Population pharmacokinetic modelling of fibrinogen in patients with congenital or acquired-chronic or acute-hypofibrinogenaemia

AIMS

Fibrinogen is the key substrate for coagulation. Fibrinogen pharmacokinetics (PK) after single doses of fibrinogen concentrate (FC), using modelling approaches, has only been evaluated in congenital afibrinogenaemic patients. The aims of this study are to characterize the fibrinogen PK in patients with acquired-chronic (cirrhosis) or acute-hypofibrinogenaemia (critical haemorrhage), showing endogenous production. Influencing factors of differences on the fibrinogen PK between subpopulations will be identified.

METHODS

A total of 428 time-concentration values from 132 patients were recorded. Eighty-two out of 428 values were from 41 cirrhotic patients administered with placebo and 90 out of 428 were from 45 cirrhotic patients that were given FC, 161 out of 428 values were from 14 afibrinogenaemic patients and 95 out of 428 values were from 32 severe acute trauma haemorrhagic patients. A turnover model that accounted for endogenous production and exogenous dose was fitted using NONMEM74. The production rate (Ksyn), distribution volume (V), plasma clearance (CL) and concentration yielding to 50% of maximal fibrinogen production (EC50) were estimated.

RESULTS

Fibrinogen disposition was described by a one-compartment model with CL and V values of 0.0456 L·h-1 and 4.34 L·70 kg-1 , respectively. Body weight was statistically significant in V. Three different Ksyn values were identified that increased from 0.00439 g·h-1 (afibrinogenaemia), to 0.0768 g·h-1 (cirrhotics) and 0.1160 g·h-1 (acute severe trauma). EC50 was of 0.460 g·L-1 .

CONCLUSIONS

This model will be key as a support tool for dose calculation to achieve specified target fibrinogen concentrations, in each of the studied populations.

Liver transplant with controlled donors after circulatory death with normothermic regional perfusion and brain dead donors: A multicenter cohort study of transfusion, one-year graft survival and mortality

BACKGROUND

Controlled donation after circulatory death (cDCD) has expanded the donor pool for liver transplantation (LT). However, transfusion requirements and perioperative outcomes should be elucidated. The aim of this multicenter study was to assess red blood cell (RBC) transfusions, one-year graft and patient survival after LT after cDCD with normothermic regional perfusion (NRP) compared with donors after brain death (DBD).

METHODS

591 LT carried out in ten centers during 2019 were reviewed. Thromboelastometry was used to manage coagulation and blood product transfusion in all centers. Normothermic regional perfusion was the standard technique for organ recovery.

RESULTS

447 patients received DBD and 144 cDCD with NRP. Baseline MCF Extem was lower in the cDCD group There were no differences in the percentage of patients (63% vs. 61% p = 0.69), nor in the number of RBC units transfused (4.7 (0.2) vs 5.5 (0.4) in DBD vs cDCD, p = 0.11. Twenty-six patients (6%) died during admission for LT in the DBD group compared with 3 patients (2%) in the cDCD group (p = 0.15). To overcome the bias due to a worse coagulation profile in cDCD recipients, matched samples were compared. No differences in baseline laboratory data, or in intraoperative use of RBC or one-year outcome data were observed between DBD and cDCD recipients.

CONCLUSIONS

cDCD with NRP is not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found. Donors after controlled circulatory death with NRP can increasingly be utilized with safety, improving the imbalance between organ donors and the ever-growing demand.

Baseline haemoglobin and thromboelastometry are predictive of red blood cell requirements and one-year mortality in liver transplantation

BACKGROUND

To determine the predictive capacity of baseline haemoglobin and maxim clot firmness (MCF) EXTEM thromboelastometry for intraoperative red blood cell (RBC) requirements and its influence on mortality.

METHODS

591 adult liver transplant (LT) recipients from ten Spanish centres were reviewed. The main outcomes were the percentage of patients who received RBC and massive transfusion (≥ 6 RBC units), RBC units transfused, and mortality.

RESULTS

76 % received a donor after brain death graft and 24 % a controlled donor after circulatory death graft. Median (interquartile ranges) RBC transfusion was 2 (0-4) units, and 63 % of patients were transfused. Comparing transfused and non-transfused patients, mean (standard deviation) for baseline haemoglobin was 10.4 (2.1) vs. 13.0 (1.9) g/dl (p = 0.001), EXTEM MCF was 51(11) vs. 55(9) mm (p = 0.001). Haemoglobin and EXTEM MCF were inversely associated with the need of transfusion odds ratio (OR) of 0.558 (95 % CI 0.497-0.627, p < 0.001) and OR 0.966 (95 % CI0.945-0.987, p = 0.002), respectively. Pre-operative baseline haemoglobin ≤ 10 g/dL predicted RBC transfusion, sensitivity of 93 % and specificity of 47 %. Massive transfusion (MT) was received by 19 % of patients. Haemoglobin ≤10 g/dL predicted MT with sensitivity 73 % and specificity of 52 %. One-year patient and graft survival were significantly lower in patients who required MT (78 % and 76 %, respectively) vs. those who did not (94 % and 93 %, respectively).

DISCUSSION

whereas EXTEM MCF is less dreterminant predicting RBC requirements, efforts are required to improve preoperative haemoglobin up to 10 g/dl in patients awaiting LT.

Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: A STROBE-compliant cohort study

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.

Thromboelastometric Profile and Acute Coagulopathy of the Polytraumatized Patient: Clinical and Prognostic Implications

INTRODUCTION

About 25-35% of polytraumatized patients have a profound alteration of hemostasis on arrival at the hospital (acute traumatic coagulopathy [CAT]). Viscoelastic tests (ROTEM^®) measure the hemostatic capacity and provide an early detection of CAT. The objectives of this study are to describe the initial thromboelastogram of these patients and to determine the prevalence of CAT according to predefined thromboelastographic profiles.

METHODS

Single-center, observational, prospective study in polytraumatic patients. Initial blood and thromboelastographic test (ROTEM^®) were made, and pre-hospital, hospital, transfusion, initial surgical/angiographic interventions, cardiac arrest and mortality data were collected. ROTEM^®-based, patients were classified as: normal, hypercoagulable, hypocoagulable, hipocoagulable +hyperfibrinolytic and isolated hyperfibrinolysis.

