOI: 10.1016/j.amjsurg.2024.115815] [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: 04/30/2024] [Revised: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Direct peritoneal resuscitation (DPR) is associated with improved outcomes in trauma. Animal models suggest DPR has favorable effects on the liver. We sought to evaluate its safety and assess for improved outcomes in liver transplantation (LT). METHODS LT patients with renal dysfunction and/or obesity were enrolled in a phase-I clinical trial. DPR lasted 8-24 h depending on postoperative disposition. Primary outcome was percent of patients completing DPR. Secondary outcomes evaluated complications. Controls with either obesity (control-1) or both risk factors (obesity + renal dysfunction, control-2) were analyzed. RESULTS Fifteen patients were enrolled (seven with both criteria and eight with obesity alone). DPR was completed in 87 % of patients, with one meeting stopping criteria. Controls included 45 (control-1) and 24 (control-2) patients. Return to operating room, graft loss, and late infections were lower with DPR. CONCLUSION DPR appears to be safe in closed abdomens following LT, warranting a follow-up phase-II trial to assess efficacy.
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Affiliation(s)
- Ivan E Rodriguez
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Zachary P Asher
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katherine Klingenberg
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Franklin L Wright
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Trevor L Nydam
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Megan A Adams
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Yanik J Bababekov
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Eric Peltz
- Department of Surgery, Logan Health Medical Center, Kalispell, MT, USA
| | - Jason W Smith
- Department of Surgery, University of Louisville Health, Louisville, KY, USA
| | - Jessica L Saben
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Peter Kennealey
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - James J Pomposelli
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth A Pomfret
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hunter B Moore
- AdventHealth Transplant Institute at Porter, Denver, CO, USA.
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Rodriguez IE, Saben JL, Moore EE, Knudson MM, Moore PK, Pieracci F, Sauaia A, Moore HB. Fibrinolysis Resistance After Injury Is a Risk Factor for a Hospital-Acquired Pneumonia-Like Disease Pattern. Surg Infect (Larchmt) 2024; 25:87-94. [PMID: 38394296 PMCID: PMC10924191 DOI: 10.1089/sur.2023.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
Background: Pneumonia is associated with increased morbidity and costs in the intensive care unit (ICU). Its early identification is key for optimal outcomes, but early biomarkers are lacking. Studies suggest that fibrinolysis resistance (FR) after major abdominal surgery is linked to an increased risk of infection. Patients and Methods: Patients in a randomized controlled trial for hemorrhagic shock were evaluated for FR. Fibrinolysis resistance was quantified by thrombelastography with exogenous tissue plasminogen activator (tPA-TEG) at 24- and 48-hours post-injury and measuring LY30 (%). A receiver-operating characteristics (ROC) curve analysis was used to identify a cutoff for increased risk of pneumonia, which was then validated in ICU patients at risk for venous thromboembolism (VTE). Multivariable logistic regression was used to control for confounders. Results: Forty-nine patients in the hemorrhagic shock cohort had tPA-TEGs at 24- and 48-hours (median ISS, 27; 7% pneumonia). A composite tPA-TEG LY30 of less than 4% at 24 and 48 hours was found to be the optimal cutoff for increased risk of pneumonia. This cohort had a seven-fold increased rate of pneumonia (4% vs. 28%; p = 0.048). Eighty-eight patients in the VTE cohort had tPA-TEGs at 24 and 48 hours post-ICU admission (median ISS, 28; 6% pneumonia). The tPA-TEG LY30 of less than 4% was associated with a 10-fold increased rate of pneumonia (19% vs. 1.5%; p = 0.002). In patients with traumatic brain injury, the same association was found (33% vs. 3.2%; p = 0.006). Adjusting for confounders, the tPA-TEG persisted as a substantial risk factor for pneumonia (adjusted odds ratio [OR], 35.7; 95% confidence interval [CI], 1.9-682; p = 0.018). Conclusions: Fibrinolysis resistance quantified by tPA-TEG within 48 hours of ICU admission is associated with an increased risk of pneumonia in patients in hemorrhagic shock and those at risk for VTE. Prospective validation of the tPA-TEG LY30 optimal cutoff for pneumonia and further investigation into whether endogenous FR is a cause of an altered immunity is warranted.
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Affiliation(s)
- Ivan E. Rodriguez
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jessica L. Saben
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, Ernest E. Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - M. Margaret Knudson
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Peter K. Moore
- University of Colorado Denver, Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Fredric Pieracci
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, Ernest E. Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - Angela Sauaia
- Department of Surgery, Ernest E. Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - Hunter B. Moore
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Transplant Institution at Porter, AdventHealth, Denver, Colorado, USA
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Gaspari R, Spinazzola G, Aceto P, Avolio AW, Delli Compagni M, Postorino S, Michi T, Fachechi DC, Modoni A, Antonelli M. Intensive Care Unit-Acquired Weakness after Liver Transplantation: Analysis of Seven Cases and a Literature Review. J Clin Med 2023; 12:7529. [PMID: 38137598 PMCID: PMC10743957 DOI: 10.3390/jcm12247529] [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: 10/25/2023] [Revised: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.
