Anesthesia for Liver Transplantation

The provision of anesthesia for a liver transplant program requires a dedicated team of anesthesiologists. Liver transplant anesthesiologists must have an understanding of liver physiology and anatomy; the spectrum of clinical disease associated with liver dysfunction; the impact of warm and cold ischemia times, surgical techniques in liver transplantation, and the impact of ischemia-reperfusion syndrome; and optimal practices to protect the liver. The team must provide a 24-hour service, be actively involved in the selection committee process, and stay current with advances in the subspecialty.

Cardiac beriberi: often a missed diagnosis

Thiamine deficiency leads to various manifestations due to dysfunction of nervous or cardiovascular system, commonly known as dry and wet beriberi, respectively. The latter, also known as cardiac beriberi is usually missed in clinical practice because of the absence of classically described symptoms such as pedal edema/anasarca. We investigated 55 such infants and prospectively followed their clinical course. All the babies were exclusively breast-fed and their mothers belonged to low socio-economic status with their staple diet consisting of non-parboiled polished rice. Majority presented with tachypnea, chest indrawing and tachycardia and cardiomegaly with dilatation of right heart and pulmonary hypertension on 2D-echocardiography. Low levels of erythrocyte transketolase activity suggested thiamine deficiency that was confirmed by reversion of several clinical features including cardiologic abnormalities to normalcy on thiamine supplementation. We recommend thiamine therapy for infants with unexplained congestive cardiac failure or acute respiratory failure from precarious socio-economic background since it is life-saving in many instances.

High-output heart failure caused by arteriovenous fistula long after nephrectomy

A 70-year-old Japanese woman was admitted to our hospital because of anasarca. At 32 years of age, she had undergone nephrectomy for renal tuberculosis. A continuous abdominal bruit was heard. The chest X-ray showed cardiomegaly and dilatation of the pulmonary artery. Abdominal three-dimensional computed tomography scanning clearly revealed an arteriovenous fistula. Cardiac catheterization disclosed cardiac output of 9.2 l/min and a step-up of oxygen saturation at the renal vein level of the inferior vena cava. Surgical closure of the fistula promptly decreased her cardiac output and improved the heart failure. This is a rare case of an arteriovenous fistula developing long after nephrectomy and causing high-output heart failure.

Prenatal sonographic diagnosis of Klippel-Trénaunay-Weber syndrome with cardiac failure

This report describes the prenatal sonographic diagnosis of a case of Klippel-Trénaunay-Weber syndrome. The sonographic appearance of this disorder was characterized by the presence of multiple distorted cystic areas involving the right leg and abdomen and cardiomegaly with early fetal heart failure. Despite the prenatal detection of the extensive cutaneous and visceral involvement, the infant died soon after birth of high-output cardiac failure and Kasabach-Merritt syndrome.

Prenatal evaluation of fetal neck masses in preparation for the EXIT procedure: the value of pulmonary Doppler ultrasonography (PDU)

Sonographic demonstration of normal tracheal diameter and breathing-related lung fluid flow at 30 weeks' gestation in a fetus with a giant neck mass confirmed patent airways, thus avoiding an EXIT procedure.

New perspectives on the management of septic shock in the cancer patient

Septic shock is a common life-threatening problem, usually presenting with fever, tachycardia, tachypnea, and often a source of infection. The cardiac index is increased, with a decreased systemic vascular resistance, and a reversibly decreased ejection fraction with an increased end diastolic volume. The myocardial depression is most likely caused by a circulating humoral substance that depresses myocardial contractility. The initial treatment of septic shock is aggressive fluid resuscitation and antibiotic therapy, with vasopressors and inotropes being indicated in those patients who do not respond adequately to fluids. Therapy directed against the mediators of septic shock is theoretically promising, but to date has not been successful.