RESULTS

One hundred and twenty-three patients were analyzed. 32 cases (26%) with CAT: 15 patients with hypocoagulability, 9 with hyperfibrinolysis alone and 8 with hypocoagulability +hyperfibrinolysis. The CAT group, related to the normal group, presented higher ISS (23 vs. 16, P<.01), higher blood products transfusion (2.5 vs. 0; P=.001), more cardiac arrest (19 vs. 1%, P<.01), and higher mortality (34 vs. 5%, P<.01). The subgroup with hypocoagulability/hyperfibrinolysis, related to the groups with hypocoagulability or hyperfibrinolysis alone, presented a higher ISS (41 vs. 25 vs. 15, P<.01), higher angiographic procedures (62% vs. 13% vs. 0%, P<.01) and higher mortality (75% vs. 33% vs. 0%, P=.05).

CONCLUSIONS

Twenty-six percent of the polytrauma patients presented early coagulopathy assessed by thromboelastography. It is associated with higher consumption of blood products and lower survival. The presence of hypocoagulability +hyperfibrinolysis is associated with greater severity and a higher requirement of blood products.

Analgesia with continuous wound infusion of local anesthetic versus saline: Double-blind randomized, controlled trial in hepatectomy

BACKGROUND

Surgical wound is source of pain in hepatectomy with laparotomy. Continuous wound infusion of ropivacaine may provide effective analgesia.

METHODS

This prospective, randomized trial, patients scheduled for hepatectomy received a 48-h preperitoneal continuous wound infusion of either 0.23% ropivacaine or 0.9% saline at 5 ml/h. Primary endpoint was 48 h morphine consumption.

RESULTS

53 patients included in the ropivacaine group and 46 in the saline group. Morphine consumption was 24.63 mg in the ropivacaine group, and 26.78 mg (p = 0.669) in the saline group. Pain was comparable between groups and there were no differences in solid food intake, ambulation, or length of hospital stay. No local or systemic complications were recorded.

CONCLUSIONS

Continuous wound infusion with ropivacaine is safe, but it neither reduced morphine consumption nor enhanced recovery in patients undergoing hepatectomy. Success of enhanced recovery in hepatectomy is not influenced by the analgesic regimen if pain is well controlled.

[Anesthetic requirements measured by bilateral bispectral analysis and femoral blockade in total knee arthroplasty]

BACKGROUND AND OBJECTIVES

A continuous peripheral nerve blockade has proved benefits on reducing postoperative morphine consumption; the combination of a femoral blockade and general anesthesia on reducing intraoperative anesthetic requirements has not been studied. The objective of this study was to determine the relevance of timing in the performance of femoral block to intraoperative anesthetic requirements during general anesthesia for total knee arthroplasty.

METHODS

A single-center, prospective cohort study on patients scheduled for total knee arthroplasty, were sequentially allocated to receive 20mL of 2% mepivacaine throughout a femoral catheter, prior to anesthesia induction (Preoperative) or when skin closure started (Postoperative). An algorithm based on bispectral values guided intraoperative anesthetic management. Postoperative analgesia was done with an elastomeric pump of levobupivacaine 0.125% connected to the femoral catheter and complemented with morphine patient control analgesia for 48hours. The Kruskall Wallis and the chi-square tests were used to compare variables. Statistical significance was set at p<0.05.

RESULTS

There were 94 patients, 47 preoperative and 47 postoperative. Lower fentanyl and sevoflurane were needed intraoperatively in the Preoperative group; median values and range: 250 (100-600) vs 450 (200-600)μg and 21 (12-48) vs 32 (18-67)mL p=0.001, respectively. There were no differences in the median verbal numeric rating scale values 4 (0-10) vs 3 (0-10); and in median morphine consumption 9 (2-73) vs 8 (0-63)mg postoperatively.

CONCLUSIONS

A preoperative femoral blockade is useful in decreasing anesthetic requirements in total knee arthroplasty surgery but no added effect in the postoperative analgesic control.

The bilateral bispectral and the composite variability indexes during anesthesia for unilateral surgical procedure

Background:

The composite variability index (CVI), derived from the bispectral analysis (BIS), has been designed to detect nociception; however, there is no evidence that bilateral BIS and CVI show intrapatient reproducibility or variability.

Methods:

We conducted an observational study in patients who underwent for total knee arthroplasty. A BIS Bilateral Sensor was applied and continuously recorded at different points of the anesthesia procedure. Bland–Altman limits of agreement and dispersion for BIS and for CVI were applied.

Results:

Forty-nine right-handed patients were studied. There were differences between the right and left BIS values after tracheal intubation (which was higher on the right side) and at surgical stimulus (higher on the left side). The maximum BIS and minimum, mean, and maximum CVI scores were higher on the left side for left-side procedures, but there were no differences in any indexes for the right-side procedures. Except for the baseline measurements, both CVI and BIS scores presented high interpatient variability. Although the right to left bias was < 3% for the BIS index, dispersion was large at different stages of the anesthesia. The right to left bias for the CVI was 3.8% at tracheal intubation and 5.7% during surgical stimulus.

Conclusions:

Our results indicate that the large interindividual variability of BIS and CVI limits their usefulness. We found differences between the left and right measurements in a right-handed series of patients during surgical stimuli though they were not clinically relevant.

Postoperative analgesia with continuous wound infusion of local anaesthesia vs saline: a double-blind randomized, controlled trial in colorectal surgery

AIM

The aim of this prospective double-blind randomized clinical trial was to determine whether preperitoneal continuous wound infusion (CWI) of the local anaesthetic ropivacaine after either laparotomy or video-assisted laparoscopy for colorectal surgery would reduce patient consumption of morphine.

METHOD

Patients scheduled for colorectal surgery randomly received a 48-h preperitoneal CWI of either 0.38% ropivacaine or 0.9% saline at rates of 5 ml/h after laparotomy or 2 ml/h after laparoscopy. The primary end-point was total morphine consumption in surgery and afterwards through a patient-controlled analgesia device. Results in the laparotomy and laparoscopy subgroups were also compared.