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Affiliation(s)
- Rita Gaspari
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giorgia Spinazzola
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Paola Aceto
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy;
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Manuel Delli Compagni
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Stefania Postorino
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Teresa Michi
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Daniele Cosimo Fachechi
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Anna Modoni
- Department of Geriatric, Neurologic, Orthopedics and Head-Neck Science, Area of Neuroscience, Institute of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Massimo Antonelli
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
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Moore HB, LaRiviere W, Rodriguez I, Brown K, Hadley K, Pomposelli JJ, Adams MA, Wachs ME, Conzen KD, Kennealey PT, Kaplan B, Pomfret EA, Nydam TL. Early predictors of prolonged intensive care utilization following liver transplantation. Am J Surg 2023; 226:829-834. [PMID: 37604748 DOI: 10.1016/j.amjsurg.2023.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Creatinine, bilirubin, and fibrinolysis resistance are associated with multi-organ dysfunction and likely risk factors for prolonged intensive care unit (pICU) stay following liver transplantation (LT). We hypothesize postoperative day-1 (POD-1) labs will predict pICU. METHODS LT recipients had clinical laboratories and viscoelastic testing with tissue plasminogen activator thrombelastography (tPA TEG) to quantify fibrinolysis resistance (LY30) on POD-1. pICU was defined as one week or longer in the ICU. Logistic regression was used to identify the relationship between POD-1 labs and pICU. RESULTS Of 304 patients, 50% went to the ICU, with 15% experiencing pICU. Elevated creatinine (OR 6.6, P < 0.001) and low tPA TEG LY30 (OR 3.7, P = 0.004) were independent predictors of pICU after controlling for other risk factors. A 9-fold increase in the rate of 90-day graft loss (19% vs 2% p < 0.001) was observed patients who had these risk factors for pICU. CONCLUSION Elevated creatine and fibrinolysis resistance are associated with pICU and poor outcomes following LT.
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Affiliation(s)
- Hunter B Moore
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA.
| | - Wells LaRiviere
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Ivan Rodriguez
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kristen Brown
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kyndall Hadley
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - James J Pomposelli
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Megan A Adams
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Michael E Wachs
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kendra D Conzen
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Peter T Kennealey
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Bruce Kaplan
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Elizabeth A Pomfret
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
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张 雪, 陈 思, 郭 军, 张 中, 胡 海, 杨 家, 康 焰. [Application Value of Novel Coagulation Markers in Predicting Postoperarative Complications in the Early Stage After Liver Transplantation]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:1024-1029. [PMID: 37866963 PMCID: PMC10579085 DOI: 10.12182/20230960105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Indexed: 10/24/2023]
Abstract
Objective To investigate the relationship between thrombin-antithrombin complex (TAT), plasmin-α 2-plasmininhibitor complex (PIC), soluble thrombomodulin (sTM), and tissue plasminogen activator-inhibitor complex (tPAIC) and postoperative complications in the early stage after liver transplantation (LT). Methods We analyzed the perioperative clinical data, including plasma TAT, PIC, sTM, and tPAIC, of 130 post-LT patients admitted to the intensive care unit (ICU), West China Hospital, Sichuan University between December 2021 and November 2022. Patients were divided into two groups, a complication group and a non-complication group, according to whether they experienced complications of Clavien-Dindo (CD) grade Ⅲb and above within 30 days after the surgery. Univariate analysis and binary multivariate logistic regression models were used to determine the risk factors for complications within 30 days post-LT. Results The incidence of complications of CD grade Ⅲb and above within 30 days post-LT was 33.1% (43/130). Patients in the complication group had significantly higher scores for the Model for End-Stage Liver Disease (MELD), operative time, intraoperative red blood cell transfusion volume, intraoperative plasma transfusion volume, and plasma TAT, PIC, sTM and tPAIC measured at the time of admission to ICU after the operation than those in the non-complication group did (all P<0.05). Logistic regression showed that for every single U of red blood cells transfused during the transplant surgery, the probabilities of complications within 30 days post-LT increased by 15.1% (95% confidence interval [ C I]: 1.070-1.239, P<0.001) and for the increase of every single TU/mL of plasma sTM measured upon post-LT admission to ICU, the probabilities of complications increased by 13.7% (95% CI: 1.060-1.220, P<0.001). Conclusion Plasma sTM measured upon admission to ICU after LT is an independent risk factor for complications within 30 days post-LT, and additional assessment of sTM may help predict complications in the early stage post-LT.
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Affiliation(s)
- 雪 张
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 思敏 陈
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 军 郭
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 中伟 张
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 海 胡
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 家印 杨
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 焰 康
- 四川大学华西医院 重症医学科 (成都 610041)Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
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