Reversal of refractory hypotension in septic shock by inhibitor of nitric oxide synthase

Septic shock is a life-threatening condition that results from exposure to bacterial endotoxin. It is mediated by the release of cytokines. Some of these cytokines cause the release of vasoactive substances. We report the case of a 62-year-old male patient who received redo operation for replacement of the degenerative porcine aortic and mitral prostheses. High cardiac output shock developed on the seventh postoperative day with severe metabolic acidosis and oliguria. Systemic vascular resistance and mean arterial pressure elevated within 5 min and stabilized 60 min after the start of a single dose of intravenous administration of NG-monomethyl-L-arginine (50 mg), a potent and selective inhibitor of nitric oxide synthesis. These findings indicate that nitric oxide overproduction is an important contributor to refractory hypotension in high cardiac output septic shock. Our findings suggested the utilization of nitric oxide synthase inhibitor in the treatment of septic shock in humans.

Indicator amount, temperature, and intrinsic cardiac output affect thermodilution cardiac output accuracy and reproducibility

OBJECTIVE

To determine the accuracy and reproducibility of four thermodilution indicators (5-mL room temperature, 10-mL room temperature, 5-mL iced, and 10-mL iced injectates) at clinically relevant flow rates.

DESIGN

Quasi-experimental study.

SETTING

Animal research laboratory of a health sciences university.

SUBJECTS

Six virgin western-breed ewes.

INTERVENTIONS

Data were collected from six ewes that had ascending aorta electromagnetic flow probes and inferior vena cava occluders. Cardiac output was manipulated by inferior vena cava occlusion and isoproterenol infusion. Four thermodilution indicators were tested at high and low levels of cardiac output and compared with the electromagnetic flowmeter measurements of cardiac output.

MEASUREMENTS AND MAIN RESULTS

The indicator amounts were determined from both injectate volume and temperature difference between the injectate and blood. Using 5-mL room temperature injectate as a reference, 10-mL room contained 2 x, 5-mL iced 2.1 x, and 10-mL iced 4.1 x the indicator amount of 5-mL room temperature injectate. Approximately 210 simultaneous thermodilution and electromagnetic flow measurements were made for each injectate over a flow range of 1.5 to 15.7 L/min. For the entire cardiac output range, systematic error was not present. However, the r2 value (.92) for the 10-mL iced injectate group was greater (p < .05) than that value (.79) for the 5-mL iced injectate group, while r2 values were .79 for the 10-mL room temperature group and .49 for the 5-mL room temperature group. At flow rates of < 4.7 L/min, r2 was not different among injectates, but reduced indicator amounts progressively overestimated output (p < .05), reaching 21% for the 5-mL room temperature group. At flow rates of > 7.7 L/min, the r2 value (.81) for the 10-mL iced group was greater (p < .05) than that value (.45) for the 5-mL iced group, while r2 values were .24 for the 10-mL room temperature group and .08 for the 5-mL room temperature group. Systematic error was not present.

CONCLUSIONS

At low cardiac output levels, reduced indicator impairs accuracy but not reproducibility, a phenomenon that is perhaps related to indicator loss. At high cardiac output rates, reduced indicator impairs reproducibility. This phenomenon is probably related to low signal-to-noise ratio. Thermodilution indicator amounts should be tailored to the output range.

Circulatory studies in Wernicke's encephalopathy: with special reference to the occurrence of a state of high cardiac output and postural hypotension

Although Wernicke's disease is clearly related to thiamine deficiency, it is rarely accompanied by the overt signs of congestive failure. There are symptoms of disordered cardiovascular function in many patients with this disease, but the relation of these symptoms to thiamine deficiency has remained undefined. In the present study, an attempt is made to define these symptoms, particularly, in relation to specific treatment with thiamine. Part 1 of this study is concerned mainly with the determination of the cardiac output in 7 patients, as determined by the Evans blue dye-dilution technic; part 2 describes the postural response to tilting in 12 patients.

Increased cardiac output caused by secondary hypernephroma

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