RESULTS

Sixty-seven patients were included, 33 in the ropivacaine CWI group and 34 in the saline group. Median [interquartile range (IQR)] morphine consumption was lower in the ropivacaine group [23.5 mg (11.25-42.75)] than in the saline group [52 mg (24.5-64)] (P = 0.010). Morphine consumption was also lower in the laparotomy subgroup receiving ropivacaine [21.5 (15.6-34.7)] than in the saline group [52.5 (22.5-65) ml] (P = 0.041). Consumption was statistically similar in laparoscopy patients on ropivacaine or saline. No side effects were observed. Sixteen patients had a surgical wound infection (23.9%); 11 (16.4%) presented wound infection and five (7.5%) organ space infection. Forty-six catheter cultures were obtained; 10 (21.7%) were positive, assessed to be due to contamination.

CONCLUSION

Preperitoneal CWI of ropivacaine is a good, safe addition to a multimodal analgesia regimen for colorectal surgery. CWI can reduce morphine consumption without increasing adverse effects.

Ultrasound-guided saphenous nerve block is an effective technique for perioperative analgesia in ambulatory arthroscopic surgery of the internal knee compartment

OBJECTIVES

Arthroscopic knee surgery is a minimally invasive technique with moderate pain during the first 24h. Our main objective was to evaluate the efficacy of ultrasound guided saphenous nerve block as a method of pain control intraoperatively and postoperatively for this surgery.

MATERIAL AND METHODS

A prospective and observational study. All patients received general anesthesia with laryngeal mask in the saphenous group, nerve block was performed with 10 ml ropivacaine 0.475%. Location of the surgery (external compartment group/internal compartment group), morphine consumption, VAS for pain at 5, 30, 60 and 120 min and 24 h after surgery, need for rescue medication, onset of nausea and vomiting, length of stay in PACU, delayed discharge and satisfaction were evaluated.

RESULTS

The study included 73 patients. Of these, 46 received saphenous nerve block and 27 didn't receive it. Consumption of intraoperative, postoperative and total morphine was significantly lower in the saphenous group as well as VAS at 24h. In the subgroup of internal compartment surgery differences in VAS 24 h, morphine consume and lenght of stay in PACU were mantained.

CONCLUSIONS

The ultrasound-guided block of saphenous nerve, particularly in the internal compartment arthroscopic knee surgery, decreases analgesic requirements, obtaining more effective pain control in the first 24 h postoperatively and without any known side effects.

Postoperative respiratory outcomes in laparoscopic bariatric surgery: comparison of a prospective group of patients whose neuromuscular blockade was reverted with sugammadex and a historical one reverted with neostigmine

PURPOSE

Bariatric surgery patients are at high risk of perioperative respiratory adverse events. We hypothesized that the use of sugammadex to reverse neuromuscular blockade could improve postoperative respiratory outcomes.

METHODS

Prospective observational series of consecutive patients scheduled for laparoscopic bariatric surgery in whom neuromuscular blockade was reverted with sugammadex were compared with a historical matched cohort of patients reverted with neostigmines. The necessity of postoperative mechanical ventilation or pathological changes in postoperative chest X-ray were two of the comparisons done.

RESULTS

We enrolled 160 patients in each group (Sugammadex - SG and Historical - HG). Two patients (mean, CI 95%), (1.25, 0.34-4.4) in the SG and five patients in the HG (mean, CI 95%), (3.13, 1.34-7.11) required mechanical ventilation immediately after surgery (p=0.38, chi-square test). Significantly less chest X-ray postoperative changes were observed in the SG: 11 patients (6.9%) versus 26 patients (16.3%) in the HG (Odds ratio OR, CI 95%) (0.36, 0.18-0.8).

CONCLUSION

Requirement of mechanical ventilation is not associated to the reversal agent employed. Less pathological postoperative chest X-ray changes were found in the group of patients whose neuromuscular blockade was reverted with sugammadex.

Do the severity and the body region of injury correlate with long-term outcome in the severe traumatic patient?

BACKGROUND AND OBJECTIVES

To investigate if the Injury Severity Score (ISS) and the Abbreviated Injury Score (AIS) are correlated with the long-term quality of life in severe trauma patients.

METHODS

Patients injured from 2005 to 2007 with an ISS≥15 were surveyed 16-24 months after injury. The Health Assessment Questionnaire (HAQ-DI) was used for measuring the functional status and the Short Form-12 (SF-12) was used for measuring the health status divided into its two components, the PCS (Physical Component Summary) and the MCS (Mental Component Summary). The results of the questionnaires were compared with the ISS and AIS components. Results of the SF-12 were compared with the values expected from the general population.

RESULTS

Seventy-four patients filled the questionnaires (response rate 28%). The mean scores were: PCS 42.6±13.3; MCS 49.4±1.4; HAQ-DI 0.5±0.7. Correlation was observed with the HAQ-DI and the PCS (Spearman's Rho: -0.83; p<0.05) and no correlation between the HAQ-DI and the MCS neither between the MCS and PCS (Spearman's Rho=-0.21; and 0.01 respectively). The cutaneous-external and extremities-pelvic AIS punctuation were correlated with The PCS (Spearman's Rho: -0.39 and -0.34, p<0.05) and with the HAQ-DI (Spearman's Rho: 0.31 and 0.23; p<0.05). The physical condition compared with the regular population was worse except for the groups aged between 65-74 and 55-64.

CONCLUSIONS

Patients with extremities and pelvic fractures are more likely to suffer long-term disability. The severity of the external injuries influenced the long-term disability.

[Hypoglossal nerve neuropraxia after shoulder hemiarthroplasty]

We report a case of hypoglossal nerve damage after shoulder hemiarthroplasty with the patient in "beach chair" position, performed with general anesthesia with orotracheal intubation, and without complications. An ultrasound-guided interscalene block was previously performed in an alert patient. After the intervention, the patient showed clinical symptomatology compatible with paralysis of the right hypoglossal nerve that completely disappeared after 4 weeks. Mechanisms such as hyperextension of the neck during intubation, endotracheal tube cuff pressure, excessive hyperextension, or head lateralization during surgery have been described as causes of this neurological damage. We discuss the causes, the associated factors and suggest preventive measures.

[Analysis of difficult intubation factors in bariatric surgery. Influence of the choice of neuromuscular blocker on the availability of sugammadex]

OBJECTIVE

To determine the incidence of difficult tracheal intubation (DTI), as well as predictive factors for DTI and what influences the choice of the neuromuscular blocking agent (succinylcholine or rocuronium).

METHODS

This is an observational, prospective study on consecutive bariatric surgery patients. Tracheal intubation was performed by direct laryngoscopy with a preformed tracheal tube. DTI was considered when there was a Cormack-Lehane classification of iii-iv or when it was necessary to apply the DTI algorithm, which consisted in the use of Frova guide, and Airtraq video-laryngoscope as second choice, and finally awaking the patient and sugammadex reversal if rocuronium was the selected neuromuscular blocking agent. Thereafter, tracheal intubation was performed using an awake fibroscopic technique

RESULTS

One hundred and sixty six patients were included. In one case, conscious fiberscope tracheal intubation was performed. Succinylcholine was selected for 14 patients, and rocuronium for 151 patients. Fifteen patients had a DTI (9%): in 4 Airtraq was deemed necessary. One patient received sugammadex to reverse neuromuscular blockade. Conscious tracheal intubation represented 1.2% (95% CI; 0.3-4%). DTI was associated with Mallampati score of 3-4 (odds ratio, 3 [95% CI; 1.37-6.8], sensitivity of 33%, specificity of 91%) and with thyromental distance<6cm (odds ratio, 4.8 [95% CI; 1.45-16]; sensitivity of 53%; specificity of 79%).

CONCLUSION

Rescue airway protocol with Frova and Airtraq avoided the use of sugammadex, except in one patient.

Risk factors and mortality after elective and emergent laparatomies for oncological procedures in 899 patients in the intensive care unit: a retrospective observational cohort study

Background

Abdominal surgeries for cancer are associated with postoperative complications and mortality. A view of the success of anaesthetic, surgical and critical care can be gained by analyzing factors associated with mortality in patients admitted to intensive care units (ICUs). The objective of this study was to identify the postoperative mortality rate and the causes of perioperative death in high-risk patients after abdominal surgery for cancer. A secondary objective was to explore possible risk factors for death in scheduled and emergency surgeries, with a view to finding guidance on preventable risk factors.

Methods

An observational study, in a 12-bed surgical ICU of a tertiary hospital. Patients admitted after abdominal surgery for cancer to the ICU for more than 24 hours’ care were included from January 1, 2008–December 31, 2009. Data were extracted from the minimum basic dataset. The main outcome considered was 90-day mortality.

Results

Of 899 patients included, 80 (8.9%) died. Seven died within 48 hours of surgery, 18 died between 2 and 7 days, and 55 died after 7 days. Non-survivors were older and had more respiratory comorbidity, chronic liver disease, metastasis, and underwent more palliative procedures. 112 patients underwent emergency surgery; mortality in these patients for resection surgery was 32.5%; in the 787 patients who underwent scheduled surgery, mortality was 4.7% for resection procedures. The estimated odds ratios (95% confidence interval) of preoperative patient factors in emergency surgery confirmed a negative association between survival and older age 0.96 (0.91–1), the presence of respiratory comorbidity 0.14 (0.02–0.77) and metastasis 0.18 (0.05–0.6). After scheduled surgery, survival was negatively associated with age 0.93 (0.90–0.96) and chronic liver disease 0.40 (0.17–0.91). Analysis of complications after emergency surgery also indicated a negative association with sepsis 0.03 (0.003–0.32), respiratory events 0.043 (0.011–0.17) and cardiac events 0.11 (0.027–0.45); after scheduled surgery, respiratory 0.03 (0.01–0.08) and cardiac 0.11 (0.02–0.45) events, renal failure 0.02 (0.006–0.14) and neurological events 0.06 (0.007–0.5).

Conclusions

As most deaths occurred after discharge from the ICU, postoperative sepsis, respiratory and cardiac events should be watched carefully on the ward.

[Neurological complications associated with ultrasound-guided interscalene and supraclavicular block in elective surgery of the shoulder and arm. Prospective observational study in a university hospital]

OBJECTIVES

The incidence of postoperative neurological symptoms after performing interscalene block varies between 4 and 16%. The majority of cases are resolved spontaneously within a year, but some patients have their symptoms permanently. Our objective was to assess the incidence of postoperative neurological symptoms after performing the ultrasound-assisted interscalene and supraclavicular anaesthetic blocks.

MATERIAL AND METHODS

A prospective and observational study was conducted on consecutive patients who had undergone upper extremity surgery with an interscalene or supraclavicular block as an isolated technique, or as a complement to general anaesthesia. Seven days after the intervention, a telephone interview was conducted that focused on the detection of neurological symptoms in the operated limb. Further serial interviews were conducted on patients with symptoms (after the first, the third and the sixth month, and one year after surgery) until resolution of symptoms. Neurological evaluation was offered to those patients with persistent symptoms after one year.

RESULTS

A total of 121 patients were included, on whom 96 interscalene blocks and 22 supraclavicular blocks were performed. Postoperative neurological symptoms were detected in 9.9% (95% CI, 5-15%) of patients during the first week. No significant differences were observed between interscalene (9%) and supraclavicular block (14%). After 3 months the symptoms persisted in 9 patients (7.4%), with symptoms remaining in 4 patients (3.3%) after 1.5 years. Electromyogram was performed on 3 patients who tested positive for nerve damage.

CONCLUSIONS

A high incidence of postoperative neurological symptoms was observed, and a worrying percentage of permanence of them. There were no significant differences in incidence according to the type of block, or any features of the patient or the anaesthesia technique that were associated with the incidence of these symptoms, except a marginal relationship with age. These complications must be clearly explained to the patients before performing these blocks.

[Anesthesia in the patient with impaired liver function]

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.

[Multidisciplinary protocol for computed tomography imaging and angiographic embolization of splenic injury due to trauma: assessment of pre-protocol and post-protocol outcomes]

OBJECTIVES

To assess conservative treatment of splenic injury due to trauma, following a protocol for computed tomography (CT) and angiographic embolization. To quantify the predictive value of CT for detecting bleeding and need for embolization.

MATERIAL AND METHODS

The care protocol developed by the multidisciplinary team consisted of angiography with embolization of lesions revealed by contrast extravasation under CT as well as embolization of grade III-V injuries observed, or grade I-II injuries causing hemodynamic instability and/or need for blood transfusion. We collected data on demographic variables, injury severity score (ISS), angiographic findings, and injuries revealed by CT. Pre-protocol and post-protocol outcomes were compared. The sensitivity and specificity of CT findings were calculated for all patients who required angiographic embolization.

RESULTS

Forty-four and 30 angiographies were performed in the pre- and post-protocol periods, respectively. The mean (SD) ISSs in the two periods were 25 (11) and 26 (12), respectively. A total of 24 (54%) embolizations were performed in the pre-protocol period and 28 (98%) after implementation of the protocol. Two and 7 embolizations involved the spleen in the 2 periods, respectively; abdominal laparotomies numbered 32 and 25, respectively, and 10 (31%) vs 4 (16%) splenectomies were performed. The specificity and sensitivity values for contrast extravasation found on CT and followed by embolization were 77.7% and 79.5%.

CONCLUSIONS

The implementation of this multidisciplinary protocol using CT imaging and angiographic embolization led to a decrease in the number of splenectomies. The protocol allows us to take a more conservative treatment approach.

[Measurement of 75Se-SeHCAT abdominal retention in the initial diagnosis of Bile Acid Absorption (BAM)]

AIM

To evaluate the usefulness of the (75)SeHCAT abdominal retention (AR) measurement in the early diagnosis of diarrhea syndrome (DS).

METHODS

Thirty-seven patients with diarrhea syndrome within the first month of evolution were prospectively evaluated. The (75)Se-SeHCAT abdominal retention was measured 4 and 7 days post-administration of 0.01 mCi of (75)SeHCAT. The test was performed prior to treatment and at 3 months when the baseline study was positive. The test was considered positive if the RA was <25% at 4(th) and <10% on the 7th day. The patients were visited at 3 months. Depending on the response, 3 groups were established: a) complete response: normalization of stool frequency, b) partial response, decrease of frequency or c) no response.

RESULTS

Group A: The AR of (75)Se-SEHCAT was normal in 21 patients. Six were diagnosed of colonic diverticulosis, 8 of irritable bowel syndrome, 1 of lymphocytic colitis, 1 of post-gastroenteritis syndrome, 1 of celiac disease and 1 of stenosis of the cardia. Four are still under study. Group B: The AR of (75)Se-SEHCAT decreased in 16 patients. All showed abnormal AR at day 7 and all but 1 at day 4. Following administration of cholestyramine resin, 8 (50%) presented partial response and 8 (50%) complete response. At 3 months, AR had increased at day 4 and 9 at day 7.

CONCLUSION

The measurement of (75)SEHCAT abdominal retention allows the early diagnosis of bile acid malabsorption in 43% of the patients with DS. Measurement at 7 days seems more accurate than that at 4 days.

[Perioperative mortality: retrospective cross-sectional study of surgical patients who died between 2004 and 2008 in a tertiary care hospital]

OBJECTIVE

Retrospective analysis of all surgical, early postoperative, and 1-week to detect risk factors.

MATERIAL AND METHODS

A database was established to record clinical, anesthetic, and surgical variables, grouped as preoperative, intraoperative and postoperative factors, and reflecting comorbidities and postoperative complications. Each patient's cause of death was also recorded. Factors influencing mortality during surgery, at 48 hours, and at 1 week were explored by comparing frequencies to detect correlations.

RESULTS

From 2004 to 2008, a total of 809 deaths occurred in the 82412 hospitalized surgical patients. Patients who died during surgery or within 48 hours were younger, had a higher ASA physical status classification, had more cardiovascular risk factors, were less likely to have a diagnosis of cancer, and had spent less time in hospital before the operation. Intraoperative complications, particularly bleeding and cardiac events, were more frequent in patients whose condition was more complex and who died during surgery; that pattern was similar but less marked in patients dying within 48 hours. The patients who died within 48 hours had a higher rate of postoperative hemodynamic complications; the patients who died during the week following surgery had higher rates of septic, neurologic, and respiratory complications.

CONCLUSIONS

Emergency surgery stands out as an important predictor of death during or after surgery; other significant risk factors are postoperative complications.

[Charlson index and the surgical risk scale in the analysis of surgical mortality]

INTRODUCTION

There is controversy over how to assess surgical mortality risks after different operations. The purpose of this study was to assess the surgical factors that influenced surgical mortality and the ability of the Charlson Index and The Surgical Risk Scale (SRS) to determine low risk patients.

MATERIAL AND METHODS

All patients who died during the period 2004-2007 were included. The score of both indices (Charlson and SRS) were recorded. A score of «0» for the Charlson Index and «8» for the SRS were chosen as the cut-off point between a low and high probability of death. Three risk groups were established: Low when the Charlson was =0 and SRS was <8; Intermediate when the Charlson was >0 and the SRS <8 or Charlson=0 and SRS ≥8; and high when the Charlson was>0 and the SRS ≥8. The risks factors before, during and after surgery were compared between the groups.

RESULTS

A total of 72,771 patients were surgically intervened, of which 7011 were urgent. One in every 1455 patients died during surgery and 1 in every 112 died during their hospital stay. Thirteen (2%) patients who died belonged to the low risk group, 199 (30.7%) to the intermediate risk group, and 434 (67.2%) to the high risk group. Heart disease was associated with the high risk group. The urgency of the operation was a determining factor associated with surgical complexity. Re-intervention and sepsis predominated as a cause of death in the low risk group, and in the rest of the groups a cardiac cause was the predominant factor.

CONCLUSIONS

The combination of the Charlson Index and SRS detected those patients with a low risk of death, thus making it a useful tool to audit surgical results.

[Mortality risk factors in surgical patients in a tertiary hospital: a study of patient records in the period 2004-2006]

OBJECTIVE

To determine mortality risk factors in surgical patients.

MATERIAL AND METHOD

A cross-sectional study was carried out on all surgical patients who died while in hospital, over a period of three years (2004-2006). Pre, intra and postoperative variables were analysed. Comparisons were made between patients operated on as emergencies and elective surgery patients. Multivariate analysis was performed on the pre, intra and postoperative variables, using chi(2) of Pearson correlation with a confidence interval of 95%.

RESULTS

Surgery was performed on a total of 38 815 patients, of which 6 326 were emergency procedures and 32 489 as elective. There were 479 deaths registered: 36 occurred in the operating theatre and 443 died after the operation. Arterial hypertension, diabetes mellitus and cancer were significant causes of death. Intraoperative complications were associated with mortality during the surgical procedure. Emergency surgery was an independent risk factor (mortality, 5.5% vs. 0.4% for elective surgery). Sepsis, cardiac and respiratory related deaths were the main risk factors for postoperative death.

CONCLUSIONS

Prevention and adequate treatment of perioperative risk factors should significantly reduce morbidity and mortality rates, mainly in those patient operated as emergencies.

[Mortality in patients with multiple injuries: analysis using the trauma and injury severity score in a referral hospital]

BACKGROUND AND OBJECTIVES

A growing number of patients with multiple injuries are being treated. Injury severity scales can be used to assess outcomes objectively. This study aimed to assess our hospital's cases on the basis of the Trauma and Injury Severity Score (TRISS) and compare outcomes to those reported in the Major Trauma Outcome Study, as well as to determine preventable mortality and analyze causes of death and associated factors.

PATIENTS AND METHODS

Data were extracted from the records of patients admitted with multiple injuries in 2005 and were used to calculate the Revised Trauma Score (RTS), the Injury Severity Score (ISS), and the TRISS or probability of survival. Hospital mortality was also calculated. A TRISS between 25 and 50 was considered to indicate a preventable avoidable death; a TRISS over 50 indicated a preventable death. Logistic regression analysis was used to identify factors associated with mortality.

RESULTS

We studied the cases of 198 patients with a mean (SD) age of 43.9 (19) years. Ninety-three percent had suffered blunt trauma. The mean ISS, the prehospital RTS, and the TRISS were 16.9 (11.2), 10.8 (2.5), and 0.95 (0.2), respectively. Twenty-five patients died. Fifteen deaths were classified as preventable or potentially preventable. Factors related to exitus were head injury and age (odds ratios, 4.6 and 4.0, respectively).

CONCLUSIONS

The rate of preventable death in our hospital was higher than expected. Mortality was strongly associated with head injury and age. The TRISS model can identify preventable deaths objectively.

Improvement of associated respiratory problems in morbidly obese patients after open Roux-en-Y gastric bypass

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is present in 44% of patients scheduled for bariatric surgery. Respiratory dysfunction associated with this syndrome is attributable to chronic obstructive pulmonary disease (COPD) and/or obesity hypoventilation syndrome (OHS). We studied the long-term effect of bariatric surgery on weight loss, on the respiratory comorbidities associated with obesity, and on the need for non-invasive positive pressure ventilation.

METHODS

We followed a sample of patients with respiratory co-morbidity scheduled for open Capella Roux-en-Y gastric bypass (RYGBP) over 5-years. Patients who were positive for polysomnographic studies and required continous positive airway pressure (CPAP) before surgery were included. All patients were subjected to the same anesthetic and surgical protocols. At 1 year after surgery, polysomnographic studies were performed and arterial blood gases and pulmonary function were tested.

RESULTS

Of the 209 patients scheduled for bariatric surgery during the study period, 105 had respiratory co-morbidity. Of these, 30 required CPAP-BiPAP treatment before surgery and were included in our study. Surgery took 128 minutes (range 70 to 210 minutes). Tracheal extubation in the operating theater was possible for 26 patients (86.7%). During the early postoperative period, 7 patients (23.3%) presented respiratory complications. Length of hospitalization was 6.87 days (range 4 to 11 days). At 1 year after RYGBP, patients presented significant weight loss and improvement of hypoxemia (from 73.3 +/- 10.6 to 90.5 +/- 11.5, P = 0.000), hypercarbia (from 44.5 +/- 5.7 to 40.6 +/- 4.9, P = 0.005), and in spirometric (P = 0.004) and polysomnographic results (P = 0.001). CPAP-BiPAP treatment after weight loss was necessary in only 14% of patients (P = 0.001).

CONCLUSIONS

Weight loss after RYGBP improved arterial blood gases, respiratory tests and polysomnographic studies. CPAP treatment can be withdrawn in most patients.

Hemodynamic profile and tissular oxygenation in orthotopic liver transplantation: Influence of hepatic artery or portal vein revascularization of the graft

We performed a prospective, randomized study of adult patients undergoing orthotopic liver transplantation, comparing hemodynamic and tissular oxygenation during reperfusion of the graft. In 30 patients, revascularization was started through the hepatic artery (i.e., initial arterial revascularization) and 10 minutes later the portal vein was unclamped; in 30 others, revascularization was started through the portal vein (i.e., initial portal revascularization) and 10 minutes later the hepatic artery was unclamped. The primary endpoints of the study were mean systemic arterial pressure and the gastric-end-tidal carbon dioxide partial pressure (PCO(2)) difference. The secondary endpoints were other hemodynamic and metabolic data. The pattern of the hemodynamic parameters and tissue oxygenation values during the dissection and anhepatic stages were similar in both groups At the first unclamping, initial portal revascularization produced higher values of mean pulmonary pressure (25 +/- 7 mm of Hg vs. 17 +/- 4 mm of Hg; P < 0.05) and wedge and central venous pressures. At the second unclamping, initial portal revascularization produced higher values of cardiac output and mean arterial pressure (87 +/- 15 mm of Hg vs. 79 +/- 15 mm of Hg; P < 0.05) and pulmonary blood pressure. Postreperfusion syndrome was present in 13 patients (42.5%) in the arterial group and in 11 patients (36%) in the portal group. During revascularization, the values of gastric and arterial pH decreased in both groups and recovered at the end of the procedure, but were more accentuated in the initial arterial revascularization group. In conclusion, we found that initial arterial revascularization of the graft increases pulmonary pressure less markedly, so it may be indicated for those patients with poor pulmonary and cardiac reserve. Nevertheless, for the remaining patients, initial portal revascularization offers more favorable hemodynamic and metabolic behavior, less inotropic drug use, and earlier normalization of lactate and pH values.

[Factors related to renal dysfunction after liver transplantation in patients with normal preoperative function]

OBJECTIVE

To determine perioperative factors related to postoperative renal dysfunction in patients receiving liver transplants who had normal renal function before surgery.

PATIENTS AND METHODS

We analyzed the cases of 189 consecutive patients. Patients with hepatorenal syndrome and previously diagnosed renal insufficiency were excluded, as were patients undergoing a second transplant operation. Postoperative renal dysfunction was diagnosed when creatinine levels exceeded 1.5 mg x dL(-1) in the first postoperative week. Multivariate analysis of preoperative variables (patient characteristics; Child-Pugh score; status with the United Network for Organ Sharing; and sodium, coagulation, hemoglobin, and creatinine levels); intraoperative variables (blood product units required, duration of surgery, reperfusion syndrome, surgical technique, and crystalloids required); and postoperative variables (hemodialysis or filtration, reoperation, mortality, creatinine levels at 6 and 12 months).

RESULTS

One hundred fifty patients with normal kidney function were included. Postoperative renal dysfunction developed in 45 (30%). Differences between patients with and without postoperative renal dysfunction were found for weight; sex; Child-Pugh score; blood transfusion requirements (mean [SD] of 2.36 [2.4] units of packed red cells in the group of patients with renal dysfunction vs 1.3 [1.8] in the patients with normal function); and reperfusion syndrome (26 [66.7%] patients with renal dysfunction and 35 [21.5%] without). The last 2 variables continued to be significantly correlated with renal dysfunction in the multivariate analysis with a relative risk of 1.25, (95% confidence interval [CI], 1.01-1.55) for units of blood transfusion and 2.41 (95% CI, 1.04-5.57) for reperfusion syndrome. Renal replacement therapy was used in 4 patients (2.7%). Mortality rates were similar. At 6 and 12 months, 26 (17.3%) and 18 (12%) patients had renal dysfunction.

CONCLUSIONS

Acute renal dysfunction is a frequent complication following a liver transplant and it is associated with transfusion of more units of blood products even when the average transfusion amount is not large.

[Influence of the severity of obesity on morbidity and mortality after gastric bypass surgery]

OBJECTIVE

To determine the influence of severity of obesity on morbidity and mortality following Roux-en-Y gastric bypass and vertical ringed gastroplasty, with severity classified as morbid obesity (MO) defined by a body mass index (BMI) between 35 and 55 Kg/m2 and super-morbid obesity (SMO) defined by a BMI exceeding 55 Kg/m2.

METHOD

A series of patients who underwent the aforementioned type of gastric bypass surgery were followed for 5 years. The patients were classified as to whether they had associated sleep apnea syndrome, alveolar hypoventilation, or "overlap syndrome".

RESULTS

A total of 105 patients were enrolled: 70 (66.7%) classified as having MO and 35 (33.3%) classified as having SMO. Distribution by sex was significantly different in the 2 groups, but respiratory diseases were similar. PaO2 was higher in the MO group, PaCO2 was lower, and the alveolar-arterial gradient was smaller. Duration of surgery was shorter in the MO group (120.43 +/- 32.97 vs. 136.76 +/- 28.28 minutes). The percentage of complications was similar in the 2 groups (32.86% and 45.7% in the MO and SMO groups, respectively), although the incidence of respiratory complications was higher in SMO patients (8.57% vs. 20% in the MO and SMO groups, respectively). No differences were observed in the rates of surgical, hemodynamic, or infectious complications. Length of hospital stay was similar (6.44 vs. 6.69 for MO and SMO patients, respectively).

CONCLUSIONS

More severe obesity can be associated with preoperative arterial blood gas alterations in patients with concomitant respiratory disease and a higher incidence of respiratory complications in the early phase of recovery from gastric bypass surgery.

The prophylactic use of tranexamic acid and aprotinin in orthotopic liver transplantation: a comparative study

The efficacy of tranexamic acid (TA) and aprotinin (AP) in reducing blood product requirements in orthotopic liver transplantation (OLT) was compared in a prospective, randomized and double-blind study. One hundred and twenty seven consecutive patients undergoing OLT were enrolled; TA was administered to 64 OLT patients at a dose of 10mg /kg/h and aprotinin was administered to 63 OLT patients at a loading dose of 2 x 10(6) KIU followed by an infusion of 500,000 KIU/h. The portocaval shunt could not be performed in 14 OLT patients in the TA group and in 13 OLT patients in the AP group. However, all OLT patients that received either drug were included in the analysis. Perioperative management was standardized. Hemogram, coagulation tests, and blood product requirements were recorded during OLT and during the first 24 hours. No differences in diagnosis, Child score, preoperative coagulation tests, and intraoperative data were found between groups. No significant differences were observed in hemogram and intraoperative coagulation tests with the exception of activated partial thromboplastin time (aPTT). Similarly, there were no intergroup differences in transfusion requirements. Thromboembolic events, reoperations and mortality were similar in both groups. In conclusion, administration of regular doses of TA and AP during OLT did not result in large differences between the two groups.

Sevoflurane requirements during coloproctologic surgery: difference between two different epidural regimens

STUDY OBJECTIVE

To examine the influence of epidural morphine on the end-tidal sevoflurane concentration titrated to maintain bispectral index (BIS) values between 40 and 50.

DESIGN

Prospective, double-blinded clinical trial.

SETTINGS

Anesthesia department of a university hospital.

PATIENTS

40 ASA physical status I, II, and III patients scheduled for elective coloproctological surgery.

INTERVENTIONS

Patients were randomized to receive via a thoracic epidural catheter either a) bupivacaine 0.25% (10 mL) and saline 0.9% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% (5 mL/hr) or b) bupivacaine 0.25% (10 mL) and morphine 0.1% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% plus morphine 0.025% (5 mL/hr). Anesthesia was induced with propofol, fentanyl 2 microg kg(-1) and atracurium and maintained with sevoflurane and nitrous oxide in oxygen. Sevoflurane level was titrated to maintain a BIS value between 40 and 50. After extubation, patients were asked about the presence of pain.

MAIN RESULTS

There was no significant difference between groups of end-tidal sevoflurane concentrations at identical BIS values and hemodynamic values at any time in the study. However, the morphine group had a lower pain score level at extubation than did the plain bupivacaine group (no pain on movement, 79% vs. 31.5%, p < 0.01).

CONCLUSIONS

Adding morphine to the bupivacaine epidural solution did not reduce sevoflurane requirements but did provide high-quality postoperative analgesia, mainly just after tracheal extubation.

[Hemothorax as complication of laparoscopic technique]

A 69-year-old woman with a hiatal hernia and esophagitis caused by reflux was scheduled for laparoscopic Nissen fundoplication. Anesthetic induction was accomplished with fentanyl, propofol and rocuronium and maintenance with sevoflurane and rocoronium. Hemodynamics were stable until the end of surgery, when a sudden decrease in blood pressure to 40/20 mm Hg and arterial carbon dioxide tension to 14 mm Hg were observed. Anesthetic insufflation was stopped and physiological saline solution and ephedrine were administered. Hemothorax and air embolism were ruled out. After hemodynamic recovery, renewal of anesthetic insufflation was contraindicated, laparoscopy was halted, and hemoperitoneum was ruled out. After extubation, the patient was transferred to the recovery room, where hemodynamic instability worsened progressively. A chest radiograph suggest left hemothorax and an emergency thoracotomy was performed. After evacuation of multiple clots from the pleural cavity, the point of hemorrhage was located at the right crus of the diaphragm and bleeding was arrested. Postoperative recovery continued with no further events. The most common complications of laparoscopy are pneumothorax, gastroesophageal perforation and hemorrhage. However, given the complexity of the technique, the possibility of bleeding in the pleural cavity, as occurred in this case, should be considered. This case highlights the importance of rigorous intraoperative monitoring and postoperative surveillance by the anesthesiologist.

[Changes in the bispectral index and the spectral edge frequency 90 during different phases of anesthesia with sevoflurane]

INTRODUCTION

Electroencephalographic monitoring is one of the techniques used to measure hypnosis during anesthesia. Efforts to find a means to apply this monitoring function are justified by cases of intraoperative awakening and are in the interest of guaranteeing patient welfare and controlling anesthesia.

OBJECTIVES

To determine the changes in two electroencephalographic parameters, the bispectral index (BIS) and the spectral edge frequency 90 (SEF90), during the different phases of anesthesia. Patients and method. Forty-eight patients undergoing abdominal surgery were studied prospectively. Anesthesia was induced by propofol, fentanyl or sevoflurane. Anesthesia was maintained with sevoflurane and O2/N2O at a concentration of 70% to maintain BIS between 40 and 60. Variables monitored were heart rate, blood pressure, arterial oxygen saturation (with a pulse oximeter), expired CO2 partial pressure, inspired and expired sevoflurane partial pressure, esophageal temperature, SEF90 (defined as the frequency below which 90% of the power in the electroencephalogram resides) and BIS. All variables were recorded during three phases: induction, maintenance and recovery from anesthesia. We then performed an analysis of variance, with p < 0.05 considered significant.

RESULTS

During induction mean BIS decreased from 95.6 to 34.7 after intubation, while SEF90 fell from 20.5 Hz to 11.9 Hz. During maintenance BIS, SEF90 and expired sevoflurane partial pressure remained constant. During recovery mean BIS increased from 59.2 to 92.3 upon extubation, and SEF90 went from 15.1 to 22.2 Hz; although heart rate increased, blood pressure did not. The mean electroencephalographic values recorded when movement occurred were 77 for BIS (range 58-96) and 18 for SEF90 (range 13-18).

CONCLUSION

Electroencephalographic monitoring is useful for distinguishing between states of consciousness and unconsciousness during anesthesia, and is valid for the phases of induction and recovery. BIS values over 58 and SEF90 values over 13 may indicate inadequate hypnosis.

[Analysis of 500 liver transplantations at Bellvitge Hospital, Spain]

BACKGROUND

We present the experience of the liver transplantation program at the Hospital of Bellvitge with 500 transplantations performed during 15 years, to describe changes in liver transplantation observed throughout the time and to analyze the long term results.

PATIENTS AND METHOD

Five groups each one including 100 consecutive transplantations are studied.

RESULTS

The main indications were hepatocellular carcinoma (23%), alcoholic cirrhosis (22.8%), and post-hepatitis C cirrhosis (18.8%). Sixty-five retransplantations were performed in 59 patients (13%), being the more frequent indications arterial thrombosis (13 patients) and primary nonfunction of graft (10 patients). In 10 patients a hepatorenal transplantation was performed. In group I, the most frequent donor cause of death was cranial traumatism (80%), while in group V it was the vascular pathology (52%). There were other significative differences between these groups of patients (I vs V): patients with stage 2 or 3 from UNOS status (45 vs 19%), blood use (29.6 [26] vs 4.6 [5.3] PRBC), ICU stay (13 [13] vs 7.4 [11] days), hospital stay (40 [52] vs 23.7 [17] days), rejection rate (46 vs 20%) and primary graft nonfunction (9 vs 3%). However, the infection rates (48 vs 54.5%) and biliary tract complications (26 vs 20%) have not shown statistically significant differences. Actuarial one and 5-year survival are 83 and 70% respectively.

CONCLUSIONS

An important and progressive improvement of liver transplantation results has been observed. However, de novo tumours, hepatitis C virus recurrence and chronic rejection can limit long term results.

Tranexamic acid reduces red cell transfusion better than epsilon-aminocaproic acid or placebo in liver transplantation

We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tranexamic acid for reducing blood product requirements in orthotopic liver transplantation (OLT) in a prospective, double-blinded study performed in 132 consecutive patients. Patients were randomized to three groups and given one of three drugs prophylactically: tranexamic acid, 10 mg. kg(-1). h(-1); epsilon-aminocaproic acid, 16 mg. kg(-1). h(-1), and placebo (isotonic saline). Perioperative management was standardized. Coagulation tests, thromboelastogram, and blood requirements were recorded during OLT and in the first 24 h. There were no differences in diagnosis, Child score, or preoperative coagulation tests among groups. Administration of packed red blood cells was significantly reduced (P = 0.023) during OLT in the tranexamic acid group, but not in the epsilon-aminocaproic acid group. There were no differences in transfusion requirements after OLT. Thromboembolic events, reoperations, and mortality were similar in the three groups. Prophylactic administration of tranexamic acid, but not epsilon-aminocaproic acid, significantly reduces total packed red blood cell usage during OLT.

IMPLICATIONS

In a randomized study of 132 consecutive patients undergoing liver transplantation, we found that tranexamic acid, but not epsilon-aminocaproic acid, reduced intraoperative total packed red blood cell transfusion.